2025

PFD Reports
Reports: 637 Areas: 66

96% response rate (above 63% average).

637 results
Christopher Bird
Partially Responded
2025-0477 23 Sep 2025 Wiltshire and Swindon
NHS England Oxford Health NHS Foundation Trust White Horse Medical Practice
Concerns summary (AI summary) Concerns were raised about the reliability of the nhs.net email system for transmitting critical mental health information to GPs, leading to systemic communication breakdowns between secondary and primary care.
Noted (AI summary) NHS England explains the NHSmail system's security and audit capabilities, noting that an email was recoverable and providing advice to the GP practice on future searches for missing documentation. They also describe the internal process for reviewing PFD reports. Oxford Health NHS Foundation Trust will complete a review to identify changes to current AMHT practice that may prevent the risk of a GP not receiving timely communications from the AMHT, with a wider consultation with GP representatives and the Integrated Care Board.
Tony Jackson
All Responded
2025-0475 23 Sep 2025 East London
Chief Executive Officer, Barts Health N… Secretary of State for Dept. Health & S…
Concerns summary (AI 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 (AI summary) Barts Health NHS Trust has reviewed the case through the Surgical Division’s Morbidity and Mortality (M&M) process, shared learning, implemented mandatory PEG insertion training with competency sign-off, standardized documentation within the electronic patient record, and expanded the Endoscopy Governance Meeting to include the surgical directorate. The Department of Health and Social Care is rolling out Martha’s Rule to all acute inpatient sites and has implemented medical examiners on a statutory basis to scrutinise all deaths not investigated by a coroner.
Luke Chatterton
No Identified Response CC
2025-0470 19 Sep 2025 South London
Croydon University Hospital Medicines and Healthcare Products Regul… Royal College of Emergency Medicine +3 more
Concerns summary (AI summary) Significant delays in accessing advanced life support in a mental health hospital and a lack of national guidelines for managing antipsychotic-induced bowel obstruction in emergency departments were identified.
Kwabena Amoateng
No Identified Response CC
2025-0429 19 Sep 2025 East London
South-East London Integrated Care System Chief Nursing Officer, NHS North-East L… South East London ICB +1 more
Concerns summary (AI summary) A critically important paediatric respiratory action plan was mislabelled and misfiled in online records, preventing emergency healthcare professionals from accessing vital guidance for a rare condition.
Leonardo Machado
All Responded
2025-0476 18 Sep 2025 Dorset
Deliveroo Home Office Just Eats +1 more
Concerns summary (AI 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.
Noted (AI summary) Uber Eats uses industry-leading account-sharing detection technology, including real-time identity verification software requiring couriers to take selfies that are compared with their profile photo and monitors for suspicious behaviors that may indicate attempts to circumvent their security controls. Deliveroo has strengthened checks and processes to ensure rider accounts are only used by authorized individuals, including biometric checks and identity verification, and has a dedicated team investigating potential account sharing with minors; they also terminate agreements with riders who allow unregistered substitutes to use their accounts. Just Eat has introduced enhanced checks to ensure substitutes meet requirements set for all couriers, requiring pre-registration, biometric checks, and document submission to prove age and right to work; random biometric screening checks are also performed. HSE acknowledges concerns about rental of permits, employment of minors and lone working, but notes that road traffic accidents are generally a police matter. They highlight existing guidance and legislation, and ongoing work between government and the food delivery industry to improve security checks.
Pamela Singh
All Responded
2025-0473 18 Sep 2025 South Wales Central
Minister for Health and Social Care in …
Concerns summary (AI 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 Planned (AI summary) The Welsh Government is adapting the Paul Ridd to roll it out to the social care workforce and the wider public sector, developing tier 2 and tier 3 training for health and social care professionals, and incorporating learning disability annual health checks into the GP Wales core contract.
