2025

PFD Reports
Reports: 635 Areas: 66

94% response rate (above 62% average).

Response Status
Responded 599 No Response 32 Pending 4
AI Classification
Action Taken 53%
Action Planned 26%
Noted 12%
Disputed 9%
Based on 963 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
Liliane Bowden
All Responded
2025-0570 11 Nov 2025 Hampshire, Portsmouth and Southampton
SCAS Legal Services
Concerns summary Significant ambulance delays, caused by high demand and prolonged hospital handovers, led to extended waits for Category 3 calls. This poses a serious risk to elderly and vulnerable patients needing prompt attention.
Action taken summary South Central Ambulance Service disputes the report being issued to them, stating the core issue of handover delays lies with hospital trusts. They acknowledge the problem is widespread and explain …
Tracey Oldfield
All Responded
2025-0578 11 Nov 2025 Cornwall and the Isles of Scilly
Royal Cornwall Hospital
Concerns summary Delayed prescription of usual medications for late-admitted patients leads to inappropriate alternative pain relief. The process for timely medication prescription for such patients is unclear and unresolved.
Action taken summary Royal Cornwall Hospital has established a multidisciplinary group to strengthen governance for timely prescribing of medications for unexpectedly admitted day-case patients. They have identified four
Jacqueline Aarons
All Responded
2025-0576 10 Nov 2025 North London
Department of Health and Social Care
Concerns summary A lower hospital admission threshold for patients with learning disabilities is required. Furthermore, doctor's discharge instructions and safety netting advice for non-medical care staff must be clear and actionable.
Action taken summary The Department for Health and Social Care acknowledges the concerns but states that these matters are more appropriately addressed by NHS England directly, who will provide a full and comprehensive …
Alan Mitchell
All Responded
2025-0577 10 Nov 2025 Cheshire
Optum
Concerns summary A patient's lifelong repeat prescription was removed by software without GP notification or patient choice, creating a risk that essential medication may not be provided, especially for vulnerable patients.
Action taken summary Optum disputes the factual accuracy of the concern, clarifying that their EMIS Web system does not automatically remove repeat prescriptions after 12 months without GP notification. They explain the s
Richard Worswick
All Responded
2025-0564 7 Nov 2025 Manchester South
Bamford Grange Care Home Stockport NHS Foundation Trust
Concerns summary Unclear wound care instructions on hospital discharge and a lack of documented communication between the hospital and care home led to confusion. The care home also lacked an escalation policy for such unclear care plans.
Action taken summary Bamford Grange Care Home has issued refresher guidance on existing policies for re-admission and wound care monitoring, ensuring all calls to external teams are documented (including unsuccessful ones
Ernest Gray
All Responded
2025-0579 7 Nov 2025 Kent and Medway
East Kent Hospitals University NHS Foun…
Concerns summary The hospital failed to involve the patient's primary carer in discharge planning and neglected to provide holistic information about his fluctuating delirium, including potential aggression, leaving carers unprepared for his complex needs.
Action taken summary East Kent Hospitals has updated their discharge checklist to ensure identification of main carers, developed a care advice leaflet for patients with carers, and implemented a 'carer's passport' and a
Anthony Card
All Responded
2026-0068 7 Nov 2025 Suffolk
Suffolk Constabulary Suffolk County Council
Concerns summary There is no formal mechanism for police to share medium-risk mental health information with care providers, even with consent. This prevents crucial risk data from informing future assessments and potentially vital support decisions.
Action taken summary Suffolk County Council clarifies that direct mental health provision is primarily an NHS responsibility, and they will not establish a new MASH pathway for medium risk mental health-only cases. Howeve
Judith Hughes
All Responded
2025-0563 6 Nov 2025 Cambridgeshire and Peterborough
Chief Medical Officer for North West An…
Concerns summary The hospital's fall risk assessment tool is confusing due to unclear factor definitions, risking incorrect scores, insufficient observation levels, and increased patient falls.
