2026

PFD Reports
Reports: 131 Areas: 47

19% response rate (below 62% average).

Response Status
Responded 25 No Response 12 Pending 94
AI Classification
Action Taken 66%
Action Planned 11%
Noted 18%
Disputed 5%
Based on 38 classified responses
Top Categories
Hospital Death (Clinical Procedure… (43) Suicide (from 2015) (21) Alcohol, drug and medication relat… (16) Other related deaths (16) Child Death (from 2015) (14)
Clear 94 results
Rita Thomas and Christine Dale
Response Pending
2026-0093 12 Feb 2026 Cumbria
National Highways
Concerns summary The junction design, coupled with the national speed limit on the A684, provides drivers with insufficient reaction time, increasing the risk of serious collisions.
Chloe Ulett
Response Pending
2026-0086 11 Feb 2026 Birmingham and Solihull
Royal College of Emergency Medicine (‘R… Royal College of Obstetricians and Gyna… Royal College of Physicians +2 more
Concerns summary There is a lack of routine ammonia testing for acutely confused adults, and current RCEM guidelines for metabolic disorders are not well-embedded or sufficiently clear, especially for postpartum women.
David Thompson
Response Pending
2026-0080 10 Feb 2026 Devon, Plymouth & Torbay
Devon & Cornwall Police
Concerns summary Police widely use the term 'suicidal ideation' which is not understood by the public or consistently by officers, risking critical information being missed in missing person reports.
Samuel Dickinson
Response Pending
2026-0082 10 Feb 2026 Manchester West
Department of Health and Social Care Home Office
Concerns summary Gaps in firearms legislation mean licence holders are not required to self-report medical conditions, and GPs are not obligated to record licences or report relevant issues to police.
Barbara Wingate
Response Pending
2026-0088 10 Feb 2026 Kent and Medway
Department of Health and Social Care
Concerns summary Persistent issues with patient discharge delays due to inadequate community care provisions cause emergency department overcrowding and restrict timely access to acute care.
Liam Sutton
Response Pending
2026-0090 10 Feb 2026 Kent and Medway
Department of Health and Social Care
Concerns summary Persistent delays in discharging medically fit patients due to inadequate community care provision block acute beds, leading to dangerous overcrowding in emergency departments and delayed critical care.
Josh Tarrant (1)
Response Pending
2026-0075 9 Feb 2026 Mid Kent & Medway
NHS England
Concerns summary Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
Josh Tarrant (2)
Response Pending
2026-0076 9 Feb 2026 Mid Kent & Medway
Prisons Probation and Reducing Reoffending
Concerns summary Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
Josh Tarrant (3)
Response Pending
2026-0077 9 Feb 2026 Mid Kent & Medway
HMP Elmley
Concerns summary Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
Gareth Chumber-Kelly
Response Pending
2026-0073 9 Feb 2026 North London
HMP Pentonville Serco Ministry for Justice +1 more
Concerns summary Inefficient prison reception processes lead to lost critical prisoner information, and suicide/self-harm training for staff was suspended despite high rates of suicidal ideation and ligature deaths.
Helen Patching, Rachael Patching and Corey Longdon
Response Pending
2026-0081 9 Feb 2026 South Wales Central
Powys County Council Bannau Brycheiniog National Park Natural Resources Wales +2 more
Concerns summary Inadequate signage fails to address significant falling risks in 'Waterfall Country', and poor mobile phone signal hinders emergency services' response times.
Brody O’Brien
Response Pending
2026-0084 9 Feb 2026 Lancashire and Blackburn with Darwen
Rossendale Borough Council Health and Safety Executive
Concerns summary An unsecured ligature point was accessible, and emergency services faced difficult, treacherous access to the location, hindering timely intervention.
Janet Tripp
Response Pending
2026-0091 9 Feb 2026 Cornwall & the Isles of Scilly
Royal Cornwall Hospital
Concerns summary Insufficient evidence shows that previously identified hospital failings have been addressed, indicating ongoing risks to patient safety.
Elise Sebastian
Response Pending
2026-0078 8 Feb 2026 Essex
Essex University Partnership Trust
Concerns summary Mental health ward staff lacked neurodiversity training and were inexperienced, leading to insufficient staffing, missed patient observations, and incorrect medication charting.
John Franklin
Response Pending
2026-0110 8 Feb 2026 Worcestershire
Worcestershire County Council
Concerns summary A high-risk falls patient was discharged home before a careline/lifeline pendant was provided, delaying assistance when the patient subsequently fell.
Bonita Cleary
Response Pending
2026-0067 7 Feb 2026 Blackpool & Fylde
Curo Care Delahey’s Care Quality Commission
Concerns summary A lack of awareness among care staff regarding when CPR should be attempted risks potentially reversible deaths in vulnerable residents.
Janet Springall
Response Pending
2026-0074 7 Feb 2026 Blackpool & Fylde
Department of Health and Social Care Care Quality Commission
Concerns summary Hospital emergency departments face significant pressures, causing unwell patients to remain in ambulances and delaying critical treatment, which reduces survival chances.
Paul Thompson
Response Pending
2026-0066 6 Feb 2026 Suffolk
HM Prison Probation and reducing offending
Concerns summary HMP Norwich had inadequate arrangements for releasing prisoners needing mental health care, leading to failures in ensuring follow-up and timely information sharing with Probation Services.
Micheala Finch
Response Pending
2026-0064 6 Feb 2026 Manchester West
Greater Manchester Mental Health Greater Manchester Integrated Care Part…
Concerns summary Hospital discharge decisions failed to adequately assess a patient's significant mental health deterioration and suicidal ideation, attributing issues solely to alcohol misuse and not deploying escalated home-based treatment.
Roger Smith
Response Pending
2026-0069 6 Feb 2026 Suffolk
West Suffolk NHS Foundation Trust
Concerns summary Ineffective electronic patient records failed to flag critical medication information, and poor communication led to anticoagulation being administered against patient wishes, without specialist stroke input.
Emmett Morrison
Response Pending
2026-0071 6 Feb 2026 Worcestershire
Prison Probation and Reducing Offending
Concerns summary HMP Long Lartin suffered from a continued influx of illicit drugs. There were also systemic failures in the ACCT process, with no support actions recorded for a prisoner with a history of self-harm.
Mansoor Zaman
Response Pending
2026-0072 6 Feb 2026 East London
Department of Health and Social Care East London Foundation NHS Trust
Concerns summary Nursing staff failed to instigate MHA authorisations, adequately document care, reappraise risk after violent behaviour and absconding, and promptly report a missing patient to the police via emergency channels.
Stephen Rhodes
Response Pending
2026-0083 6 Feb 2026 Black Country
NHS England Quarry Bank Medical centre
Concerns summary A GP practice failed to adequately scrutinise abnormal blood test results, missing a critical referral for specialist cardiac assessment despite clear laboratory advice.
Linda Books
Response Pending
2026-0085 6 Feb 2026 Devon, Plymouth and Torbay
Torbay and South Devon NHS Trust
Concerns summary The Trust showed a lack of staff training in escalating serious clinical incidents, no effective process for reviewing notes to identify issues, and confusion about Serious Incident Report procedures.
Sam Dudley
Response Pending
2026-0060 5 Feb 2026 Sefton, St Helens and Knowsley
North West Route Director
Concerns summary Limited and ineffective signage on railway pedestrian gates, especially for earphone users, fails to provide adequate warnings at a critical "decision point."