2025
PFD Reports
Reports: 637
Areas: 66
96% response rate (above 63% average).
Maureen Gilbert
All Responded
2025-0456
8 Sep 2025
Derby and Derbyshire
Environment Agency
Derbyshire County Council
[REDACTED], Parliamentary Under-Secreta…
Concerns summary (AI 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.
Noted
(AI summary)
Derbyshire County Council is exploring the feasibility of removing an access bridge to reduce flood risk and constructing a Flood Alleviation Scheme on the Spital Brook. They will also continue to work collaboratively with the Environment Agency to encourage residents to sign up for flood warnings and review existing flood plans and evacuation procedures. The Environment Agency expresses condolences and explains that while they have powers to build flood defences, they are not able to eliminate the risk of flooding entirely. They will continue to work with communities and provide a Flood Warning Service and carry out winter maintenance walkovers. Defra acknowledges the concerns and highlights its national responsibility for flood risk management. The Minister will meet with representatives from Derbyshire County Council and the Environment Agency to discuss flood protection in Chesterfield ahead of winter.
Victoria Taylor
No Identified Response CC
2025-0455
5 Sep 2025
North Yorkshire and York
Tees, Esk and Wear Valleys NHS Foundati…
Concerns summary (AI summary)
Secondary mental health services failed to offer appropriate trauma-informed treatment pathways or initiate a multi-agency approach for a patient with acknowledged childhood trauma and complex needs.
James Cochrane
All Responded
2025-0454
5 Sep 2025
Rutland and North Leicestershire
Leicestershire Partnership NHS Trust
Concerns summary (AI 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
(AI summary)
The Trust has implemented several changes, including ensuring carers' views can be documented with consent, incorporating carer perspectives into safety plans, and updating risk assessment documentation to include carer input. They also provide support to carers via signposting and offer a Carers pack, and are launching a course for carers through the Leicestershire Recovery College.
Nicola Mulliss
All Responded
2025-0453
4 Sep 2025
Newcastle and North Tyneside
Newcastle upon Tyne Hospitals NHS Found…
Concerns summary (AI 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 Planned
(AI summary)
The Trust will strengthen pathways to ensure appropriate cultures are undertaken in a timely manner when a patient is suspected of having an infection, including wound swabs, and that, where clinically appropriate, patients are commenced promptly on antibiotics and compliance with these standards is regularly monitored.
Khalif Mohammed
All Responded
2025-0452
4 Sep 2025
Birmingham and Solihull
Home Office
Concerns summary (AI summary)
West Midlands Police experienced significant delays in allocating officers to a priority case due to insufficient resources, posing a risk of future deaths.
Noted
(AI summary)
The Home Office acknowledges the concerns and outlines government funding provided to West Midlands Police. Decisions around resourcing are the responsibility of the Police and Crime Commissioner and Chief Constable.
Cheryl Edwards
All Responded
2025-0449
4 Sep 2025
Hertfordshire
Chief Executive Hertfordshire County Co…
Concerns summary (AI 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.
Noted
(AI summary)
The Road Policing Unit provides context from the perspective of detectives and Traffic Management Officers, stating that the speed limit does not need to be reduced and offering to speak to the Coroner or the family to explain their views further; the decision of the road's safety sits with HCC colleagues. Hertfordshire County Council will maintain the current speed limit, apply targeted vegetation clearance, consider area-wide rural speed management approaches as part of their Speed Management Strategy review, and strengthen messaging to the public on road safety and vegetation responsibilities. They will also propose regular multi-agency collision review meetings.
Lucy-Anne Dyson
Partially Responded
2025-0451
3 Sep 2025
Hampshire, Portsmouth and Southampton
Department for Education
Women and Equalities
Concerns summary (AI 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
(AI summary)
The Department for Education highlights the work being done across government to protect women and girls from violence, including the Tackling Domestic Abuse Plan, the Domestic Abuse Act 2021, and updated statutory safeguarding guidance 'Working Together to Safeguard Children'.
Peter Thomas
All Responded
2025-0450
3 Sep 2025
South Wales Central
National Institution for Health and Car…
Concerns summary (AI 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 Planned
(AI summary)
NICE will reconsider its guideline on alcohol-use disorders, with the prioritisation board looking at the topic again in approximately February-March 2026 to determine if any changes are needed, including pharmacological treatment for acute alcohol withdrawal.
