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
Owen Donnelly
All Responded
2025-0532 17 Oct 2025 Manchester West
Department of Health and Social Care
Concerns summary Easy online access to information for constructing weapons, currently not illegal to possess, creates a real risk due to the proliferation of unlicensed weapons while legislation is pending.
Action taken summary The Home Office confirms that the Border Security, Asylum and Immigration Bill, expected to achieve Royal Assent by December, will make it a criminal offence to import, make, adapt, supply, …
Melanie Walker
All Responded
2025-0529 17 Oct 2025 Manchester West
NHS England Department of Health and Social Care
Concerns summary Heart monitors have a critical design flaw where disconnected leads do not continuously re-alarm after initial acknowledgement, risking unobserved and fatal cardiac events in other hospitals.
Action taken summary Philips reset the 'ECG Leads Off' alarm at the specific hospital to its factory default medium priority. However, Philips disputes the need for wider changes to their product's default settings, …
Theo Treharne-Jones
All Responded
2025-0521 16 Oct 2025 South Wales Central
TUI UK Association of British Travel Agents
Concerns summary The hotel room lacked secondary security for its easily disengaged door locks, and the pool had no physical barrier, allowing unsupervised access by a vulnerable child.
Action taken summary ABTA disputes the recommendation for additional security chains on hotel room doors, stating they could create fire safety risks and hinder evacuation, though their existing guidance allows for such m
Martin Evans, Patricia Evans and Neil Errington
All Responded
2025-0523 16 Oct 2025 Cumbria
Department for Transport
Concerns summary The DVLA's over-reliance on drivers self-reporting medical unfitness is problematic, as some individuals with impairments may lack insight or be unwilling to inform them, risking future deaths.
Action taken summary The DVLA will review its guidance to clinicians to make it clearer and more consistent for estimating driving risk. This review will include exploring the development of structured tools and …
Tony Duncan
All Responded
2025-0516 15 Oct 2025 City of London
South London and Maudsley NHS Foundatio…
Concerns summary A psychiatric liaison team failed to conduct a proper risk assessment, overlooking suicidal ideation and acute mental health deterioration, leading to inappropriate discharge without medication review or escalation.
Action taken summary The Trust has strengthened its psychiatric liaison service at King's College Hospital ED by extending hours to 24/7, introducing comprehensive training, increasing staff, and launching a new ED Low In
Katie Overd
All Responded
2025-0517 15 Oct 2025 Manchester North
College of Policing RCRP Strategic Partnership Board
Concerns summary A lack of proactive public communication about the "Right Care Right Person" policy risks the public delaying seeking emergency assistance, misunderstanding response times.
Action taken summary The RCRP Strategic Oversight Board will review learning from the case and discuss the issue of call transfer and external communications again with GMP, NWAS, and wider health and local …
Malik Bunton
All Responded
2025-0519 15 Oct 2025 North Yorkshire and York
Ministry of Defence
Concerns summary Inadequate inquiry into a previous incident, flawed clinical review processes, and deliberate obstructions to evidence gathering impeded the RAF's ability to assess suicide risk and learn lessons.
Action taken summary The Ministry of Defence has issued further direction and guidance to avoid delays in providing statements for service inquiries. A new process has been directed for all suspected suicides to …
Mohan Hothi
No Identified Response
2025-0513 14 Oct 2025 East London
Barking, Havering and Redbridge Univers…
Concerns summary The Trust failed to investigate two serious unwitnessed falls, hindering its ability to identify and remediate suboptimal practices, with vague evidence of reflection and remediation.
David Jones
All Responded
2025-0514 14 Oct 2025 Nottingham and Nottinghamshire
Nottingham University Hospitals NHS Tru…
Concerns summary The Emergency Department failed to review an undiagnosed aortic dissection, and a middle-grade doctor did not escalate a changing clinical picture, indicating ineffective training on atypical presentations.
Action taken summary Nottingham University Hospitals NHS Trust has launched an Acute Aortic Dissection Improvement project, which will be undertaken by a newly formed Acute Aortic Dissection Improvement Group. This group
Thompson Elliott
All Responded
2025-0515 14 Oct 2025 Sunderland
Care UK
Concerns summary Absence of clear policy for medication administration when hospital discharge letters are missing caused staff confusion, resulting in an opioid overdose and continued use of harmful medication.
Action taken summary Care UK has conducted extensive staff discussions and reminded all care homes of internal policies on discharge information and handover procedures. The Grangewood care home has updated its contact do
William Roath
All Responded
2025-0518 14 Oct 2025 Worcestershire
University Hospitals Birmingham NHS Fou…
Concerns summary A doctor's failure to advise "Nil by Mouth" and delay a SALT referral led to continued oral feeding, worsening aspiration pneumonia. Specific actions for doctors to prevent recurrence are still outstanding.
Action taken summary University Hospitals Birmingham NHS Foundation Trust has delivered comprehensive training to doctors on recognizing and acting upon swallowing difficulties, emphasizing clear documentation and communi
Paula Doreen
All Responded
2025-0511 14 Oct 2025 Inner South London
Royal College of Physicians Lewisham and Greenwich NHS Trust NHS England +2 more
Concerns summary National risk of concurrent paracetamol prescriptions due to prescribing system deficiencies and inadequate assessment of patient confusion. Inconsistent management of therapeutic excess persists, and new systems risk losing safety nets.
Action taken summary NHS England explains that the Cerner system's duplicate checking functionality was available but likely not enabled and defers to the Royal College of Physicians for national ACVPU assessment training
Jamie Funnell
All Responded
2025-0508 13 Oct 2025 East Sussex
Practice Plus Group
Concerns summary An expired alcohol dependence policy, chaotic emergency care with faulty equipment and incorrect CPR, and insufficient training evidence demonstrate a cavalier attitude to patient safety.