Brian Davies
All Responded
2025-0631 17 Sep 2025 Swansea Neath & Port Talbot
HSE South Wales Police
Concerns summary (AI 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 Planned (AI summary) The HSE will raise the coroner's concerns at an upcoming WRDP National Liaison Committee (NLC) meeting, recommending refresher communications to signatory organizations, providing an update on national training material for work-related elements of investigations, and providing an update on a proposed 'Suspected Gas Explosion checklist'. They will also provide the Senior Coroner with HSE guidance related to gas safety investigations. South Wales Police will raise the coroner's concerns with the National Liaison Committee regarding the Work Related Death Protocol and collaborate with the HSE and other signatories to ensure any appropriate amendments are made to the protocol. They also noted that they will work with the HSE to ensure the service is able to gather evidence and information needed to identify the cause of explosion.
Martin Collins
All Responded
2025-0497 17 Sep 2025 Suffolk
Minister of State for Prisons, Probatio…
Concerns summary (AI summary) The prison telephone system lacks automated monitoring for unusual call volumes and there's no system for manual oversight, leading to missed opportunities to identify risk triggers and prevent suicide.
Action Planned (AI summary) HMPPS has initiated discussions with BT to explore the feasibility of monitoring call volumes as a potential indicator of heightened suicide/self-harm risk as part of an ongoing development project. They emphasize that any technical solution would be an additional tool to their existing holistic approach, including ACCT and the Listener scheme.
Keith Hankin
All Responded
2025-0472 17 Sep 2025 West Sussex, Brighton and Hove
Chief Executive, CQC Integrated Care Board Heath Secretary, Department of Health +2 more
Concerns summary (AI 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.
Disputed (AI summary) Circle Health Group disputes the need for further action regarding consultant responsibilities and practicing privileges, stating that their existing policies and monitoring systems are clear, effective, and compliant with national guidance, and that consultants' responsibilities are clearly identified in their Practicing Privileges policy. The CQC reviewed Goring Hall Hospital's updated investigation and action plan following the inquest, finding that the hospital had implemented most of the planned actions, including sharing the coroner's findings with governance committees, introducing documentation for recording antimicrobials, updating patient materials, clarifying consultant responsibilities, implementing a digital report summarising procedures, and strengthening training with sepsis scenarios and escalation protocols. They will continue to monitor the provider’s compliance. NHS Sussex has served a contract performance notice to Goring Hall Hospital following concerns about governance and response to a serious patient safety incident; Goring Hall Hospital submitted a comprehensive reply, including a revised and updated Post-Inquest Action Plan, and the finalized Serious Incident Investigation Report. NHS England has taken steps to ensure effective governance processes are in place for regulated services, NHS Sussex have visited Goring Hall and are following up on the recommendation that they refer themselves to GMC. The ICB would consider an independent review if the quality of the provider report was an issue or did not elicit appropriate learning. Sussex Medical Chambers outlines actions it will take, including reviewing and updating its Clinical Governance Policy to reflect the coroner's comments, considering further guidance for consultant appointments, and ensuring consultant indemnity insurance coverage. They will also ensure that all doctors undergo annual appraisals, provide evidence of GMC registration, and ensure policy implementation across all clinics.
Hilary Chapman
All Responded
2026-0111 16 Sep 2025 County Durham and Darlington
TEWV
Concerns summary (AI summary) The updated section 17 leave policy does not reflect the new processes for discussing and prescribing leave, creating a gap between practice and documented policy, with no review expected until 2026.
Action Planned (AI summary) • The Section 17 policy has been amended to direct staff to PIPA (Purposeful In - Patient Admission) procedures and standard processes as of April 3rd 2026. • A full review of the Section17 Leave Policy is planned for early June 2026 which will involve all stakeholders, including those with lived experience of receiving services and of caring for those who receive services. • The working group agreed that immediate policy changes were required for clinicians to have clear direction regarding the expected processes for prescribing and arranging Section 17 leave, for consideration of contingencies to be incorporated into Section 17 leave planning, wherever possible and practicable, to increase family involvement in leave planning, and uniformity throughout the Trust for risk assessing when planning Section 17 leave and the recording of this within the patient electronic care record.
John Franklin
No Identified Response CC
2025-0474 16 Sep 2025 Worcestershire
Worcestershire County Council
Concerns summary (AI summary) A high-risk falls patient was discharged home before a careline pendant was confirmed as installed, with conflicting records on its provision, raising concerns about safety post-discharge.
