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)
Clear 532 results
Pamela Honeybone
All Responded
2025-0485 25 Sep 2025 North Yorkshire and York
York and Scarborough Teaching Hospitals…
Concerns summary Persistent failures in patient identification processes, including staff not checking identity and delayed recognition of errors, continue to pose a significant risk to patient safety across hospital sites.
Action taken summary The Trust has reviewed and strengthened its patient identification policy using findings from the case, leading to significant improvement in audit results. The Patient Safety Incident Response Framew
Mark Smith
All Responded
2025-0478 24 Sep 2025 Essex
Addison House Surgery
Concerns summary The GP practice lacked a system or policy to ensure appropriate medication reviews for vulnerable patients with addiction or self-harm history, risking stockpiling and misuse of prescribed drugs.
Action taken summary Addison House Health Centre has completed a comprehensive review of its vulnerable patient database and updated its Polypharmacy and High-Risk Prescribing Policy, including new rules for pharmacists t
Honoria Culshaw (1)
All Responded
2025-0479 24 Sep 2025 Manchester South
Manchester University NHS Foundation Tr…
Concerns summary Critical information regarding the need for pacemaker extraction was not adequately communicated between specialist and local hospitals, nor to the patient's GP, delaying essential treatment for infection.
Action taken summary Manchester University NHS Foundation Trust is currently implementing new processes within its electronic patient record (HIVE) to allow discharge letters to be sent to additional healthcare providers.
Honoria Culshaw (2)
All Responded
2025-0480 24 Sep 2025 Manchester South
Lancashire Teaching Hospitals NHS Found…
Concerns summary A lack of information sharing regarding positive bacterial swab results from a pacemaker wound potentially delayed necessary extraction, contributing to prolonged infection.
Action taken summary The Trust has implemented a new 'Wound Swab Policy and Guidance for Device Related Infections' and delivered training to cardiology staff on expected management. A Standard Operating Procedure for pre
Tony Jackson
All Responded
2025-0475 23 Sep 2025 East London
Barts Health NHS Foundation Secretary of State for Dept. Health & S… Chief Executive Officer
Concerns summary A fatal iatrogenic injury went undetected due to extremely poor patient records, and the Trust's governance failed to identify the case for investigation, hindering learning and remediation of sub-optimal practice.
Action taken summary Barts Health NHS Trust has reviewed the case through its Surgical M&M process and shared learning. It completed audits of Best Interests Decisions and clinical record availability, disseminating revis
Pamela Singh
All Responded
2025-0473 18 Sep 2025 South Wales Central
Minister for Health and Social Care in …
Concerns summary There is a lack of specific practice tools for family and care staff to recognise and escalate acute health deterioration in people with learning disabilities, despite national recommendations for such tools.
Action taken summary The Welsh Government has incorporated annual health checks for people with learning disabilities into the GP Wales core contract from April 2025, providing additional funding to health boards. They ar
Leonardo Machado
All Responded
2025-0476 18 Sep 2025 Dorset
Just Eats Deliveroo Uber Eats +1 more
Concerns summary A lack of oversight regarding the 'rental' of food delivery licenses to children under 18 places them in vulnerable lone-working situations, increasing their risk of road traffic collisions and harm.
Action taken summary Uber Eats confirms Mr. Machado was not delivering for them at the time of the incident. The company states it already employs age verification checks, real-time identity verification software (selfie
Keith Hankin
All Responded
2025-0472 17 Sep 2025 West Sussex, Brighton and Hove
Chief Executive Care Quality Commission Department of Health and Social Care +2 more
Concerns summary A community urology service lacked robust clinical governance, integration with NHS services, and proper appraisal of clinicians, leading to fragmented care and potential detriment to patient safety.
Action taken summary Circle Health Group disputes the concerns regarding practising privileges and consultant responsibilities, stating their existing policies are robust, clear, and comply with national guidance, explici
Brian Davies
All Responded
2025-0631 17 Sep 2025 Swansea Neath & Port Talbot
HSE South Wales Police
Concerns summary The investigation into a domestic explosion was compromised by police disposing of critical debris. There was no understanding of evidence preservation or protocol between police and HSE for such events.