Action taken summary Practice Plus Group has implemented bimonthly dip tests for emergency response bags, delivered comprehensive training, and implemented a new guidance document. They also confirm that the alcohol depen
Abigail Jelley
All Responded
2025-0509 13 Oct 2025 Hampshire, Portsmouth and Southampton
Hampshire and Isle of Wight Healthcare
Concerns summary Community Mental Health Teams lack mandatory perinatal red flag training and professional curiosity, exacerbated by cultural issues and structural leadership problems, risking inappropriate care for vulnerable mothers.
Action taken summary The Trust has established multidisciplinary team (MDT) huddle meetings, weekly MDT reviews, and provided senior clinical leadership to support staff. They are also rolling out a redesigned training pr
Jack Peatling
All Responded
2025-0510 13 Oct 2025 Essex
NHS England Department of Health and Social Care
Concerns summary A chronic lack of available in-patient mental health beds for high-risk patients who cannot be safely managed in the community led to an avoidable suicide.
Action taken summary NHS England has made £75 million available for local systems to improve bed capacity and developed a national mental health and children and young people’s bed management platform. They are …
Mark Townsend
All Responded
2025-0512 13 Oct 2025 South Yorkshire West
Sheffield Wednesday Football Club
Concerns summary Stewards' lack of awareness regarding the nearest radio location caused delays in summoning medical assistance, posing a future risk for timely emergency response.
Action taken summary Sheffield Wednesday Football Club disputes that the brief delay in radio communication indicates an unsafe system, noting the inquest found no causative failings. They state they will continue existin
Sarah Healey
All Responded
2025-0520 11 Oct 2025 West Sussex, Brighton and Hove
Department of Health and Social Care
Concerns summary Inadequate information sharing and a lack of a joined-up approach across health services for mental health patients with physical issues led to fragmented care. Over-reliance on remote appointments may fail vulnerable individuals.
Action taken summary The Department of Health and Social Care notes there are no plans to develop a national policy on mandatory face-to-face appointments. They are working with NHS England on new Personalised …
Joanna Chamberlain
All Responded
2025-0571 11 Oct 2025 West Sussex, Brighton and Hove
NHS England
Concerns summary A gap exists in safe spaces for mental health patients needing more support than home teams provide. National guidance is needed for proactively including family and GP input in care plans.
Action taken summary NHS England is trialling neighbourhood mental health centres in six areas to provide community support for mental health patients not in immediate crisis. They have also shared draft 'Personalised Car
Adrienne Studholme
All Responded
2025-0504 10 Oct 2025 Lancashire and Blackburn with Darwen
East Lancashire NHS Trust
Concerns summary Inaccurate fluid balance charting, unrecorded seizure activity, and a lack of procedures for ED readmission after recent surgery, including insufficient triage training, posed significant risks.
Action taken summary The Trust has clarified that seizure activity is escalated regardless of who witnesses it, communicating this to clinical teams. They have also reminded ED and surgical clinicians to ensure urgent …
Jillian Steedman
All Responded
2025-0506 10 Oct 2025 Essex
Essex Partnership NHS Foundation Trust Essex County Council
Concerns summary Failures in information sharing, incomplete care plans, and inadequate risk assessments led to an inappropriate discharge placement that was not adequately monitored, despite repeated crises and professional warnings.
Action taken summary Essex County Council has undertaken joint work with EPUT resulting in an updated PSIRF Policy. They are reviewing Mental Health Act obligations and their Approved Mental Health Professional service, a
William Puplett
All Responded
2025-0526 10 Oct 2025 North London
International Academies of Emergency Di…
Concerns summary Emergency dispatch protocols lack specific questions for tracheostomy patients regarding suction equipment availability and use, risking delayed high-priority responses for breathing difficulties.
Action taken summary The IAED states the emergency medical dispatcher was compliant with existing protocol and correctly assigned the appropriate dispatch code. It argues the caller was asked about special equipment and t
Matthew Goldsmith
All Responded
2025-0499 9 Oct 2025 East London
Barking, Havering and Redbridge Univers…
Concerns summary Multiple significant abnormal findings in abdominal CT scans were repeatedly missed by radiologists, aggravated by the absence of a required peer review system for quality assurance at the Trust.
Action taken summary The Trust has implemented an action plan by reconfiguring its radiology IT system for mandatory internal peer review, establishing a Radiology Quality and Safety Team, and rolling out a formal …
Pauline Stirling
Partially Responded
2025-0503 9 Oct 2025 Gateshead and South Tyneside
Malhorta Group Prestwick Care
Concerns summary Inadequate documentation of positional changes, insufficient training for agency nurses, and a lack of wound care training despite safeguarding referrals contributed to poor patient safety and persistent record-keeping failures.
Action taken summary Malhotra Group has implemented an electronic care recording system (Nourish) which now includes specific fields for positional tilts and enhanced wound management oversight. They have also updated the
Derek Crowther
All Responded
2025-0500 9 Oct 2025 Manchester South
Pennine Care NHS Foundation Trust
Concerns summary Staff worked without mandatory life support training, and the lack of a digital system for contemporaneous patient observations hindered accurate monitoring and trend analysis, risking future deaths.
Action taken summary The Trust has launched a new Mandatory Training Policy and a monitoring dashboard to ensure staff complete required Intermediate Life Support training. They have also established a project group to …
Leo Barber
All Responded
2025-0505 9 Oct 2025 South London
Google UK & Ireland
Concerns summary Vulnerable children can access online suicide material, and international service providers’ jurisdictional stance can obstruct coronial investigations, hindering efforts to prevent future deaths.
Action taken summary Google details its existing safety measures for suicide and self-harm content on Google Search and notes that the report did not suggest the content was found via their search engine. …