2026

PFD Reports
Reports: 191 Areas: 58

70% response rate (above 63% average).

Response Status
Responded 133 No Response 42 Pending 16
AI Classification
Action Taken 50%
Action Planned 13%
Noted 36%
Disputed 2%
Based on 198 classified responses
Top Categories
Hospital Death (Clinical Procedure… (56) Suicide (from 2015) (26) Other related deaths (23) Alcohol, drug and medication relat… (19) Mental Health related deaths (16)
191 results
Kiefer Fraser-Phillips
Response Pending
2026-0216 14 Apr 2026 Birmingham and Solihull
Birmingham and Solihull Mental Health N…
Concerns summary (AI summary) Therapeutic observations were not accurately recorded due to Wi-Fi signal issues, and there was no care plan in place to address the physical health conditions, such as sleep apnoea, associated with long-term mental health medication.
Catherine Oliver
Response Pending
2026-0215 14 Apr 2026 Oxfordshire
Sanctuary Housing Association
Concerns summary (AI summary) Prolonged storage of household items in the main living area created a hazard for an elderly tenant, and there were no clear policies or time limits governing such storage or mitigating steps.
Susan Toft
Response Pending
2026-0214 14 Apr 2026 Manchester South
British Health Trades Association Wheelchair Alliance Wheelchair Accessible Vehicle Converter…
Concerns summary (AI summary) The detachment of a wheelchair seat cushion after only 9 months raised concerns about the robustness of the attachment method, and a lack of assessment of the vehicle restraint system's fit contributed to the deceased being thrown into the footwell during transport.
Wayne Austin
Response Pending
2026-0213 10 Apr 2026 Shropshire, Telford and Wrekin
Joint Royal Colleges Ambulance Liaison … West Midlands Amublance Service
Concerns summary (AI summary) Difficulties locating the appropriate cardiac arrest guidance on the JRCALC app, the inability of paramedics to comply with respiratory arrest guidelines, and insufficient Naloxone supplies in ambulances were identified as concerns.
Garry Mills
Response Pending
2026-0212 10 Apr 2026 Surrey
Attorney General of England and Wales Public Prosecutions
Concerns summary (AI summary) The coroner raises concerns that the £250 per week allowance for reasonable living expenses under Proceeds of Crime Act Restraint Orders, which has not been reviewed since 2009, is insufficient given the increased cost of living, especially for those with dependents.
Richard Whelan
Response Pending
2026-0208 9 Apr 2026 West Yorkshire Western
South West Yorkshire Partnership NHS Fo…
Concerns summary (AI summary) The coroner noted that non-urgent referrals to the Single Point of Access (SPA) for mental health support may take up to 14 days to triage, and referrals could come from individuals without mental health experience.
Jonathan Thornton
Response Pending
2026-0200 8 Apr 2026 Nottingham and Nottinghamshire
HMP Nottingham Ministry of Justice Northampton Healthcare NHS Foundation T… +2 more
Concerns summary (AI summary) Information sharing barriers between the Community Forensic Team and prison healthcare, as well as between prison healthcare and operational prison staff, were identified as concerns. The limited and broad categorisation of alerts on NOMIS/DPS was also raised as an issue.
Gary Starbuck
Response Pending
2026-0204 8 Apr 2026 Surrey
Care Quality Commission Royal College of Surgeons
Concerns summary (AI summary) The coroner expressed concern that patients receiving private care for skin cancers may receive inferior care compared to NHS patients, due to a lack of mandated care standards and access to specialist skin MDTs.
Mark Smith
Response Pending
2026-0205 7 Apr 2026 Inner South London
1. Chief Executive Officer, Practice Pl… Chief Executive Officer, Practice Plus … 2. Chief Executive Lewisham and Greenwi… +3 more
Concerns summary (AI summary) The report identifies concerns about the potential for incorrect medication dosages to be prescribed or administered, the risk of patients being discharged back to prison from QEH without an MDT meeting, and healthcare staff being unable to access a prisoner's cell at night.
Matilda Davis
Response Pending
2026-0198 7 Apr 2026 Warwickshire
Warwickshire County Council – Children … Warwickshire County Council – Children …
Concerns summary (AI summary) Suicide prevention training is not mandatory for frontline practitioners within Warwickshire Children’s Services, potentially leading to variability in practice when responding to indications of self-harm or suicidal thoughts.
Joshua Perry
Response Pending
2026-0206 7 Apr 2026 Liverpool & Wirral
Secretary of State for building safety,…
Concerns summary (AI summary) A conflict exists between Building Regulations and BSI Standards regarding the measurement of barrier heights when a wall or parapet is used as guarding, and the guidance does not mention horizontal railings being a climbing risk for adults and children over 5 years old.
Allan Stevenson
Response Pending
2026-0207 6 Apr 2026 Suffolk
Anglican Water Core Highways Group Limited Secretary of State for Transport +1 more
Concerns summary (AI summary) A traffic management plan was incorrectly implemented due to inaccurate map coordinates, leading to improper signage and a road traffic collision; special signage was unavailable due to the plan flip.
Roman Barr
No Identified Response
2026-0197 3 Apr 2026 Coventry
Asthma & Lung (for information) Care Quality Commission NHS England +3 more
Concerns summary (AI summary) The report identifies limited awareness of salbutamol overuse, inconsistent identification and follow-up of reliever overuse, ambulance handover delays affecting emergency availability, risks when families transport critically unwell patients, and unclear NHS Pathways triage wording.