Margaret Bailey
All Responded
2025-0448
3 Sep 2025
Manchester South
Chief Executive, Care Quality Commission
Secretary of State for Health and Socia…
Concerns summary (AI summary)
Care agencies lack a clear triage algorithm for non-medical call handlers and carers cannot perform basic observations, hindering effective client monitoring and response to illness.
Noted
(AI summary)
The Care Quality Commission explains its role and inspection methodology and states that it is outside CQC's scope to amend regulations to allow HCAs to take on medical or nursing observations, noting that the report has also been sent to The Secretary of State for Health and Social Care. The Department of Health and Social Care will ask NICE to consider developing a national standard on the prevention and management of choking hazards in domiciliary and residential care settings, after concerns were raised about a lack of basic observation ability of carers.
Marcia Grant
All Responded
2025-0447
3 Sep 2025
South Yorkshire (West)
Chief Executive, Rotherham Metropolitan…
Secretary of State for Education, Depar…
Concerns summary (AI summary)
A shortage of foster placements, combined with inadequate documentation, poor communication of risks, and a failure to assess risks to carers, led to an unsuitable child placement.
Action Planned
(AI summary)
The Department for Education will set out plans to significantly increase foster care numbers, backed by additional funding and investment in regional recruitment support hubs and a foster care retention model called Mockingbird. Rotherham Metropolitan Borough Council will continue to pursue their Looked After Children and Care Leavers Sufficiency Strategy, make improvements to documentation, recording and approval processes, and enhance risk assessment processes.
Edward Funnell
All Responded
2025-0445
2 Sep 2025
South Wales Wales
Powys Teaching Hospital Board
Concerns summary (AI 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
(AI summary)
Powys Teaching Health Board has provided podiatry awareness training to ward teams, shared Regulation 28 learning, and will ensure all staff attend training provided by Tissue Viability Specialist Nurses. The Lead podiatrist will attend all wards to ensure the teams are aware of the scope and breadth of the role of the podiatrist.
Ayan Sediqi
All Responded
2026-0014
1 Sep 2025
Greater Lincolnshire
Lincolnshire County Council
Lincolnshire Police
National Highways Midlands region
Concerns summary (AI summary)
Dangerous road conditions, including ungritted ice and flowing water, were not addressed despite public reports. The existing reporting systems for road faults were unclear and disparate, leading to a failure to act on these critical safety concerns.
Action Planned
(AI summary)
Lincolnshire County Council plans to improve public awareness of road hazard reporting by increasing visibility at public events, using social media, and developing the FixMyStreet platform. They will measure performance via user numbers and feedback, aiming for annual improvement. Lincolnshire Police will support National Highways in promoting their 24/7 Customer Contact Centre for road-related issues. They will incorporate the contact number into public materials, engagement sessions, and digital communications. National Highways will include contact details in all communications, incorporate their website into fleet vehicle livery, establish a Social Media Response Team, explore wayfinding services, and better inform on-road staff. They will also investigate hard plate signage to guide road users.
Sarah Heaver
All Responded
2026-0010
1 Sep 2025
Kent and Medway
East Kent Hospitals University NHS Foun…
Kent and Medway NHS and Social Care Par…
Concerns summary (AI summary)
Critical neurological investigations and structured observations were omitted for a low GCS patient, compounded by inconsistent medical records. Additionally, patients are discharged to inadequate psychiatric care.
Action Taken
(AI summary)
• The Trust had already identified a lack of consistent prescribing cover over weekends in February 2025.
• The lack of cover occurred because 2 of the 3 Independent prescribers were on annual leave at the same time due to additional university training.
• The Trust stated it will ensure this situation does not arise again. • The Trust referenced NICE CG176 (Head Injury guidelines), Royal College of Emergency Medicine guidelines on self-harm, and 2022 NICE guidance (NG225) guidance on self-harm.
• The Trust stated that the evidence and handover from paramedics was clear on Mrs. Heaver's history and that she had no signs of trauma that would have necessitated a CT scan.
• The Trust indicated that Mrs. Heaver's GCS improved significantly after being administered Naloxone.
[REDACTED]
All Responded
2025-0507
1 Sep 2025
Inner North London
East London NHS Foundation Trust
Concerns summary (AI summary)
There were widespread failures in the quality, accuracy, and auditing of patient observations, including staff distraction during crucial monitoring. Concerns also persist regarding the door-locking system's reliability and staff guidance for its failure.
