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
Robyn Chambers
All Responded
2025-0370 22 Jul 2025 Gwent
Aneurin Bevan University Health Board
Concerns summary Significant delays in ambulance dispatch were caused by prolonged handover times at emergency departments, potentially impacting patient care despite not affecting the specific outcome in this case.
Action taken summary The Health Board has implemented several initiatives, including a Red2Green project, a Hospital at Home service, and a Corporate Site Clinical Operations Team managing an escalation policy to improve
Isaac Ingle-Gillis
All Responded
2025-0373 22 Jul 2025 Gwent
Aneurin Bevan University Health Board
Concerns summary The Crisis Resolution and Home Treatment Team's lack of access to GP records poses a future risk by preventing comprehensive mental health assessments, despite not altering the outcome in this instance.
Action taken summary The Health Board has commenced work to broaden secondary care practitioners' access to the summary GP record via the Welsh Clinical Portal, including for the Crisis Resolution and Home Treatment …
Melissa Mathieson
All Responded
2025-0367 21 Jul 2025 Avon
Alexandra Homes Ltd
Concerns summary The care home provided misleading information on supervision levels and lacked formal induction periods, regular reviews for residents, and comprehensive updates to support plans and risk assessments.
Action taken summary Alexandra House has taken action by revising their Client Referral Form, developing a new Compatibility Profile & Impact Assessment framework, and introducing a 'New Resident – 6 Week Observation & …
Madeline Reding
All Responded
2025-0368 21 Jul 2025 East London
Aspray House Nursing Home
Concerns summary Delayed and disorganised staff emergency response, including failures to promptly raise alarms or call 999, coupled with inadequate CPR due to a misunderstanding of Do Not Resuscitate orders, led to critical care gaps.
Action taken summary Aspray House Nursing Home has implemented extensive changes, including creating a new Clinical Leadership role, appointing a Clinical Lead, conducting widespread Basic Life Support/CPR and choking tra
Christopher O’Donnell
All Responded
2025-0369 21 Jul 2025 Wiltshire and Swindon
Home Group Limited
Concerns summary The supported living accommodation's policy, which prohibits staff from removing excess medication for safeguarding without resident consent, creates a risk when residents are in mental health crisis.
Action taken summary Home Group has updated its Medication, Welfare Check, and Safeguarding Adults Policies and Procedures to include clearer guidance on medication management and concerns. They have also introduced a vir
Jean Dye
All Responded
2025-0412 21 Jul 2025 Greater Lincolnshire
HSE NHS England
Concerns summary An unexplained Emergency Power Off (EPO) circuit activation caused a critical power loss during an emergency procedure, with no in-lab indicators or reset, significantly delaying treatment and highlighting a guidance gap.
Action taken summary NHS England plans to amend existing guidance documents (HTM 06-01 and HBN 01-01) to address the siting of Emergency Power Off (EPO) controls, including the location of reset buttons. These …
Darren Reilly
All Responded
2025-0362 18 Jul 2025 Hertfordshire
National Highways Agency
Concerns summary An unexplained gap in the motorway safety barrier, adjacent to established trees, poses a significant risk of severe injury or death if vehicles lose control and leave the carriageway at high speed.
Action taken summary Nottinghamshire Police has conducted demand pattern analysis of mental health incidents and s.136 detentions. Based on this, they are exploring extending the hours of the Street Triage Team until 03:0
Dorothy Wagstaff
All Responded
2025-0365 18 Jul 2025 West Yorkshire (East)
Leeds City Council
Concerns summary Ineffective temporary plastic road barriers that offer no resistance, allowing vehicles to leave the carriageway, remain present in gaps along the A660, posing a risk of future fatal collisions.
Action taken summary Leeds City Council has implemented a new computer monitoring system (AMX) and an improved process to better track temporary repairs and ensure immediate raising of work orders for permanent solutions.
Marie Theobald
All Responded
2025-0366 18 Jul 2025 East London
London Metropolitan Police
Concerns summary Delays in a criminal investigation mean a suspect in a fatal road incident is unrestricted, posing a risk of further harm due to the absence of bail conditions or driving disqualification.