Action taken summary The Trust's 'Enhanced Care Risk Assessment Form' was revised in 2022 to clarify the distinction between 'previous falls in the last 12 months' and 'inpatient fall during this admission'. Nursing …
Aaron Taylor
Partially Responded
2025-0565 6 Nov 2025 Lancashire and Blackburn with Darwen
Medical Director Practice Plus Group [REDACTED]
Concerns summary HMP Garth has a critical lack of psychologist resources for prisoners, with severe staffing gaps and extensive waiting lists for mental health support.
Action taken summary Practice Plus Group has advertised new psychologist roles at HMP Garth, contacted agencies for interim cover, and has interviews scheduled for the Principal Psychologist post. While awaiting permanent
Aaron Taylor
All Responded
2025-0566 6 Nov 2025 Lancashire and Blackburn with Darwen
[REDACTED] HMP Garth
Concerns summary Prison staff failed to open an ACCT process after a self-harm incident and lacked ACCT training. Keyworker sessions for vulnerable prisoners were not consistently conducted, with staff unaware of required frequency.
Action taken summary HMPPS ensures all new officers receive training on suicide and self-harm prevention, including ACCT processes. HMP Garth has issued staff notices and a Governor's order in October and November 2025 …
Samuel Vass
No Identified Response
2025-0568 6 Nov 2025 Cornwall & the Isles of Scilly
[REDACTED] Service Director for Environment Cornwa…
Concerns summary The lack of speed enforcement on a specific A3083 road stretch has contributed to multiple fatal collisions caused by excessive speeding.
Jennifer Cahill and Agnes Cahill
All Responded
2025-0559 5 Nov 2025 Manchester North
National Institute for Clinical Excelle… NHS England Nursing and Midwifery Council, [REDACTE… +4 more
Concerns summary There is a critical absence of national guidance for home births, particularly for high-risk pregnancies, leading to inconsistent midwife practice, insufficient risk discussions, and inadequate midwife training.
Action taken summary NHS England is developing national home birth guidance for consultation by Q2 2026 and will work with UKMIDSS to improve national data collection. An updated Neonatal Life Support (NLS) course …
Vivian Nolan
All Responded
2025-0560 5 Nov 2025 Teesside and Hartlepool
President of the British Society of Gas…
Concerns summary Clinicians lack sufficient knowledge and guidance on the increased risks associated with diagnostic colonoscopies for patients aged 80 and over.
Action taken summary The British Society of Gastroenterology clarifies that current UK guidance emphasizes individualised patient consent, balancing risks and benefits for colonoscopy, including for those over 80. They di
Matthew Singh Prevention of future deaths report
Partially Responded
2025-0567 5 Nov 2025 North Wales (East and Central)
Ministry of Justice c/o Government Lega… HMP Berwyn London +1 more
Concerns summary High availability and use of illicit psychoactive substances persist at HMP Berwyn, posing significant risks to prisoner health and contributing to future deaths.
Action taken summary HMPPS has implemented physical security enhancements, including anti-drone measures and window improvements, and invested over £40 million this financial year. They have also established Incentivised
Oliver Gorman
All Responded
2025-0558 4 Nov 2025 Manchester South
Department for Culture Department for Business and Trade British Aerosol Manufacturers Associati… +3 more
Concerns summary There are inadequate age restrictions on dangerous aerosol products and unclear warnings about instant death. Social media platforms also fail to take responsibility for harmful content promoting such misuse.
Action taken summary The Office for Product Safety and Standards (OPSS) is working with industry to develop a new voluntary initiative to introduce prominent safety warnings on aerosol products, with anticipated implement
Maureen Christy
All Responded
2025-0561 4 Nov 2025 Blackpool & Fylde
Blackpool Teaching Hospitals NHS Founda…
Concerns summary There were critical shortcomings in disseminating and understanding policy changes, specifically for Covid contact testing, leading to clinician confusion and policies not being consistently applied.
Action taken summary Blackpool Teaching Hospitals plans to roll out a digital solution called ‘Alertive’ from Q4 2025/2026 to improve the dissemination of critical messages and ensure staff acknowledgment of policies, wit
Brian Lloyd
All Responded
2025-0557 3 Nov 2025 North London
High Meadows Care Home
Concerns summary Patients with two failed catheter insertion attempts are not being transferred to hospital promptly, creating a risk of delay in necessary medical intervention.
