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
Stella LeClaire
No Identified Response
2025-0619 9 Oct 2025 Northamptonshire
Secretary of State for the Home Departm… Secretary of State for Health and Socia…
Concerns summary The rising number of deaths from a substance sold for suicide raises concerns, emphasizing the need for routine toxicological analysis to improve evidence for potential prosecutions against suppliers.
Richard Hunt
Partially Responded
2025-0498 8 Oct 2025 Rutland and North Leicestershire
Crown Premises Fire & Safety Inspectora… His Majesty’s Prison & Probation Service Governor HMP Stocken
Concerns summary Deliberate tampering with prison fire alarm systems, disabling their buzzers, led to undetected fires, a systemic issue worsened by the absence of central oversight for wing office fault reporting.
Action taken summary The Crown Premises Fire Safety Inspectorate (CPFSI) has already taken enforcement action by issuing a Prohibition Notice and a Directive Notice due to defects in the fire alarm system. CPFSI …
William King
All Responded
2025-0496 8 Oct 2025 Milton Keynes
Milton Keynes University Hospital Royal College of Surgeons Royal College of Anaesthetists +1 more
Concerns summary Failures in documenting consent, insufficient explanation of treatment risks, and a lack of clear professional responsibility meant essential medical policies were not followed, creating a risk of recurrence.
Action taken summary The Royal College of Surgeons of England plans to update its guidance on consent, develop a practical toolkit and a short set of principles on shared decision-making by Spring 2026, …
Brian Ingram
Partially Responded
2025-0501 8 Oct 2025 Cornwall and the Isles of Scilly
Lifestar Medical Limited Cornwall Partnership Foundation Trust South West Ambulance Service Trust
Concerns summary Inadequate staff introductions, family exclusion leading to incomplete patient history, poor inter-organisational information sharing, and incomplete patient assessments by triage staff resulted in missed symptoms.
Action taken summary Lifestar Medical Limited has issued a mandatory memorandum requiring staff to clearly identify their clinical role and facilitate patients and family members remaining together. Cornwall Partnership N
Imogen Nunn Prevention of future deaths report
All Responded
2025-0494 7 Oct 2025 West Sussex, Brighton and Hove
Cabinet Office, 1 Horse Guards Road Caxton House Department for Work and Pensions +8 more
Concerns summary A national shortage and lack of regulation for British Sign Language interpreters, alongside procurement issues and few BSL-proficient clinicians, create significant risks for deaf mental health patients.
Action taken summary The Department for Education acknowledges concerns regarding BSL interpreter shortages and procurement, but maintains the government's preference for industry self-regulation. The Minister will raise
Amanda Wood
Partially Responded
2025-0495 7 Oct 2025 Manchester South
Tameside and Glossop Integrated Care NH… Chief Executive
Concerns summary No sepsis screen was performed before discharge from the Emergency Department, indicating a failure in early identification and treatment of sepsis.
Action taken summary The Trust disputes the necessity of a sepsis screen prior to discharge, explaining that the patient's low NEWS score and triage category did not trigger the sepsis pathway in line …
Ann Laskowsky
All Responded
2025-0502 7 Oct 2025 West Yorkshire Western
National College of Policing National Police Chiefs Council
Concerns summary Inadequate first aid training for police officers in assessing patient conditions and poor awareness of a dedicated medical advice line led to a failure to recognise severe medical needs.
Action taken summary The College of Policing revised its First Aid Learning Programme (FALP) in 2023, expanding content and training time to include advanced casualty assessment and recognition of acute alcohol intoxicati
Angela Thompson
All Responded
2026-0027 7 Oct 2025 City of Kingston Upon Hull and the County of the East Riding of Yorkshire
HM Prison & Probation Service
Concerns summary A lack of liaison between prison and community psychiatric services for released prisoners with ongoing mental health issues, especially when geographically distant, creates risks for continuity of care.
Action taken summary HM Prison and Probation Service highlights the establishment of Regional Health & Justice Teams and regular multidisciplinary meetings to improve integrated health services and support transitions. It
Steven Turzynski
All Responded
2025-0492 6 Oct 2025 Gwent
Aneurin Bevan University Health Board Velindre University Nhs Trust
Concerns summary Inadequate communication between dietetic teams and insufficient monitoring of telephone-based nutritional assessments for cancer patients led to poor nutritional status and potentially earlier death.
Action taken summary Velindre University NHS Trust has undertaken a comprehensive review, implementing improvements to nutritional assessment, strengthening communication, and introducing guidelines for dietetic assessmen
Georgia Barter
Partially Responded
2025-0491 2 Oct 2025 East London
[REDACTED] [REDACTED] Secretary of State for the H…
Concerns summary Frontline police officers face difficulty accessing the Police National Database for domestic abuse history across different force areas, hindering proactive identification and intervention for victims.
Action taken summary The Home Office explains the Police National Database (PND) is a national intelligence system accessed by designated trained staff, with a current programme underway to alleviate legacy challenges and
Beatrice Smith
Partially Responded
2025-0493 2 Oct 2025 Cumbria
Cheshire SK4 1RD Dodge Hill Harbour Healthcare Limited +3 more
Concerns summary No effective internal investigation was conducted after the death, missing learning opportunities. Staff also received no additional training or guidance, risking a repeat of inadequate practices.