Action taken summary The Metropolitan Police report that the Serious Collision Investigation Unit has recruited new detectives, and the unit's leadership and processes have been changed and implemented for improved effici
David Hayes
All Responded
2025-0371 18 Jul 2025 Manchester West
Royal Society for Prevention of Acciden… Department of Environment Food and Rura…
Concerns summary Liquid washing detergent packaged deceptively like food and lacking safety features poses a severe ingestion risk, especially for vulnerable adults with dementia, due to inadequate warnings and public awareness.
Action taken summary Dementia UK states its 'Keeping safe at home' leaflet already provides information on safe use and storage of laundry products. They are actively engaging with the UK Cleaning Products Industry …
Jacqueline Langworthy
All Responded
2025-0386 18 Jul 2025 Coventry and Warwickshire
Lift and Escalator Industry Association Department of Health and Social Care HSE
Concerns summary The widespread use of platform lifts without hold-to-run controls in care settings, coupled with limited awareness of these risks and easy retrofitting options, poses safety hazards.
Action taken summary The organisation has published a safety notice on its website and emailed it to members regarding the specific manufacturer's lifts. They are also working with specialist committees to investigate oth
Alfie Lydon
All Responded
2025-0358 15 Jul 2025 Inner London North
Royal College of Paediatrics and Child … NHS England
Concerns summary Hospital trusts generally lack processes to document external calls from midwives, leading to poor continuity and escalation of care, especially regarding parental concerns, and increasing risk of future deaths.
Action taken summary NHS England has engaged with regional chief midwives and shared the coroner's concerns with maternity and neonatal units across the East of England, issuing a reminder to staff to record …
Noreen McGlynn
All Responded
2025-0355 11 Jul 2025 Inner North London
Central London Community Healthcare NHS… Mountfield Surgery
Concerns summary There was a lack of capacity for community healthcare teams and GPs to offer home rehydration for a dehydrated patient, leading to unwanted hospital admission despite family preferences for home care.
Action taken summary Mountfield Surgery disputes the feasibility of providing intravenous rehydration at home due to clinical safety, monitoring requirements, and the scope of primary care services. They state current NHS
Myles Scriven
All Responded
2025-0356 11 Jul 2025 West Yorkshire Western
CQC North NHS England Dalton Surgery
Concerns summary GPs demonstrated insufficient understanding of Learning Disability and Autism needs, resulting in inadequate adjustments and ineffective use of the Learning Disabilities Register, contributing to a lack of appropriate secondary care referral.
Action taken summary NHS England has engaged with the Integrated Care Board, which is undertaking a LeDeR review. They report that the GP surgery has improved processes for managing patients with learning disabilities …
Jairus Earl
All Responded
2025-0349 10 Jul 2025 Dorset
Home Office Department of Health and Social Care
Concerns summary Significant gaps in shotgun licence regulation, including no requirement to declare multiple properties or movement, and less stringent application criteria compared to firearms, create a risk of future deaths.
Action taken summary The NPCC commenced an additional two-day course in June 2025 for Firearms Licensing Enquiry Officers, focusing on domestic abuse, family turmoil, mental health, and wellbeing. They also clarified the
Gavin Wheale
All Responded
2025-0350 10 Jul 2025 Birmingham and Solihull
HM Prison & Probation Service
Concerns summary The prison's secreted item policy inadequately addresses ingestion, and the handover from other agencies removes constant supervision, compromising the duty of care for prisoners with concealed items.
Action taken summary HMP Birmingham has committed to updating its Secreted Items Policy to include clear guidance for staff on managing prisoners suspected of ingesting items. Additionally, the prison will issue guidance
Gemma Poterajko
All Responded
2025-0351 10 Jul 2025 Nottinghamshire
Nottingham University Hospitals NHS Tru…
Concerns summary The absence of formal risk stratification and a written Standard Operating Procedure for lead extraction led to unclear planning and inadequate timely cardiac surgical team support during procedures.
