2026
PFD Reports
Reports: 191
Areas: 58
70% response rate (above 63% average).
James Fitzpatrick
All Responded
2026-0087
12 Feb 2026
Dorset
Dorset Healthcare University NHS Founda…
National Institute for Health and Care …
General Medical Council (GMC)
+1 more
Concerns summary (AI summary)
A lack of national and local written guidance for patient handovers between staff and wards leads to incorrect or incomplete information being transferred, risking patient care.
Disputed
(AI summary)
• The GMC met with the Nursing and Midwifery Council (NMC) to discuss alignment across their respective pieces of guidance.
• The GMC and NMC explored opportunities for future collaborative working to develop some joint messaging highlighting the expected standards for communication within and across the multi-disciplinary team. • Dorset Healthcare University NHS Foundation Trust undertook a review to determine whether any national guidance was in development regarding community and mental health handover processes.
• The Trust awaits the response from NICE, GMC, and NMC, and any guidance that is issued in this area.
• The Trust has reviewed its own local arrangements and additional action in relation to this is set out in section 3.
Chloe Ulett
All Responded
2026-0086
11 Feb 2026
Birmingham and Solihull
Faculty of Intensive Care Medicine
Royal College of Emergency Medicine (‘R…
Royal College of Midwives
+1 more
Concerns summary (AI 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.
Noted
(AI summary)
• The Faculty of Intensive Care Medicine will highlight the case of Ms. Chloe Ulett in its tri-annual Safety Bulletin, which is distributed to all Fellows and Members.
• The Safety Bulletin will signpost open access resources and highlight the utility of testing ammonia levels in encephalopathy of unknown cause.
• The Faculty will draw attention to this being the second Regulation 28 Report in recent years stressing the need to test ammonia levels in patients who present in extremis with an unknown cause, referencing the Rohan Godhania case.
Liam Sutton
All Responded
2026-0090
10 Feb 2026
Kent and Medway
Department of Health and Social Care
Kent and Medway Integrated Care Board
Kent County Council
+1 more
Concerns summary (AI 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.
2 responses
from Kent County Council, Kent and Medway ICB
Barbara Wingate
All Responded
2026-0088
10 Feb 2026
Kent and Medway
Department of Health and Social Care
Kent and Medway Integrated Care board
Kent County Council
+1 more
Concerns summary (AI summary)
Persistent issues with patient discharge delays due to inadequate community care provisions cause emergency department overcrowding and restrict timely access to acute care.
2 responses
from Kent County Council, Kent and Medway ICB
Samuel Dickinson
All Responded
2026-0082
10 Feb 2026
Manchester West
Department of Health and Social Care
Home Office
Concerns summary (AI 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.
Noted
(AI summary)
• A new Statutory Instrument will add a new condition to firearms and shotgun licences to require the holder to inform the police if they begin to suffer from a new relevant medical condition, or if an existing condition significantly worsens, during the lifetime of the licence.
• A new licensing condition will require the licence holder to inform the police if they consult a third-party medical practitioner who is not their GP.
David Thompson
All Responded
2026-0080
10 Feb 2026
Devon, Plymouth & Torbay
Devon & Cornwall Police
Concerns summary (AI 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.
Action Planned
(AI summary)
• Devon & Cornwall Constabulary acknowledges the concerns raised regarding the use and understanding of the term ‘suicidal ideation’ within operational decision- making and communications with members of the public.
• As a Force, we will continue to deliver refresher training to Control Room Staff to further strengthen their understanding of suicidality, associated risks, and the dynamic and fluctuating nature of such incidents.
• Guidance issued in 2024 clarified that the term ‘suicidal ideation’ refers to thoughts of suicide (with reference to publications within the Lancet, and commentary provided in open-source by the Samaritans within which ‘ideation’ relates primarily to ‘thinking abou
Janet Tripp
All Responded
2026-0091
9 Feb 2026
Cornwall & the Isles of Scilly
Royal Cornwall Hospital
Concerns summary (AI summary)
Insufficient evidence shows that previously identified hospital failings have been addressed, indicating ongoing risks to patient safety.
Action Taken
(AI summary)
• The hospital reiterated the contents of a previous statement confirming that nursing documentation indicated care rounding had been carried out every two hours in line with policy while the patient was on the Trauma Unit and this continued in the Discharge.
Brody O’Brien
All Responded
2026-0084
9 Feb 2026
Lancashire and Blackburn with Darwen
Health and Safety Executive
Rossendale Borough Council
Concerns summary (AI summary)
An unsecured ligature point was accessible, and emergency services faced difficult, treacherous access to the location, hindering timely intervention.