Action taken summary Harbour Healthcare Limited completed a Serious Untoward Incident Root Cause Analysis, introduced daily safety huddles, implemented Wound Care Champions, and provided comprehensive staff training on wo
Milos Jankovic
Partially Responded
2025-0490 1 Oct 2025 East London
[REDACTED] Chief Executive of Digital H… Minister for Health and Social Services…
Concerns summary Inadequate follow-up for Barrett’s oesophagus in primary care, including a lack of routine recall and prompts for GPs to consider endoscopy, is leading to missed surveillance and preventable cancers.
Action taken summary The Cabinet Secretary for Health and Social Care disputes that GPs should be involved in recalling patients for Barrett's Oesophagus surveillance, stating this responsibility lies with secondary care
Jake Girton
Partially Responded
2025-0488 29 Sep 2025 East London
[REDACTED] Commissioner of Police of the Metropolis
Concerns summary Police failed to inform the hospital of a patient's release from custody, hindering mental health support efforts. The Metropolitan Police Service also showed no evidence of identifying shortcomings or implementing remediation.
Action taken summary The Metropolitan Police Service disputes the coroner's concern, stating that the hospital was not the victim or complainant of the offence for which Mr Girton was arrested. Therefore, the obligation …
Mohammad Asghar
Partially Responded
2025-0489 29 Sep 2025 East London
[REDACTED] Barts Health NHS Foundation Trust Chief Executive Officer
Concerns summary The Trust's governance failed to investigate a serious incident, despite multiple triggers and court orders, revealing a misunderstanding of patient safety guidelines and an inability to learn from adverse events.
Action taken summary Barts Health NHS Foundation Trust acknowledges failures in its governance and decision-making for patient safety investigations. It is commissioning an independent review of its PSIRF governance proce
Naomi Aylott
All Responded
2025-0522 29 Sep 2025 Hampshire, Portsmouth and Southampton
Hampshire and Isle of Wight Healthcare
Concerns summary The patient received no face-to-face care due to geographical distance, and the CMHT had inadequate risk assessment training, auditing, and family involvement in remote care.
Action taken summary The Trust has remedied a data capture issue for carer information, with the data now captured on their visualisation platform, and is achieving greater alignment in the Carers function post-merger.
Susan Barrett
All Responded
2025-0590 29 Sep 2025 Essex
East Suffolk and North Essex NHS Founda…
Concerns summary Serious concerns exist regarding the absence of embedded Tissue Viability Nurses and a Tissue Viability Service in community hospitals, leading to inadequate care for pressure ulcers and an increased risk of future deaths.
Action taken summary The Trust has confirmed funding for a 0.6wte Band 6 Tissue Viability CNS substantive post, with the establishment control form approved and active recruitment underway to embed a Tissue Viability …
Richard Ellis
Partially Responded
2025-0483 26 Sep 2025 West Sussex, Brighton and Hove
Great Minster House 33 Horseferry Road … Department for Transport
Concerns summary There are no legal requirements for the servicing and maintenance of agricultural tractors, leaving safety dependent solely on owner discretion and posing a risk on public roads.
Action taken summary The Department for Transport acknowledges the lack of specific legal requirements for agricultural tractor maintenance on private land. It has asked officials to investigate how to raise awareness of
Zara Cheesman
Partially Responded
2025-0481 25 Sep 2025 Nottingham and Nottinghamshire
East Midlands Ambulance Service NHS Tru… Chief Executive
Concerns summary Emergency medical services lacked detailed understanding of child assessment issues, relied on incorrect physiological scoring, and had insufficient audit, monitoring, and professional development for staff on paediatric guidelines.
Action taken summary East Midlands Ambulance Service has appointed senior clinicians to lead specific areas including children and young people, adopted the UK Sepsis Trust’s paediatric sepsis assessment tool, and expande
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
Catherine Moore
No Identified Response
2025-0486 25 Sep 2025 Suffolk
Secretary of State for Defence
Concerns summary The MOD's vehicle maintenance system (JAMES) is complex, lacks audit capabilities, and has no formal processes for inspecting, testing, or providing feedback on repairs, risking vehicle safety.
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
Steven Hart
Partially Responded
2025-0487 24 Sep 2025 Bedfordshire and Luton
CEO of HMPPS [REDACTED] Governor [REDACTED] HM Chief Inspector of Prisons [REDACTED]
Concerns summary Systemic failings included an unmonitored ligature point in a 'safer cell,' inadequate communication of mental state risks during handovers, and observations not being carried out to standard, contributing to the death.
Action taken summary HM Prison and Probation Service has implemented interim measures by replacing ligature-resistant cell observation panels at HMP Bedford and completed a full review of all LR doors. Handover procedures
Tony Jackson
All Responded
2025-0475 23 Sep 2025 East London
Secretary of State for Dept. Health & S… Barts Health NHS Foundation 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