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
Edith Millington
All Responded
2026-0183 27 Mar 2026 Manchester South
Sai SKN Ltd
Concerns summary (AI summary) The structure/design of the store's access ramp is unsafe, because it is not fixed to the ground, the rubber mat is not fixed, there are no easily accessible handrails, and the ramp is too short, making the slope steeper.
Action Taken (AI summary) • The metal access ramp has been completely removed. • The entrance has been restructured to eliminate the previous ramp arrangement and replaced with a small, stable step. • Additional fixed grab rails have been installed on both sides of the entrance.
Alex Ganski
No Identified Response
2026-0180 26 Mar 2026 West Sussex, Brighton and Hove
Department of Health and Social Care
Concerns summary (AI summary) There was no designated lead with oversight and authority over the deceased's care, and a 'care gap' resulted in fragmented information sharing and updating regarding the deceased's multiple health and drug issues; this was exacerbated by the lack of a simple mechanism to know of wider health and drug misuse issues.
Melanie Pinnell
All Responded
2026-0185 26 Mar 2026 Suffolk
Unity Healthcare
Concerns summary (AI summary) No follow-up was offered to the deceased by the GP practice after she described suicidal ideation and suicidal thoughts; a Consultant Psychiatrist's request for Sertraline was not actioned by a GP, posing a risk to patient safety.
Action Taken (AI summary) • Following this incident, Unity Healthcare commissioned a comprehensive Patient Safety Incident Investigation (PSII) in accordance with the NHS Patient Safety Incident Response Framework (PSIRF). • The investigation utilised system-based analytical tools, including the Systems Engineering Initiative for Patient Safety (SEIPS) and the Yorkshire Contributory Factors Framework.
Elizabeth Lang and Katie Lang
All Responded
2026-0182 26 Mar 2026 Northumberland
Northumberland County Council
Concerns summary (AI summary) Surface friction was low at the collision site, and while the council had undertaken roadworks, there was no advance warning signage alerting unfamiliar drivers to the severity of the bend where the collision occurred.
Action Taken (AI summary) • The location on the A1068 Sheepwash Road has been identified and recorded by the Council’s Highways service as a high-risk site for the purposes of traffic safety assessment. • The site has already been subject to resurfacing and road marking works during 2025/26 and has also been included within the 2026–2027 Local Transport Plan programme for traffic safety improvements. • The Council has now commenced a review of the site to consider options to improve the visibility and awareness of the bend for road users, including the potential use of advance warning measures.
Madison Smith
All Responded
2026-0179 26 Mar 2026 Manchester South
Department of Health and Social Care
Concerns summary (AI summary) There is no statutory regulation of agencies or individuals offering sleep routine services for young children, and anyone can attach the term 'nurse' to a word such as 'maternity' without being a registered nurse, potentially misleading families; prone sleeping promotion by unqualified individuals poses a significant risk to babies.
Action Taken (AI summary) • Departmental officials made enquiries with NHS England to address the coroner's concerns. • The Department of Health and Social Care is taking action to address the misuse of the title 'nurse' by unregulated individuals.
[REDACTED]
Response Pending
2026-0178 25 Mar 2026 Inner West London
College of Policing Haleon UK Trading Limited Metropolis +1 more
Concerns summary (AI summary) Child death investigation teams may be too easily reassured by well-presented homes, leading to perfunctory scene examinations and lost forensic opportunities.
Thomas Ruggiero
No Identified Response
2026-0172 24 Mar 2026 Ian Potter
HMP Swaleside
Concerns summary (AI summary) Key issues include a vulnerable cell bell system that can be silenced externally, staff failing to complete critical ACCT documentation, and confusion regarding emergency 'Code Blue' protocols.
Thomas Ruggiero
No Identified Response
2026-0171 24 Mar 2026 Ian Potter
Oxlease NHS Foundation Trust
Concerns summary (AI summary) Healthcare team, particularly mental health staff, inconsistently attended ACCT reviews, leaving vulnerable prisoners without adequate safety netting and protective measures.
Thomas Ruggiero
No Identified Response
2026-0170 24 Mar 2026 Ian Potter
Department for Prison, Probation and Re…
Concerns summary (AI summary) Widespread reliance on inexperienced, probationary prison officers across the prison estate leads to poor communication, lack of control, and increased risk of deaths in custody.
Robert Day
No Identified Response
2026-0169 24 Mar 2026 Kent and Medway
Department for Women’s Health and Metal… Department of Health and Social Care Home Office
Concerns summary (AI summary) Frontline emergency services lack national guidance for managing complex, time-critical mental health crises where existing legal powers may be insufficient or unclear, risking patient lives.
Ronald Meikle
No Identified Response
2026-0168 24 Mar 2026 Milton Keynes
Central & North West London NHS Foundat… Chief Inspector of Prisons HMPPS +3 more
Concerns summary (AI summary) Key concerns include widespread availability of illicit drugs, inconsistent response to intoxication, fragmented information sharing, blocked observation panels, and inadequate support for vulnerable prisoners.
Richard Hopkins
Partially Responded
2026-0155 23 Mar 2026 Coventry and Warwickshire
Driver and Vehicle Standard Agency Health and Safety Executive Society of Motor Manufacturers and Trad…
Concerns summary (AI summary) An unrecognised proximity risk exists from sudden, unexpected failure of pressurised air suspension systems during undisturbed visual inspections, unsupported by current guidance or sector awareness.