Peter Pettit
No Identified Response
2026-0196 2 Apr 2026 Suffolk
Multi-Care Community Services Suffolk
Concerns summary (AI summary) Inadequate record keeping, poor medication management support, and deficient catheter management were identified in community care services. There were also concerns that training inadequacies had not been addressed.
David Abbot
No Identified Response
2026-0195 2 Apr 2026 Suffolk
West Suffolk NHS Foundation Trust
Concerns summary (AI summary) Incorrect advice was given to a patient upon discharge from West Suffolk Hospital regarding weight bearing and mobilisation, potentially contributing to the development of a DVT; additionally, concerns were raised about ineffective communication processes between hospital staff and patients.
Benjamin Rowley
No Identified Response
2026-0192 1 Apr 2026 Greater Lincolnshire
Medicines and Healthcare Products Regul… Medtronic Limited University Hospitals of Leicester NHS T…
Concerns summary (AI summary) Two incidents at a dialysis centre involved the detachment of a port from a Covidien Palindrome Chronic Dual Lumen Catheter, leading to blood loss; the coroner recommends reporting these events to the Medicines and Healthcare products Regulatory Agency (MHRA) due to concerns about a potential widespread vulnerability.
Susan Whittles
No Identified Response
2026-0191 1 Apr 2026 East Riding and Hull
Department for Transport Driver and Vehicle Standards Agency
Concerns summary (AI summary) Nationals of non-designated countries who fail a GB driving test can continue to drive in the UK for up to 12 months on their foreign licence without supervision, despite not meeting the DVSA's safety standards.
Lucy Phelan
No Identified Response
2026-0209 1 Apr 2026 Worcestershire
NHS Wales NHS England Worcestershire Acute Hospital NHS Trust
Concerns summary (AI summary) The use of the "latching" facility on patient monitoring equipment may contribute to alarm fatigue, making it difficult for staff to respond to different alarms; the manufacturer no longer recommends its use on Emergency Department monitors.
Hollie Loraine
All Responded
2026-0193 1 Apr 2026 Sunderland
NHS England
Concerns summary (AI summary) The national NHS pathways telephone triage system provides no specific guidance on whether to maintain telephone contact with a patient expressing suicidal intent, or how to do so to mitigate the risk.
1 response from NHS England
Colin Foley
All Responded
2026-0188 1 Apr 2026 Hull and East Riding
NHS England
Concerns summary (AI summary) The coroner recommends that the NHS at large should be aware of issues relating to the insertion, maintenance, and documentation of intravenous access devices, as well as awareness of associated complications.
Action Taken (AI summary) • NHS England stated that established guidance already supports safe and standardised practice for the insertion and management of intravenous (IV) access devices. • The UK Vessel Health and Preservation (VHP) Framework (2020) promotes a proactive, evidence-based approach to vascular access. • National infection prevention standards, including NICE Quality statement 5: Vascular access devices and High Impact Intervention (HII) care bundles, set out National guidance.
Raisa Iordan
No Identified Response
2026-0190 31 Mar 2026 West Yorkshire Western
Mid Yorkshire Teaching Hospital NHS Tru… Telemedicine Clinic Limited
Concerns summary (AI summary) A junior doctor's concerns were ignored by a senior doctor, whose assessment was limited; out-of-hours radiology interpretation was provided by an agency whose expertise was limited to adult radiology, and there were delays in obtaining a scan and intubating the patient.
Jack Saunders
No Identified Response
2026-0187 31 Mar 2026 Lancashire with Blackburn and Darwen
Scouting Association
Concerns summary (AI summary) Borrowed equipment lacked instructions, and while national carbon monoxide poisoning risk training existed, it had not reached trainers within individual troops; the deceased had also observed leaders using gas equipment in tents previously.
John Hay
No Identified Response
2026-0189 31 Mar 2026 Northamptonshire
CQC QCC Care Bureau +1 more
Concerns summary (AI summary) Risk assessments in the care plan were not completed or reviewed with nursing or medical input, and the escalation process for medical input was unclear; also unclear was the system for actioning missing or spent medication.
Oliver Roberts
All Responded
2026-0184 30 Mar 2026 Dorset
National Police Chiefs' Council College of Policing Devon and Cornwall Police +2 more
Concerns summary (AI summary) There is a lack of practical guidance for police officers on applying their powers to obtain communications data under the Investigatory Powers Act 2016, especially regarding urgent Grade 2 requests.
Noted (AI summary) • The College of Policing provides eLearning training for investigators on the national ‘College Learn’ platform. • These learning packages “Introduction to Communications Data,” sit within the Digital Media Investigators (DMI) modules. • This training is available for all police officers and staff across England and Wales.
John Tarrant
No Identified Response
2026-0199 30 Mar 2026 Berkshire
Frimley Health NHS Foundation Trust
Concerns summary (AI summary) Falls risk assessments were carried out based on incorrect data, and the Trust lacked a way of auditing their accuracy; a doctor did not appreciate the urgency of the situation after a fall, and the importance of considering anticoagulation reversal medication may be underappreciated.