Action taken summary The HSE will raise the coroner's concerns at the WRDP National Liaison Committee, recommend refresher communications to all signatory organisations, provide updates on national training material devel
Mohammed Khan
All Responded
2025-0469 16 Sep 2025 Birmingham and Solihull
Association of Ambulance Chief Executive Telford and Wrekin ICB NHS Staffordshire and Stoke-on-Trent ICB +6 more
Concerns summary Paramedics lacked mandatory training and experience in obstetric emergencies, specifically breech deliveries, and national guidelines were not adhered to, leading to delayed intervention during a critical birth.
Action taken summary NHS Birmingham and Solihull ICB acknowledges serious concerns and will work closely with Black Country ICB to coordinate a single, collective response to the Regulation 28 notice. They are committed …
Christian Marsh Prevention of future deaths report
All Responded
2025-0471 16 Sep 2025 West Yorkshire (East)
Leeds and Yorkshire Partnership Foundat… Leeds Survivor-Led Crisis Service (Leed…
Concerns summary There is no formal system for communication, information sharing, and handover of patient data between a respite facility and the Intensive Support Service, creating significant risk.
Action taken summary Leeds and Yorkshire Partnership NHS Foundation Trust and Leeds Survivor-Led Crisis Service have implemented a standardised daily handover template and daily 'huddle' meetings to improve formal communi
Linda Sharp
All Responded
2025-0468 15 Sep 2025 East Riding and Hull
President of the Royal College of Gener…
Concerns summary Relying solely on a low Wells score is a fundamentally flawed approach to exclude deep vein thrombosis or pulmonary embolus, potentially leading to missed diagnoses.
Action taken summary The Royal College of General Practitioners acknowledges the misinterpretation of the Wells score in this case and has commissioned an e-learning module to highlight its correct interpretation. This mo
Charlotte Tetley
All Responded
2025-0465 14 Sep 2025 Cheshire
Chief Constable of Cheshire Police
Concerns summary A narrow police policy interpretation requires explicit intent to end life for high-risk missing person response, while ambulance services decline calls if whereabouts are unknown, increasing risk of death.
Action taken summary Cheshire Constabulary explains their 'Right Care, Right Person' policy and states that the hospital's subsequent enquiries led to them determining no further concerns, thereby withdrawing their reques
Charlotte Tetley
All Responded
2025-0466 14 Sep 2025 Cheshire
Cheshire and Wirral Partnership NHS Tru…
Concerns summary A patient was prematurely removed from the inpatient bed list before an appropriate daily mental health review, despite documented need for admission, risking patient safety.
Action taken summary Cheshire and Wirral Partnership NHS Foundation Trust has implemented system changes including direct documentation of Clinical Prioritisation Meeting outcomes, establishing a Patient Flow Meeting, dev
Gareth Johnson
All Responded
2025-0464 12 Sep 2025 South Wales Central
Chief Executive Cardiff & Vale Universi… Cabinet Secretary for Health and Social…
Concerns summary Deteriorating hospital infrastructure and critical care capacity issues pose a significant risk, as safeguards against moving critically ill patients may fail under pressure.
Action taken summary The Health Board has developed an Electrical Failure Emergency Action Card (E1) outlining immediate actions, escalation principles, staff roles, and communication protocols for power failures, with an
Michael Moore
All Responded
2025-0463 11 Sep 2025 Norfolk
NHS England
Concerns summary Persistent NHS capacity constraints are causing significant and increasing delays in cancer referrals, diagnosis, and treatment, risking patient outcomes.
Action taken summary NHS England disputes the coroner's claim of a further decline in cancer waiting times, highlighting improved performance and met targets. Regionally, a 'capacity and demand' review and validation of t
Keith Reynolds
All Responded
2025-0461 10 Sep 2025 Newcastle and North Tyneside
NEWCASTLE UPON TYNE HOSPITALS NHS FOUND…
Concerns summary Mechanical thrombectomy services are unavailable outside 9 am-5 pm due to insufficient neuroradiologists, posing a risk of preventable deaths for patients requiring urgent treatment.