Action Taken
(AI summary)
East London NHS Foundation Trust has already made progress improving patient observations, observation practices, record keeping, risk assessments, understanding of risk, and clinical oversight, with interventions like new observation policy, therapeutic engagement improvements, enhanced auditing, and strengthened handover procedures.
Audrey Newman
All Responded
2025-0443
29 Aug 2025
Manchester South
CEO, Stockport NHS Foundation Trust
Concerns summary (AI summary)
A lack of trained ward doctors for lumbar punctures and the absence of a formal escalation pathway for assistance created significant delays in crucial diagnostic testing.
Action Planned
(AI summary)
Stockport NHS Foundation Trust is rolling out training on using the IT booking system for theatres to medical staff, formulating a flowchart for escalating lumbar puncture procedures to anaesthetics, and ensuring patients awaiting lumbar punctures are not transferred off the acute medical unit or transferred off the unit on weekends to avoid delays.
Kore Padgett
All Responded
2025-0441
28 Aug 2025
West Yorkshire West
Calderdale and Huddersfield NHS Foundat…
Concerns summary (AI summary)
There was a lack of staff training for hard collar fitting and poor communication between clinicians, leading to insufficient consideration of treatment options and risks, preventing informed patient decisions.
Action Planned
(AI summary)
Calderdale and Huddersfield NHS Foundation Trust will implement a Trust-wide training program for applying and managing hard collars, led by senior clinicians, with sessions scheduled for December 2025 and January 2026. They are also developing a Standard Operating Procedure (SOP) for collar initiation and management to be implemented by the end of January 2026, and care plans are being revised to ensure that discussions around risk and benefit are documented clearly within the Electronic Patient Record (EPR).
Edwin Price
All Responded
2025-0440
28 Aug 2025
Somerset
Somerset NHS Foundation Trust
Concerns summary (AI summary)
A falls risk assessment was not completed within the required timeframe, failing to identify specific risks and implement mitigation measures, and no subsequent actions were taken to address these systemic gaps.
Action Taken
(AI summary)
Somerset NHS Foundation Trust has mandated falls risk assessments within 12 hours of admission and weekly reviews, with clear display of risk status. They are also carrying out patient and relative engagement walk rounds and have launched a test of change with Quality and Safety Lead Nurse roles.
Gabriella Jaiyesimi
All Responded
2025-0444
26 Aug 2025
Inner North London
Chief Executive Security Industry Autho…
Chief Executive Tesco PLC
Chief Executive Total Security Services…
Concerns summary (AI summary)
Tesco staff, including duty managers, lacked basic first aid and CPR training, resulting in a failure to recognize cardiac arrest, perform life-saving actions, or effectively communicate crucial information to emergency services.
Noted
(AI summary)
Total Security Services clarifies that its security officer was not employed as a first-aider and it's not contractually required by Tesco for security officers to provide first aid. The company expects its employees to follow their SIA licence training and will conduct monthly audits to ensure that all its employees continue to hold valid licences that have neither been revoked nor expired. Tesco will deliver "Appointed Person" training to approximately 30,000 UK store management colleagues starting December 1, 2025, with completion by February 28, 2026. This training will provide managers with the skills to relay information to Ambulance Control, follow their instructions, and administer basic first aid when directed. The Security Industry Authority (SIA) investigated the training and conduct of the security operative and Total Security Services Limited, and will consider regulatory action if necessary. They have also offered expert witness assistance to coroners in relevant inquests.
Anne Dyson
All Responded
2025-0439
26 Aug 2025
Sunderland
South Tyneside and Sunderland NHS Found…
Concerns summary (AI summary)
Radiologists receive inconsistent and limited patient information, often focused to specific areas, risking confirmation bias and delayed diagnoses by restricting comprehensive scan interpretation.
Action Taken
(AI summary)
South Tyneside and Sunderland NHS Foundation Trust has shared learning with radiologists about the importance of thorough searches, awareness of confirmation bias, and comparing prior relevant imaging. They are updating induction training and developing a Standard Operating Procedure with 4Ways for radiology reporting.