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 (AI 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 (AI summary) Leeds and York Partnership NHS Foundation Trust and Leeds Survivor-Led Crisis Service have jointly developed a standardised daily handover template and implemented daily 'huddle' meetings for patients admitted to the respite facility. Additional measures include joint referral points, book-in meetings, joint reviews, weekly interface meetings, recommencement of operations meetings, and Clinical Improvement Forum meetings.
Mohammed Khan
All Responded
2025-0469 16 Sep 2025 Birmingham and Solihull
NHS Birmingham and Solihull ICB NHS Black Country ICB NHS Coventry and Warwickshire ICB +5 more
Concerns summary (AI 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.
Noted (AI summary) NHS Birmingham and Solihull acknowledges the concerns raised and will work with Black Country ICB to coordinate a single response. The ICB takes the recommendations seriously and is committed to support Black Country ICB and WMAS in delivering necessary improvements. West Midlands Ambulance Service has implemented several actions, including face-to-face mandatory refresher training for breech birth in 2026-2027, resumption of the e-PROMPT course, a Trust focus on learning and improvement of obstetric emergencies, and removal of out-of-date WMAS Maternity Action Cards from all Trust Vehicles. They have also issued a clinical notice to all staff to remove and destroy the out-of-date cards. AACE acknowledges the concerns and explains its role in providing advisory guidelines (JRCALC) for ambulance services. While AACE is not responsible for training, it has shared the report with relevant networks for consideration, noting variations in paramedic training for maternity care and breech birth.
Linda Sharp
All Responded
2025-0468 15 Sep 2025 East Riding and Hull
President of the Royal College of Gener…
Concerns summary (AI 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 Planned (AI summary) The RCGP has commissioned internal work through their elearning team to highlight the specific issue of interpretation of the Wells score. This will be published and available to members in the first quarter of 2026 and promoted through their members network and Chair’s blog. An Electronic Safety Notice has been issued to prevent steering system misalignment checks being missed on MOD Land Rovers. Work is also underway to update the inspection criteria for MOD Land Rovers to provide a comprehensive and long-term solution.
Charlotte Tetley
All Responded
2025-0466 14 Sep 2025 Cheshire
Cheshire and Wirral Partnership NHS Tru…
Concerns summary (AI 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 (AI summary) The Trust has implemented several system changes, including documenting Clinical Prioritisation Meeting outcomes in SystmOne, establishing a Patient Flow Meeting, inviting clinicians to the Clinical Prioritisation Meeting, developing an SOP for Escalation of Clinical Differences, undertaking reflective supervision with the Mental Health Practitioner involved, and reinforcing training around record keeping, communication, and risk-informed decision-making.
Charlotte Tetley
All Responded
2025-0465 14 Sep 2025 Cheshire
Chief Constable of Cheshire Police
Concerns summary (AI 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.
Noted (AI summary) Cheshire Constabulary provides background information on the Right Care, Right Person policy and explains their actions in this specific case, noting that hospital staff made further enquiries and determined they no longer required police assistance.
Gareth Johnson
All Responded
2025-0464 12 Sep 2025 South Wales Central
Cabinet Secretary for Health and Social… Chief Executive Cardiff & Vale Universi…
Concerns summary (AI 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 Planned (AI summary) The Health Board has developed an Electrical Failure Emergency Action Card outlining actions to respond to power failures, developed an updated Critical Care Escalation Plan, and integrated key elements into the Major Incident Plan. They are also undertaking regular review and simulation of escalation and major incident plans and ongoing staff training. Welsh Government officials met with Cardiff and Vale UHB to discuss infrastructure issues at the ITU, critical care and theatres departments and a business case is being developed to refurbish the ITU. The Welsh Government will also write to Cardiff and Vale UHB to confirm what clinical governance is in place to approve changes in the location of critical care and to ensure the appropriate clinical cover is in place and write to selected health boards to request them to respond to the NHS Performance and Improvement critical care network census.
Michael Moore
All Responded
2025-0463 11 Sep 2025 Norfolk
NHS England
Concerns summary (AI summary) Persistent NHS capacity constraints are causing significant and increasing delays in cancer referrals, diagnosis, and treatment, risking patient outcomes.
