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
Patricia Genders
All Responded
2025-0551 28 Oct 2025 West Sussex, Brighton and Hove
NHS England & NHS Improvement Department of Health and Social Care
Concerns summary Over-reliance on A&E for mental health crises due to inadequate dedicated placements creates an unsuitable and insecure environment, risking patient deterioration and abscondment.
Action taken summary NHS England has initiated a pilot program for 24/7 neighbourhood mental health centres and implemented a 24/7 Mental Health Crisis Pathway. They have also published updated guidance for mental health
Shannon Lee
All Responded
2026-0032 28 Oct 2025 Black Country
Black Country Healthcare NHS Foundation
Concerns summary There is persistent staff confusion regarding the exact timing of 15-minute observations, with no clear national standard, risking inconsistent patient monitoring.
Action taken summary The Trust states its Level 2 intermittent observation policy is unambiguous and clearly specifies 15-minute intervals with no reference to 30 minutes. It describes existing electronic observation (eOb
Danielle Jones
All Responded
2025-0542 27 Oct 2025 The Black Country
Your Health Partnership Regis Medical C…
Concerns summary The GP repeatedly prescribed large amounts of medication, including substances used in overdose, without adequate review, despite the patient self-reporting multiple overdoses and external services raising concerns.
Action taken summary The practice plans to amend its Prescribing Policy by January 2026 to include clear guidance on medication quantities and reducing amounts if there is a self-harm risk. It will also …
Louisa Walker (1)
All Responded
2025-0543 27 Oct 2025 Berkshire
Royal College of Obstetricians and Gyna…
Concerns summary There is a lack of national guidance and relevant training for the increasingly common obstetric emergency of impacted fetal head during caesarean sections.
Action taken summary Maternity Newborn Safety Investigations (MNSI) reviewed its investigation process and confirmed it was correctly followed based on available evidence. The organisation has added a note to its investig
Louisa Walker (2)
All Responded
2025-0544 27 Oct 2025 Berkshire
Royal Berkshire Hospital
Concerns summary A significant majority of obstetricians have not received crucial specific training related to this incident, raising concerns about the trust's commitment to learning and patient safety.
Action taken summary Following the inquest, the Trust has ensured all obstetric doctors (ST1 and above, Consultants) and Band 7 delivery suite and maternity clinical coordinator midwives have been trained in managing Impa
Alexander Lewis
All Responded
2025-0539 24 Oct 2025 Swansea Neath & Port Talbot
Home Office South Wales Police
Concerns summary Pursuing drivers lacked the ability to communicate dynamic risk assessments, were overburdened with tasks leading to missed critical information, and police training suggested a two-officer crew for safety.
Action taken summary The Department of Transport states there are no specific statutory regulations for the minimum distance single yellow lines must be from a junction, clarifying that it is for the local …
Sophie Towle
Partially Responded
2025-0552 24 Oct 2025 Nottingham and Nottinghamshire
Department of Health and Social Care Sherwood Forest Hospitals NHS Foundatio… Nottingham Healthcare NHS Foundation Tr…
Concerns summary There was a critical lack of joint policy and liaison between physical and mental health teams for complex cases involving foreign body insertion, and the specialist Personality Disorder Hub was disbanded, reducing expert care.
Action taken summary Nottinghamshire Healthcare has collaborated with Sherwood Forest Hospital to create a joint management policy for patients with inserted foreign bodies, which is currently being trialled. The Trust ha
Caitlin Imber
All Responded
2025-0538 24 Oct 2025 North Wales (East and Central)
BCUHB
Concerns summary CAMHS closed a referral for a vulnerable child due to missing contact information without making further enquiries, causing a significant and potentially dangerous delay in support.