Action Taken
(AI summary)
• A copy of the report was sent to the owner of Sunnyside Works, together with a s29 Local Government (Miscellaneous Provisions) Act 1982, requiring the building to be secured.
• The Council has been in communication with the owner of the Albert Mill site and they have confirmed that they are agreeable to taking access over their land to his property in order to carry out the securing of the building.
• The Council has been working alongside of the Health and Safety Executive and officers have spoken with him both over the telephone and in person on site. • HSE inspected the site in November 2025 and took enforcement action regarding improvements to site security.
• A further visit was made on 17th March 2026 to re-assess site security and the necessary improvements to the site fencing have been made.
• Liaison with legal and planning representatives from Rossendale Borough Council took place to share concerns and ensure that both organisations are working together.
Josh Tarrant (3)
All Responded
2026-0077
9 Feb 2026
Mid Kent & Medway
HMP Elmley
Concerns summary (AI summary)
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
Action Planned
(AI summary)
HMPPS is consulting with clinical experts to develop and issue new written guidance for staff on recognising signs of Acute Behavioural Disturbance (ABD). This guidance aims to ensure officers identify potential medical emergencies and escalate concerns appropriately, in line with updated NHS England Use of Force frameworks.
Josh Tarrant (1)
All Responded
2026-0075
9 Feb 2026
Mid Kent & Medway
NHS England
Concerns summary (AI summary)
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
1 response
from NHS England
John Franklin
All Responded
2026-0110
8 Feb 2026
Worcestershire
Worcestershire County Council
Concerns summary (AI summary)
A high-risk falls patient was discharged home before a careline/lifeline pendant was provided, delaying assistance when the patient subsequently fell.
Action Taken
(AI summary)
• The council has reviewed its policy and procedures for hospital discharge.
• Staff have been reminded of the need to consider any risks when considering the use of AT and identifying if any of those risks must be mitigated through AT being in situ prior to discharge.
• The council will share with acute colleagues and the person/representative when AT is deemed necessary for a safe discharge and will arrange it in advance.
Elise Sebastian
All Responded
2026-0078
8 Feb 2026
Essex
Essex University Partnership Trust
Concerns summary (AI summary)
Mental health ward staff lacked neurodiversity training and were inexperienced, leading to insufficient staffing, missed patient observations, and incorrect medication charting.
Action Taken
(AI summary)
• The Trust has implemented the 'Oliver McGowan' training module.
• Tier 1 provides training on LD and ASD for those who require general awareness of the support Autistic People or those with LD may need.
• Tier 2 delivers the above alongside providing di
Luke Abrahams
All Responded
2026-0201
8 Feb 2026
Northamptonshire
NHS England
Concerns summary (AI summary)
There are difficulties in diagnosing necrotising fasciitis, and the NHS website does not make it clear that the condition can present as intense/disproportionate pain without any noticeable skin changes or wound.
Action Taken
(AI summary)
• The Necrotising Fasciitis topic was picked up as part of the regular review of NHS Website content in January 2026.
• An updated version was designed, clinically-assured and published on the 2nd February 2026.
• The updated content contains a reference to new evidence which supports that in 20% of Necrotising Fasciitis cases there is no primary infection site.
Linda Books
All Responded
2026-0085
6 Feb 2026
Devon, Plymouth and Torbay
Torbay and South Devon NHS Trust
Concerns summary (AI 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.
1 response
from Torbay and South Devon NHS Trust
Stephen Rhodes
All Responded
2026-0083
6 Feb 2026
Black Country
NHS England
Quarry Bank Medical centre
Concerns summary (AI summary)
A GP practice failed to adequately scrutinise abnormal blood test results, missing a critical referral for specialist cardiac assessment despite clear laboratory advice.
Noted
(AI summary)
• A formal written response has been sent to Mrs Rhodes offering condolences, setting out the circumstances as understood by the Practice, and detailing the system-level changes implemented following review.
• The Practice has also offered to meet with Mrs Rhodes in person to discuss the matter further should she wish to do so.
• The Practice has engaged openly and transparently throughout the coroner’s investigation and will continue to do so.
Mansoor Zaman
All Responded
2026-0072
6 Feb 2026
East London
Department of Health and Social Care
East London Foundation NHS Trust
Concerns summary (AI 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.
3 responses
from Department for Health and Social Care, East London NHS foundation Trust addendum, East London NHS Foundation Trust
Emmett Morrison
All Responded
2026-0071
6 Feb 2026
Worcestershire
Prison, Probation and Reducing Offending
Probation and Reducing Offending, Minis…
Concerns summary (AI 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.
