2025

PFD Reports
Reports: 635 Areas: 66

94% response rate (above 62% average).

Response Status
Responded 600 No Response 31 Pending 4
AI Classification
Action Taken 53%
Action Planned 26%
Noted 12%
Disputed 9%
Based on 967 classified responses
Top Categories
Hospital Death (Clinical Procedure… (204) Suicide (from 2015) (142) Alcohol, drug and medication relat… (95) Mental Health related deaths (76) Child Death (from 2015) (59)
635 results
Matthew Brierley
All Responded
2025-0008 8 Jan 2025 Cumbria
Ministry of Justice National Police Chiefs’ Council College of Policing
Concerns summary Excessive delays in police investigations prolong suicide risk for vulnerable individuals on bail. Standardised bail conditions and a lack of proactive support fail to address their elevated risk.
Action taken summary The College of Policing has produced comprehensive practitioner advice and added guidance documents for officers and staff on managing suicide risk in suspects of certain offences. They also revised t
Thomas Kingston
All Responded
2025-0007 7 Jan 2025 Gloucestershire
Royal College of General Practitioners National Institute for Health and Care … Medicines and Healthcare Products Regul…
Concerns summary There are concerns about adequate communication of suicide risks associated with SSRI medications and the appropriateness of continuing or switching them when ineffective or causing adverse effects.
Action taken summary NICE is collaborating with the MHRA to address concerns regarding SSRI suicide risks and guidance. The outcome of this joint work will inform any necessary updates to NICE's recommendations, with …
Sheila Nicholls
All Responded
2025-0009 7 Jan 2025 Buckinghamshire
Mandeville Grange Nursing Home
Concerns summary The care home had deficient policy management, poor staff understanding, and inadequate emergency response training. Internal investigations into adverse incidents were insufficient and performed by untrained staff.
Action taken summary Mandeville Grange Nursing Home has engaged Care4Quality to rewrite all policies, implementing a new process for drafting, reviewing, and distributing policies via Bright HR. They have moved staff trai
Gemma Marshall
All Responded
2025-0001 2 Jan 2025 West Yorkshire (Western)
NHS England Royal College of Radiologists
Concerns summary An outsourced radiologist with insufficient expertise misreported a CT scan, failing to identify a slipped gastric band due to a lack of specialist knowledge, compounded by staff shortages.
Action taken summary NHS England has completed the procurement of an Integrated Reporting Solution, developed a national Clinical Standard and Operating Procedure for Teleradiology Reporting (due March 2025), and circulat
Victor Knowles
Partially Responded
2025-0002 2 Jan 2025 Cheshire
Henning Hall Nursing Home Springcare Care Homes Ltd
Concerns summary The care home lacked internal investigation mechanisms and a system for learning from deaths, failing to identify missed opportunities or improve care for residents.
Action taken summary Springcare Care Homes Ltd disputes the necessity of the report, stating their existing internal investigation policies are comprehensive and appropriate. They assert that no further changes are requir
Peter Good
All Responded
2025-0003 2 Jan 2025 Manchester South
Harbour Healthcare Ltd
Concerns summary Indications of prolonged neglect, including poor hygiene and infected wounds, prompted a safeguarding alert. However, the nursing home owner failed to investigate this to identify learning or assess ongoing risks to other residents.
Action taken summary Harbour Healthcare Ltd has revised its Safeguarding and Whistleblowing Policy and Serious Incident Reporting Policy to mandate comprehensive internal investigations following serious incidents. These
Morgan Betchley
All Responded
2025-0004 2 Jan 2025 West Sussex, Brighton & Hove
NHS England Sussex Partnership NHS Foundation Trust
Concerns summary The mental health Trust lacked policy or guidance for assessing suicide risks posed by fixtures and fittings supplied to acute mental health patients.
Action taken summary NHS England is developing a national framework for inpatient mental health services to define and promote therapeutic relationships and personalised safety planning. They also note that Sussex Partner
Joseph Forbes Black
All Responded
2025-0005 2 Jan 2025 Inner North London
Department of Health and Social Care NHS England
Concerns summary Naloxone kits are not widely available to drug users, especially those not engaged with substance misuse services, despite the increased risk from potent synthetic opioids.
Action taken summary NHS England reports that community pharmacies can now supply naloxone following recent legislative changes. They are also working to disseminate good practice from Islington’s Better Lives service, wh
Alexandra Roberts
All Responded
2025-0006 2 Jan 2025 Cheshire
NHS England
Concerns summary The minimum prescribed insulin amount was excessively high (300 units), enabling a large overdose, when a smaller amount would have been preferred to reduce risk.
Action taken summary NHS England plans to recommend that annual medication reviews consider patients' mental health and wellbeing when prescribing high-risk medicines like insulin. They will also review prescription quant
James Keen
All Responded
2025-0140 2 Jan 2025 West London
Revon Healthcare
Concerns summary Untrained support workers at supported accommodation conducted physical health checks without understanding results or their implications, leading to unreliable information and a lack of proper training oversight.
Action taken summary Revon Healthcare states that all support workers have completed mandatory and additional physical health monitoring training, enabling them to identify and document abnormal readings. They confirmed a