Action taken summary The Trust has established a Mechanical Thrombectomy (MT) Steering Group, agreed a plan for a 24/7 service, and implemented a joint INR rota with James Cook University Hospital to secure …
Maureen Gilbert
All Responded
2025-0456 8 Sep 2025 Derby and Derbyshire
Parliamentary Under-Secretary of State … [REDACTED]
Concerns summary Identified flood defence measures for Tapton Terrace were not implemented due to cost, leaving the area vulnerable to flooding and posing a continued risk to life, especially for residents.
Action taken summary Derbyshire County Council is exploring the feasibility of removing an access bridge over the River Rother and constructing a Flood Alleviation Scheme on Spital Brook, having submitted two grant fundin
James Cochrane
All Responded
2025-0454 5 Sep 2025 Rutland and North Leicestershire
Leicestershire Partnership NHS Trust
Concerns summary There is no clear guidance for mental health staff on using alternative evidence formats like video footage or on ensuring carers are adequately equipped to support patients at home.
Action taken summary The Trust has updated its carer feedback form, developed a new safety and preventative care plan to incorporate carers' views, and implemented welcome and carer information packs. They also plan …
Cheryl Edwards
All Responded
2025-0449 4 Sep 2025 Hertfordshire
Chief Executive Hertfordshire County Co…
Concerns summary The 60mph speed limit on the stretch of Sarratt Road between the M25 over-bridge and Sarratt Village is too high, posing a road safety risk.
Action taken summary The Road Policing Unit, through its Traffic Management Officers, disputes the need to reduce the 60mph speed limit on Sarratt Road. They state the limit is consistent with speed management …
Khalif Mohammed
All Responded
2025-0452 4 Sep 2025 Birmingham and Solihull
Home Office
Concerns summary West Midlands Police experienced significant delays in allocating officers to a priority case due to insufficient resources, posing a risk of future deaths.
Action taken summary The Home Office has significantly increased police funding, with West Midlands Police receiving an additional £56.5 million for 2025-26. National initiatives include £120 million in-year funding and £
Nicola Mulliss
All Responded
2025-0453 4 Sep 2025 Newcastle and North Tyneside
Newcastle upon Tyne Hospitals NHS Found…
Concerns summary A lack of policy for microbiological swabbing during wound re-suturing meant a Staphylococcus Aureus infection was not detected early, delaying crucial treatment.
Action taken summary The Trust clarifies that routine swabbing of all leaking wounds is not clinically appropriate but commits to strengthening pathways. This will ensure appropriate cultures, including wound swabs, are u
Peter Thomas
All Responded
2025-0450 3 Sep 2025 South Wales Central
National Institution for Health and Car…
Concerns summary The CIWA protocol is too blunt and lacks nuance for elderly or delirious patients, leading to risks of over-sedation due to clinicians applying it without adequate guidance.
Action taken summary NICE's prioritisation board will reconsider updating the guidance on alcohol withdrawal and pharmacological treatment in February-March 2026, following an earlier conclusion that an update should be c
Lucy-Anne Dyson
All Responded
2025-0451 3 Sep 2025 Hampshire, Portsmouth and Southampton
Department for Education
Concerns summary A lack of national interface for safeguarding system communication between schools and agencies, coupled with inconsistent referral guidance, risks missed or inadequate child protection actions.
Action taken summary The Department for Education is committed to developing a new children’s social care data platform to enable more effective information sharing and working with other departments to digitise domestic
Edward Funnell
All Responded
2025-0445 2 Sep 2025 South Wales Wales
Powys Teaching Hospital Board
Concerns summary Nursing staff demonstrated a lack of knowledge regarding podiatry referrals for pressure wounds and failed to follow a Tissue Viability Nurse's dressing recommendations, leading to unaddressed issues.
Action taken summary The Health Board has reviewed and updated pressure ulcer documentation, introduced a new Tissue Viability Nurse referral proforma, and monitors pressure ulcers via the Datix system. They also plan fur