Action Planned
(AI summary)
• HMPPS is investing over £40 million in physical security measures across 34 prisons in the 2025/26 financial year.
• This includes £10 million on anti-drone measures such as window replacements, external window grilles and specialist netting across 15 priority prisons, including HMP Long Lartin.
• The Crime in Prisons Taskforce has been established to work closely with police and the CPS to improve the prosecution of those conveying contraband.
Roger Smith
All Responded
2026-0069
6 Feb 2026
Suffolk
West Suffolk NHS Foundation Trust
Concerns summary (AI 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.
1 response
from West Suffolk NHS Foundation Trust
Micheala Finch
All Responded
2026-0064
6 Feb 2026
Manchester West
Greater Manchester Integrated Care Part…
Greater Manchester Mental Health
Concerns summary (AI 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.
Noted
(AI summary)
• The Trust has recently recruited two Deputy Medical Directors for the Trust.
• The Trust is currently reviewing and updating the Trust Co-Occurring Conditions Policy with a planned publication date of May 2026.
• There is a Greater Manchester (GM) Co-Occurring Conditions Steering Group which is led by Greater Manchester ICB and has representatives from all Community Addictions Services.
Paul Thompson
All Responded
2026-0066
6 Feb 2026
Suffolk
HM Prison, Probation and reducing offen…
Concerns summary (AI 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.
1 response
from HMP Norwich
Angela Darlow
All Responded
2026-0107
5 Feb 2026
North Wales (East and Central)
Cabinet Secretary for Health and Social…
Department of Health and Social Care
Concerns summary (AI summary)
Critically long ambulance delays, exacerbated by hospital handover issues, led to patients missing crucial time-sensitive treatments like thrombectomy for stroke.
Noted
(AI summary)
The Welsh Government acknowledges the serious ambulance delays and systemic issues in North Wales, detailing ongoing efforts like providing additional financial and expert support to Betsi Cadwaladr University Health Board. An expert team has been announced to focus on reducing ambulance handover delays, improving patient flow, and strengthening governance.
Della Calvey
All Responded
2026-0063
5 Feb 2026
Gwent
Anueron Bevan University Health Board
Welsh Ambulance Service NHS Trust
Concerns summary (AI summary)
Unsafe practice of routinely downgrading NEWS scores for all COPD patients without knowing individual baseline saturations leads to inadequate clinical assessments.
2 responses
from Aneurin Bevan University Health Board, Welsh Ambulance Service NHS Trust
Bruce Caulfield
All Responded
2026-0062
5 Feb 2026
Manchester South
Manchester University NHS Foundation Tr…
Concerns summary (AI summary)
Concerns include delays in medical reviews after family concerns, insufficient intentional rounding impacting vulnerable patient hydration, and inconsistent communication practices for fall prevention across the Trust.
Action Taken
(AI summary)
Manchester University NHS Foundation Trust has updated its Adult Early Warning Score and Intentional Ward Rounding policies, with staff reminders and mandatory training rolled out. The Trust has also launched an 'Active Hospitals' programme in several inpatient areas to promote patient physical activity and prevent deconditioning.
Kallum Reed
All Responded
2026-0061
5 Feb 2026
West London
Department of Health and Social Care
West London NHS Trust
Concerns summary (AI summary)
Unacceptably long waits for ASD/ADHD services and mental health crisis team gate-keeping failures led to patients being denied crucial in-person assessments and ongoing close care.
Noted
(AI summary)
• The Trust is the provider for adult ASD assessments in Ealing.
• When this service was established in 2021, it was modelled upon historical trends in activity referred to providers outside North West London, and commissioned and resourced by North West London ICB to complete 86 assessments per year.
• In the last three full financial years against this target, we delivered 547 assessments (212%), however demand continued to grow leading to a considerable backlog of patients awaiting diagnostic assessment experiencing unacceptable delays.
Lauren Moret-Dell
All Responded
2026-0059
4 Feb 2026
Suffolk
Suffolk and North East Essex Integrated…
West Suffolk NHS Foundation Trust
Concerns summary (AI summary)
Hospital staff lacked proficiency in timely TIA Clinic referrals. Additionally, out-of-hours stroke care lacked commissioned stroke consultant input, adversely impacting patient treatment outcomes.
Action Taken
(AI summary)
• The Stroke team at WSFT immediately contacted the responsible medical team to clarify the correct TIA referral process with them.
• The Trust has updated the TIA referral guideline to improve clarity around the process.