2025

PFD Reports
Reports: 635 Areas: 66

94% response rate (above 62% average).

Response Status
Responded 599 No Response 31 Pending 5
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
Christopher Bird
Partially Responded
2025-0477 23 Sep 2025 Wiltshire and Swindon
White Horse Medical Practice NHS England Oxford Health NHS Foundation Trust
Concerns 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.
Action taken summary NHS England clarifies that the email in question was recovered from a recoverable-items folder, indicating user deletion rather than system failure. It explains that NHSmail is a secure platform with
Kwabena Amoateng
No Identified Response
2025-0429 19 Sep 2025 East London
National Medical Director NHS England NHS North-East London Integrated Care B…
Concerns 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.
Luke Chatterton
No Identified Response
2025-0470 19 Sep 2025 South London
Medicines and Healthcare Products Regul… Royal College of Psychiatrists Croydon University Hospital +3 more
Concerns 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.
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
Deliveroo Uber Eats Home Office +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
Martin Collins
Partially Responded
2025-0497 17 Sep 2025 Suffolk
Minister of State for Prisons Probation and Reducing Reoffending
Concerns 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 taken summary HM Prison and Probation Service confirms initial discussions are underway with BT to explore the technical feasibility of implementing automated monitoring of prisoner call volumes, with this work to
Brian Davies
All Responded
2025-0631 17 Sep 2025 Swansea Neath & Port Talbot
South Wales Police HSE
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
Telford and Wrekin ICB NHS Staffordshire and Stoke-on-Trent ICB Association of Ambulance Chief Executive +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 Survivor-Led Crisis Service (Leed… Leeds and Yorkshire Partnership Foundat…
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
John Franklin
No Identified Response
2025-0474 16 Sep 2025 Worcestershire
Worcestershire County Council
Concerns 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.
Hilary Chapman
Response Pending
2026-0111 16 Sep 2025 County Durham and Darlington
TEWV
Concerns 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.
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
Stuart Gilchrist
Partially Responded
2025-0460 10 Sep 2025 East Riding of Yorkshire and Hull
Health and Safety Executive Food Standards Agency East Riding Council
Concerns 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.
Action taken summary East Riding Council states it lacks the power to specify first aid equipment for businesses or publish guidance, as this falls under the Health and Safety Executive's (HSE) remit. They …
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 …
Walter Horton
Partially Responded
2025-0462 10 Sep 2025 South Yorkshire (East)
Acting Chief Medical Director Doncaster & Bassetlaw NHS Foundation Tr… Mr Nick Mallaband
Concerns 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.
Action taken summary The Trust largely disputes the factual basis of the coroner's concerns regarding falls, wound management, and aseptic technique, stating there was no evidence of issues or that policies were followed.
Air India Boeing 787
No Identified Response
2025-0575 10 Sep 2025 Inner West London
Communities and Local Government Department of Health and Social Care Departmet for Housing
Concerns 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.
Brian Burrows
Partially Responded
2025-0459 9 Sep 2025 West Yorkshire (East)
HMP Leeds Governing Governor
Concerns 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 taken summary HM Prison and Probation Service is reforming foundation training for prison officers to focus on experiential learning including dynamic risk assessment, and HMP Leeds will implement High Reliability
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
Mabel Williams
Partially Responded
2025-0457 8 Sep 2025 Avon
London SE1 1SZ Royal College Obstetricians and Gynaeco… President
Concerns 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 taken summary The RCOG has reviewed and updated its patient information leaflet 'Birth options after previous caesarean section' to explicitly include the risk of fatal uterine rupture, and the revised leaflet is …
Mabel Williams
Partially Responded
2025-0458 8 Sep 2025 Avon
Great Western Hospitals NHS Trust Marlborough Road SN3 6BB +2 more
Concerns 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 summary The Trust has revised its 'Birth After Previous Caesarean' patient information leaflet to include a clear explanation of uterine rupture and has strengthened its Maternity Safety leadership team. They