Action taken summary High Meadows Care Home has updated its catheterisation policy, created and disseminated a new Catheter Emergency and Escalation Protocol, and provided staff training. They also reconfigured their tele
Kathleen Ward
All Responded
2025-0562 3 Nov 2025 East Riding and Hull
Chief Executive – Hull Royal Infirmary
Concerns summary The emergency department faces persistent overcrowding with patients awaiting ward beds, leading to delays in appropriate emergency care and risking repeat incidents due to insufficient bed capacity.
Action taken summary Hull Royal Infirmary is strengthening escalation processes for end-of-life patients and reinforcing compassionate communication. They plan a further rollout of Comfort Observations across the organisa
Gunaratnam Kannan
All Responded
2025-0553 31 Oct 2025 Nottingham and Nottinghamshire
Nottingham Healthcare NHS Foundation Tr… Royal College of General Practitioners East Midlands Ambulance Service
Concerns summary There is a critical lack of joint policy and training among emergency and mental health services regarding Mental Capacity Act and Mental Health Act assessments, causing confusion over referral responsibilities.
Action taken summary EMAS has embedded supporting tools like non-conveyance checklists and MCA prompts into their patient record system. They are actively working with system partners to establish robust referral pathways
Gloria Simon (1)
All Responded
2025-0554 31 Oct 2025 Liverpool and Wirral
Marine Lake Medical Practice
Concerns summary A GP's misreading of oxygen saturation levels and incorrect assumption about the care facility's status led to inadequate assessment. The GP also failed to review patient history or ensure timely observations.
Action taken summary Marine Lake Medical Practice acknowledges the care provided was below expected standards and plans a formal Significant Event Analysis to review the case. They will also review and take action …
Gloria Simon (2)
All Responded
2025-0555 31 Oct 2025 Liverpool and Wirral
Riversdale Care Home
Concerns summary Miscommunication about the care home's status led a GP to not visit. Care home staff lacked training on obtaining urgent clinical input when a GP declined and failed to consistently take, record, and act on basic patient observations.
Action taken summary Riversdale Care Home has updated its 'Request for Care Form' to correctly identify as a 'Care Home'. They have also revised their policy to send letters to out-of-district GPs for …
Evan Dandou-Dambelle
All Responded
2025-0549 29 Oct 2025 Inner North London
East London NHS Foundation Trust
Concerns summary Significant changes in a mental health patient's medication are not automatically factored into decisions about their required level of contact and observation.
Action taken summary The Trust has already communicated the learning to all consultant psychiatrists via email, emphasizing that significant medication changes must be considered when determining patient contact levels. T
Alan Horrocks
All Responded
2025-0545 28 Oct 2025 West Yorkshire Western
Bradford Teaching Hospitals NHS Foundat…
Concerns summary Patient observations were not completed per escalation guidance, delaying deterioration recognition. Increased ward capacity without corresponding nursing staff and existing staffing gaps compromised patient care.
Action taken summary Bradford Teaching Hospitals has convened a multi-disciplinary Case Review Panel which has already considered the identified issues regarding observations and the adequacy of investigation reports. The
Raymond Leake
All Responded
2025-0546 28 Oct 2025 East Riding of Yorkshire and City of Kingston Upon Hull
Hull Royal Infirmary
Concerns summary An urgent radiology scan was missed, likely due to human error, and new preventative processes lack auditing due to staff shortages, leaving their effectiveness unconfirmed.
Action taken summary Hull Royal Infirmary implemented new controls in March 2025 including automatic porter dispatch and direct ward contact for urgent scans. They have now completed an initial audit of CT head …
Lewis Garfield
All Responded
2025-0547 28 Oct 2025 Northamptonshire
South Central Ambulance Service East Midlands Ambulance Service University Hospitals of Northamptonshire +1 more
Concerns summary Ambulance service communications were inadequate, leading to delayed clinician review and escalation. Lengthy hospital handover delays severely impact ambulance availability and emergency department flow.
Action taken summary EMAS's Incident Review Group has discussed the concerns, and they are now implementing dynamic strategic conveyance daily and proactively initiating rapid handover requests during high demand. They ar