Lee Stammers
All Responded
2025-0438
22 Aug 2025
South Yorkshire East
Doncaster Royal Infirmary
Concerns summary (AI summary)
Poor documentation, communication, and system failures led to urgent medical tests being missed or inaccurately recorded. Unidentified temporary staff could also cancel tests without accountability, risking patient harm.
Action Taken
(AI summary)
The Trust has completed part of recommendation 1 regarding monitoring observations and escalation of care in the ED (June 2025) and is targeting completion of the second part by October 2025. They have also completed recommendation 3 regarding user access restrictions for student nurses in Symphony, and mandatory entry of name/GMC number for locum doctors.
Nicholas Murphy
All Responded
2025-0437
21 Aug 2025
Hampshire, Portsmouth and Southampton
NHS England
Concerns summary (AI summary)
Critical information regarding a patient's refusal of treatment may be missed due to inadequate outcome codes, leading to misleading impressions and hindering proper safeguarding and decision-making.
Action Taken
(AI summary)
South Central Ambulance Service has implemented a new outcome code in their CAD system to indicate when a patient has refused treatment or conveyance to hospital, available for immediate use by crews.
Mary Fitzpatrick
All Responded
2025-0435
20 Aug 2025
Inner North London
Chief Executive Whittington Health NHS …
Concerns summary (AI summary)
An unnecessary hospital admission and inadequate district nursing care for a pressure sore, compounded by a lack of organizational reflection, led to preventable harm in an elderly patient.
Action Taken
(AI summary)
Whittington Health NHS Trust has devised new procedures to ensure all patient deaths under their care in community services are formally reviewed for learning. A new Duty of Candour proforma has been developed to accurately capture both professional and written Duty of Candour.
Masood Hamid
All Responded
2025-0434
20 Aug 2025
Manchester North
Chief Constable Greater Manchester Poli…
Chief Executive North West Ambulance Se…
Chief Executive Oldham Borough Council
+1 more
Concerns summary (AI summary)
There was a lack of planning for safe patient transport, particularly for a dementia patient, and an ineffective investigation into the death, hindering learning and future prevention.
Noted
(AI summary)
NWAS acknowledges ineffective communication between GMP and NWAS but states GMP is taking action in relation to this and will be writing separately. Pennine Care NHS Foundation Trust has commissioned a review of the governance and decision-making around which type of learning review was commissioned and undertaken following Mr Hamid’s death, expected by the end of November 2025, after which decisions around changes to the assessment process may be implemented. Oldham Council acknowledges the coroner's concerns regarding the transportation of Mr. Hamid, but states that their AMHP service acted lawfully and with appropriate consideration. They state that safeguarding adults’ partners are working with Oldham Safeguarding Adults Board to consider whether a Safeguarding Adults Review (SAR) is required. Response was empty and couldn't be classified.
Ricky O’Connell
All Responded
2025-0433
20 Aug 2025
Manchester South
Department of Health and Social Care
Concerns summary (AI summary)
Ambulance response times are severely impacted by significant delays in clearing emergency departments and high demand for services, exacerbated by challenges in primary care access and regional turnaround issues.
Noted
(AI summary)
The Department for Health and Social Care acknowledges the concerns and outlines the Government's commitment to improving urgent and emergency care, referencing the 10-Year Health Plan and the Urgent and Emergency Care Plan for 2025/26, as well as improvements to ambulance response and handover times. They do not describe specific actions taken or planned as a direct result of this case.
Charles Stonley
Partially Responded
2025-0432
20 Aug 2025
Liverpool and Wirral
Deputy Director of Patient Safety NHS E…
Health Services Safety Investigations B…
National Director FOR Mental Health
+1 more
Concerns summary (AI summary)
Limited resources and a severe shortage of mental health beds mean vulnerable patients in crisis are left in Emergency Departments for prolonged periods, increasing their risk of self-harm and death.
Action Planned
(AI summary)
NHS England states that the Department of Health and Social Care committed to engage with stakeholders to understand how the current legal framework is applied in ED settings and identify solutions to the problems raised. NHS England is tasking local health systems to improve patient flow through mental health crisis pathways and to reduce waits of more than 12 hours in EDs. The HSSIB notes the concerns raised and states that two investigations have been launched: one exploring the care of patients in mental health crisis in emergency departments (launching October 2025), and another exploring ambulance service response to patients in mental health crisis (launching Spring 2026).