Action taken summary CAMHS has changed its standard operating procedure to ensure appointments are offered even when contact numbers are missing from referrals, a change made following the investigation. The service is al
Stephen Neville
All Responded
2025-0556 24 Oct 2025 Essex
Essex Partnership NHS Foundation Trust
Concerns summary Nursing staff failed to properly conduct and record therapeutic observations due to misunderstanding and training deficits. The quality assurance and auditing processes for these critical observations were also found to be severely inadequate.
Action taken summary The Trust has updated its Observation Policy and a new training module, rolled out to all clinical staff by December 2025, with a new observation proforma also being implemented. It …
Ann Campbell
All Responded
2025-0535 23 Oct 2025 Cornwall and the Isles of Scilly
Landlord
Concerns summary The steps are unsafe as the handrail is too low and short, preventing individuals from adequately steadying themselves when descending.
Action taken summary The landlord has already installed two signs warning of steep steps, applied a non-slip coating with sand for extra safety, and fully secured the existing handrail. They also plan to …
Mark Foster
All Responded
2025-0537 23 Oct 2025 Cumbria
Castlegate & Derwent Surgery
Concerns summary The practice suffers from a lack of unified leadership, poor governance, and an inadequate system for investigating incidents.
Action taken summary The surgery has appointed a new practice manager and GP partner for governance, implemented a new governance structure, and revised its Significant Event Policy. All staff are now instructed to …
Saranveer Sihota
All Responded
2025-0540 23 Oct 2025 Derby and Derbyshire
Chesterfield Borough Council
Concerns summary The building's low top-floor wall presents a clear and known risk of fatal falls, especially for individuals with suicidal thoughts, with multiple similar incidents reported.
Action taken summary The council immediately closed the top floor of the car park using temporary fencing and completed permanent enhanced suicide prevention measures in March 2024, including full-height, heavy-duty gates
Lynn Silcock
All Responded
2025-0636 23 Oct 2025 Shropshire, Telford & Wrekin
Shrewsbury and Telford NHS Hospital Tru… NHS England
Concerns summary A patient was discharged by gastroenterology without cardiology consultation or follow-up, due to a lack of communication and document exchange between teams, leading them to be "forgotten" and without trust investigation.
Action taken summary NHS England states the specific issues raised fall outside its direct role and remit, primarily resting with Shrewsbury and Telford Hospital NHS Trust (SATH). It notes its existing national Frontline
Rashida Sultana
All Responded
2026-0026 23 Oct 2025 Black Country
Sandwell and Birmingham Hospital NHS Tr…
Concerns summary Nursing staff lacked clarity on when to call the Emergency Medical Response Team for patients with a DNAR. There was also an absence of risk assessments for Speech and Language Therapy referrals for dysphagia.
Action taken summary The organisation has approved and implemented an updated 'Emergency Medical Response Policy including Management of Resuscitation' in March 2025, which outlines systems, processes, and structures for
Amy Cross
Partially Responded
2025-0531 22 Oct 2025 Avon
IPRS Aeromed Mitie Practice Plus Group +1 more
Concerns summary There is no system to ensure vital healthcare information, including medication and observations, is shared between criminal justice healthcare providers, and no standard, accessible medical records system.
Action taken summary NHS England plans to commence a 'proof of concept' trial around February/March 2026 in specific regions, enabling healthcare providers to access the Digital Person Escort Record (DPER) system to impro
Ricky Monahan
All Responded
2025-0533 22 Oct 2025 Birmingham and Solihull
Birmingham and Solihull Integrated Care… NHS England Care Quality Commission
Concerns summary An unprotected fire escape allowed easy roof access from a rehabilitation unit due to inadequate railings, without an environmental risk assessment. There are no guidelines for fire escape protections in such settings.
Action taken summary NHS England states that appropriate national guidance regarding patient safety and risk assessment in mental health settings already exists, implying the issue was with local implementation of environ
Amber Walker
All Responded
2025-0528 21 Oct 2025 Dorset
Department of Health and Social Care
Concerns summary Doctors are reluctant or presume others have discussed SUDEP with epilepsy patients, despite its critical importance. There's a lack of universal use of SUDEP checklists and inadequate medical training on the subject.