Action Planned (AI summary) • The Health and Safety Executive (HSE) acknowledged that the proximity risk associated with visual inspection of air suspension systems was previously unrecognised. • The HSE stated that employers are required to manage risks to their employees so far as is reasonably practicable. • DVSA engaged fully with the Health and Safety Executive (HSE) and attended hearings to determine whether there was anything we could or should do. • DVSA engaged with the vehicle manufacturer in the same way we would where there is the suggestion of a potential vehicle safety defect. • DVSA will continue to collaborate with HSE to find opportunities to discuss mitigations that employers can implement to address this kind of problem, for example, in any trade communications or guidance.
Peter Coates
All Responded
2026-0154 23 Mar 2026 Teesside and Hartlepool
NHS England
Concerns summary (AI summary) There is a critical gap in ambulance response categories, as some patients requiring an immediate response to prevent life-threatening deterioration do not meet Category 1 criteria.
Action Taken (AI summary) • NHS England implemented new ambulance standards across the country in 2017. • NHS Ambulance Services are required to process 999 calls through an approved triage system. • The systems are used to prioritise 999 calls received into Ambulance Services’ Emergency Operations Centres (EOCs).
Luke Ashcroft
No Identified Response
2026-0159 20 Mar 2026 Lincolnshire
HMP Lincoln Ministry of Justice
Concerns summary (AI summary) Corded telephones in CSU cells pose a clear self-harm risk when suspended, and unreliable provision of telephone access prevents prisoners in crisis from reaching support services.
Lee Adams
No Identified Response
2026-0157 20 Mar 2026 Inner South London
Medicines and Healthcare products Regul…
Concerns summary (AI summary) Doctors, particularly GPs, require greater awareness of propranolol's high toxicity at small doses and the lack of a specific antidote for overdose.
Lee Adams
No Identified Response
2026-0156 20 Mar 2026 Inner South London
Royal College of General Practitioners
Concerns summary (AI summary) GPs need greater awareness of propranolol's high toxicity at small doses, its lack of antidote, and the need to proactively inquire about patients' gambling habits.
James Coates
No Identified Response
2026-0168-wp121078 19 Mar 2026 Cumbria
Department for Transport
Concerns summary (AI summary) The current system relies inadequately on drivers self-reporting medical conditions to the DVLA, as doctors are not required to report, risking unreviewed licenses for seriously ill drivers.
John Fisher
All Responded
2026-0166 19 Mar 2026 West Sussex, Brighton and Hove
Coastal Homecare Sussex Community NHS Foundation Trust
Concerns summary (AI summary) Poor information transfer between healthcare teams, inaccurate medication records, and inadequate handovers between care providers risk patients receiving incorrect or missed essential medication.
2 responses from Sussex Community NHS Foundation Trust, Coastal Homecare
Paul Nash
All Responded
2026-0161 19 Mar 2026 Bedfordshire and Luton
Department of Health and Social Care Sundon Medical Centre
Concerns summary (AI summary) A GP surgery failed to prioritise urgent seizure medication, and epilepsy patients nationally face difficulties obtaining sufficient quantities, leading to poor seizure control and potential delays.
Action Taken (AI summary) • Officials made enquiries with NHS England to address the coroner's concerns. • The government is committed to improving care for people with neurological conditions, including epilepsy, and ensuring they receive the support they need.
Graham Oxley
All Responded
2026-0160 19 Mar 2026 South Yorkshire
Sheffield Teaching Hospital NHS Foundat…
Concerns summary (AI summary) Unreliable systems for immunotherapy toxicity mean urgent oncology advice is delayed by triage, and patient alert cards do not trigger a dedicated fast-track pathway for specialist care.
1 response from Sheffield Teaching Hospital NHS Foundation Trust
John Beagley
All Responded
2026-0158 19 Mar 2026 Gloucestershire
Department of Health and Social Care
Concerns summary (AI summary) A national shortage of maxillofacial surgeons, exacerbated by unfunded training elements, is impacting patient care and deterring prospective candidates.
1 response from Department of Health and Social Care
Julie Pytches
All Responded
2026-0164 18 Mar 2026 Essex
Nuffield Health
Concerns summary (AI summary) Issues included unshared anaesthetist limitations, staff confusion over emergency protocols and local variations, and unclear procedures for ambulance calls to private hospitals.
1 response from Nuffield Health
Edna Wiggett
All Responded
2026-0163 18 Mar 2026 Norfolk
East of England Ambulance NHS Trust
Concerns summary (AI summary) Ambulance dispatch was delayed due to a failure to re-triage and re-classify a patient's case after receiving updated information about increased pain.
Action Taken (AI summary) • An article was published in the Emergency Operations Centre (EOC) Patient Safety and Experience Newsletter to remind staff to re-triage these types of call. • This will also be discussed at the Learning Group where potential themes are discussed.
Clare Dupree
No Identified Response
2026-0181 18 Mar 2026 Avon
Director General Operations Ministry of Justice
Concerns summary (AI summary) In-cell automatic fire detection is still to be fully implemented at Eastwood Park prison and across a number of prisons in the wider prison estate; the current use of domestic smoke detectors only mitigates the risks from an in-cell fire.
Delwyn Preece
All Responded
2026-0165 17 Mar 2026 South Yorkshire East
Rotherham Doncaster South Humber NHS Fo…
Concerns summary (AI summary) Ward leave was granted without mental state exams or risk assessments, and medical records suffered from poor detail and unacknowledged retrospective entries, hindering effective investigation.
Action Taken (AI summary) • The Trust’s patient leave policy (including Section 17 leave for detained patients, and also applicable to informal patients) has been revised to clarify and strengthen documentation requirements around leave. • Before any patient goes on leave, a thorough pre-leave mental state and risk assessment must be conducted and documented. • Upon the patient’s first return from leave, staff must record a timely review of the patient’s condition and any issues arising from the leave.