Action Planned (AI summary) NHS England describes actions agreed with the Urology department at Norfolk and Norwich University Hospital, including a capacity and demand review, review and validation of the Category P2 list, and additional funding for a locum post via the Cancer Alliance.
Air India Boeing 787
No Identified Response
2025-0575 10 Sep 2025 Inner West London
Department of Health and Social Care Departmet for Housing, Communities and …
Concerns summary (AI summary) Mortuaries demonstrate an under-appreciation of formalin dangers, lacking routine monitoring and appropriate equipment for handling highly contaminated repatriated bodies, exposing staff to severe health risks.
Walter Horton
All Responded
2025-0462 10 Sep 2025 South Yorkshire (East)
Mr Nick Mallaband, Acting Chief Medical…
Concerns summary (AI summary) Concerns include poor record keeping for falls, wound management, and handover, alongside a failure to follow aseptic techniques for wound care, increasing infection risk.
Noted (AI summary) The Trust acknowledges the concerns raised in the PFD report regarding the death of Mr. Horton, but states that a falls risk assessment was completed and wound care was delivered in accordance with Trust policy. The Trust maintains a skin integrity improvement plan and a discharge action group is in place.
Keith Reynolds
All Responded
2025-0461 10 Sep 2025 Newcastle and North Tyneside
NEWCASTLE UPON TYNE HOSPITALS NHS FOUND…
Concerns summary (AI 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 Planned (AI summary) The Trust has agreed a plan for achieving a 24/7 MT service, including a joint INR rota with colleagues at James Cook University Hospital, but the limiting factor to expansion is the approval of funding to support recruitment. If funding were approved, they envisage being able to implement an 8am to 8pm service within 6 weeks, with progression to a 24/7 service in the following 6 months.
Stuart Gilchrist
Partially Responded
2025-0460 10 Sep 2025 East Riding of Yorkshire and Hull
East Riding Council Health and Safety Executive Food Standards Agency
Concerns summary (AI summary) Restaurants and food establishments are largely unaware of useful anti-choking devices, and there is no clear responsibility for advising them to stock such potentially life-saving equipment.
Noted (AI summary) East Riding Council confirms it does not have powers to specify equipment in first aid kits or publish guidance, instead signposting businesses to HSE guidance, and recommends the Regulation 28 be served to the HSE. HSE outlines health and safety legislation regarding workplace first aid provision and clarifies that there is no requirement for employers to provide specific equipment such as anti-choking devices, advising that the MHRA is responsible for regulation of medical equipment.
Brian Burrows
All Responded
2025-0459 9 Sep 2025 West Yorkshire (East)
Governing Governor, HMP Leeds
Concerns summary (AI summary) Prison officers lack training and guidance on decision-making when faced with competing emergency tasks like multiple cell bells and ACCT checks, risking inadequate responses.
Action Planned (AI summary) HMPPS is implementing the 'Enable' program, a workforce transformation initiative with Foundation Training Reform to improve officer training and support, including dynamic risk assessment. HMP Leeds will implement High Reliability Checklist Briefings across all wings and introduce a new Supervising Officer (Wellbeing, Care and Coaching) role to provide enhanced support.
Mabel Williams
All Responded
2025-0458 8 Sep 2025 Avon
Chief Executive, Great Western Hospital…
Concerns summary (AI summary) The Trust's patient information on birth after caesarean failed to explain uterine rupture risks, hindering informed consent, and changes following serious incidents are unacceptably slow and reactive.
Action Taken (AI summary) The Trust has revised the "Birth After Previous Caesarean" patient information leaflet with a clear explanation of uterine rupture and its potential consequences. They have also implemented a mandatory training program for maternity staff, focusing on VBAC risks and communication, and strengthened internal systems for tracking and monitoring progress on serious incident investigations.
Mabel Williams
All Responded
2025-0457 8 Sep 2025 Avon
President, Royal College Obstetricians …
Concerns summary (AI summary) The RCOG information leaflet on birth options after a previous caesarean section fails to mention that uterine rupture can be fatal for mother or baby, risking uninformed patient choices.
Action Planned (AI summary) The RCOG patient information leaflet, "Birth options after previous caesarean section," has been reviewed and updated to include information about the potential fatal consequences of uterine rupture for both mother and baby and is due for publication in the very near future.