Action taken summary The Department of Health and Social Care noted the concerns, referencing existing NICE guidance on epilepsies and the Clive Treacey Checklist for systematic SUDEP risk assessment. It also explained th
Paul Appleby
All Responded
2025-0530 21 Oct 2025 Northamptonshire
Northamptonshire Healthcare Foundation …
Concerns summary The absence of a regular Saturday Court Service by the Liaison and Diversion Team, relying solely on an 'On Call' system, raises concerns about potential future deaths.
Action taken summary The Trust clarified the specific incident by explaining communication failures and stated that to mitigate future risks, they have reissued the Standard Operating Procedure to Saturday court operators
Steven Davidson
All Responded
2025-0536 21 Oct 2025 Essex
HCRG Care Group
Concerns summary Healthcare staff at HMP Chelmsford lack proficiency in navigating System One records to find critical past self-harm information, or are unaware of its importance during prisoner health assessments, indicating training deficiencies.
Action taken summary HCRG has amended its training provision to include mandatory structured SystmOne training for all new staff during induction and refresher training for existing staff. They are also embedding this tra
John Rust
All Responded
2025-0524 20 Oct 2025 Birmingham and Solihull
University Hospitals Birmingham NHS Fou…
Concerns summary Mandatory training for automated CSF drainage systems is not adequately enforced, with many staff untrained. There's no sustainable plan to ensure all current and future clinical staff receive essential training on critical equipment.
Action taken summary The response text is truncated; therefore, no actions taken or planned regarding mandatory training for CSF drainage systems can be identified.
Marc Davies
Partially Responded
2025-0525 20 Oct 2025 Gwent
MJ Events Monmouthshire County Council
Concerns summary Inadequate welfare checks by security guards, stemming from a lack of training on proper procedures and documentation, risked residents not receiving timely medical care.
Action taken summary Monmouthshire County Council and MJ Events have implemented a new three-tier training program for all Safe Guards, covering first aid, safeguarding, drug and alcohol awareness, naloxone administration
Stuart Fowkes
All Responded
2025-0527 20 Oct 2025 The Black Country
Devon & Cornwall Police
Concerns summary Devon and Cornwall Police failed to share vital information regarding the deceased's suicidal intent with West Midlands Police, leading to critical risk information being missed in subsequent actions.
Action taken summary Devon and Cornwall Police have conducted a comprehensive review of their missing persons and vulnerable people policy, resulting in a new standard operating procedure and a dedicated point of contact
Declan Carr
All Responded
2025-0541 20 Oct 2025 East Riding of Yorkshire and City of Kingston Upon Hull
NHS England
Concerns summary Inadequate national policy for sharing information on psycho-social support for substance misuse during prisoner transfers risks continuity of care and future deaths.
Action taken summary NHS England confirmed that a national pathway for transferring non-clinical healthcare information, including psycho-social support, between prisons was implemented on 24 November 2025. They also cond
Scott Berry
All Responded
2026-0038 20 Oct 2025 City of Kingston Upon Hull and the County of the East Riding of Yorkshire
HM Prison & Probation Service
Concerns summary Imprisonment for Public Protection (IPP) prisoners face profound hopelessness and mental health suffering due to indefinite detention and lack of access to parole reviews or rehabilitative programs, increasing suicide risk.
Action taken summary HM Prison and Probation Service has implemented multiple changes to policy and practice for IPP prisoners, including revisions to release on temporary licence and offender management processes. They h
Alexander McCormack
All Responded
2025-0548 19 Oct 2025 Northamptonshire
Northamptonshire Police
Concerns summary Inefficient transfer of missing persons cases between police forces due to inadequate training for transferees on data import procedures, risking delays in risk assessment and investigation.
Action taken summary Northamptonshire Police are in the process of creating new training presentations for all ranks, including updated training for transferring Inspectors on COMPACT file handling. The Detective Superint