Action taken summary The Trust has developed and approved a new Trust-wide Standard Operating Procedure for Lead Extraction, which incorporates a formalised risk stratification system and provides explicit clarity on time
Paul Ransom
All Responded
2025-0353 10 Jul 2025 Hampshire, Portsmouth and Southampton
Department for Transport Association of Directors of Environment Economy +1 more
Concerns summary Thin surface treatments on roads can cause significantly reduced friction in early life, particularly dangerous for motorcycles in dry conditions, without adequate warning signage for drivers unaware of the altered grip.
Action taken summary The ADEPT states it will work with the Department for Transport and the Road Surface Treatments Association. As a member organisation, it commits to sharing any relevant research, learning, best …
Doreen Swann
All Responded
2025-0359 10 Jul 2025 Manchester South
Greater Manchester Integrated Care Department of Health and Social Care
Concerns summary Persistent delayed hospital discharges due to social care bed shortages force high-falls-risk patients to remain in acute settings, straining resources and potentially compromising patient safety and bed availability.
Action taken summary The department acknowledges the impact of social care capacity on delayed hospital discharges, highlighting existing strategies like care transfer hubs, the Better Care Fund, and over £4 billion addit
Andrew Kenward
All Responded
2025-0346 9 Jul 2025 Surrey
Department of Health and Social Care Home Office
Concerns summary There is no central monitoring for sodium nitrite poisoning, and high-purity sodium nitrite can be easily imported and purchased in lethal quantities without regulation or consideration for dilution, posing significant risk.
Action taken summary The Home Office is researching the availability of sodium nitrite and collaborating with DHSC on legislative options. Border Force issued guidance last year on controlling items intended to assist sui
Shaun Marriott
All Responded
2025-0348 9 Jul 2025 West Sussex, Brighton and Hove
Surrey and Sussex Healthcare NHS Trust
Concerns summary The day surgery patient assessment system lacks explicit requirements to question or record details about patients' haematological family history, or adequately document negative responses to related personal history questions.
Action taken summary The Trust has already updated its patient questionnaire and pre-operative assessment form to directly ask about haematological family history and added prompts to record relevant information. They als
John Kirkman
All Responded
2025-0344 8 Jul 2025 Kingston Upon Hull and the County of the East Riding of Yorkshire
NHS England
Concerns summary Inconsistent IT systems prevent immediate sharing of mental health screening assessment results across regions, leading to a lack of vital background information and incorrect prioritisation for referrals.
Action taken summary NHS England highlights existing systems like the National Care Records Service (NCRS), Summary Care Record (SCR), and National Record Locator (NRL) that improve data sharing. They are also developing
Liliwen Thomas
All Responded
2025-0352 8 Jul 2025 South Wales Central
NICE
Concerns summary Over-administration of analgesia during labour rendered the mother comatose, masking labour progression, and current national guidelines lack explicit detail on safe analgesia levels and supervision.
Action taken summary NICE commits to considering updates to recommendations in their guidelines on inducing labour (NG207) and intrapartum care (NG235). This will specifically include reviewing the frequency of clinical a
Peter Ramsden
All Responded
2025-0467 8 Jul 2025 City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Communities and Local Government Secretary of State for the Home Departm… Ministry of Housing
Concerns summary A legal lacuna prevents police, paramedics, or fire services from forcing entry for welfare checks if a medical problem is suspected, hindering prompt, potentially life-saving treatment for incapacitated individuals.
Action taken summary The department clarifies that Fire and Rescue Authorities (FRAs) possess statutory powers of entry under the Fire and Rescue Services Act 2004 for emergencies, including welfare checks, and that these
Sarah Lewis
All Responded
2025-0337 7 Jul 2025 Avon
Department of Health and Social Care
Concerns summary Inconsistent and under-resourced ME services, coupled with a lack of professional understanding and research, hinder diagnosis, validation, and appropriate support for sufferers.
Action taken summary NICE clarifies that the provision of ME/CFS services and professional education is primarily the remit of NHS England and other bodies. They highlight that NICE has already supported e-learning materi