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)
131 results
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."
Kallum Reed
Response Pending
2026-0061 5 Feb 2026 West London
West London NHS Trust Department of Health and Social Care
Concerns 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.
Bruce Caulfield
Response Pending
2026-0062 5 Feb 2026 Manchester South
Manchester University NHS Foundation Tr…
Concerns 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.
Della Calvey
Response Pending
2026-0063 5 Feb 2026 Gwent
Anueron Bevan University Health Board Welsh Ambulance Service NHS Trust
Concerns summary Unsafe practice of routinely downgrading NEWS scores for all COPD patients without knowing individual baseline saturations leads to inadequate clinical assessments.
Angela Darlow
Response Pending
2026-0107 5 Feb 2026 North Wales (East and Central)
Department of Health and Social Care
Concerns summary Critically long ambulance delays, exacerbated by hospital handover issues, led to patients missing crucial time-sensitive treatments like thrombectomy for stroke.
Ryan Harding Prevention of future deaths report
Response Pending
2026-0054 4 Feb 2026 South Wales Central
Governor of HM Prison Parc
Concerns summary Inadequate prison infrastructure allows illicit materials to enter. Scheduled welfare checks were also frequently delayed or missed due to staffing shortages.
Joan Read Prevention of future deaths report
Response Pending
2026-0055 4 Feb 2026 South Wales Central
Chief Executive Cardiff & Vale Universi… [REDACTED}
Concerns summary A single consultant lacking cross-cover for geriatric perioperative care creates a risk of urgent test results being missed during periods of absence.
Georgia Scarff
Response Pending
2026-0057 4 Feb 2026 Suffolk
Department for Education Royal Hospital School
Concerns summary School staff unfamiliarity with the safeguarding system led to missed recordings. The lack of a single national safeguarding information management tool for schools creates inconsistent practices and risks.
Oliver Robinson
All Responded
2026-0058 4 Feb 2026 Manchester North
Curaleaf Clinic
Concerns summary A consultant with inadequate expertise prescribed medicinal cannabis based on incomplete information, without consulting existing psychiatrists, obstructing the patient's appropriate psychiatric and addiction care.
Action taken summary Curaleaf Clinic has implemented several changes following an internal investigation, including requiring specialist consultants prescribing cannabis-based medicinal products to provide evidence of com
Lauren Moret-Dell
Response Pending
2026-0059 4 Feb 2026 Suffolk
West Suffolk NHS Foundation Trust Suffolk and North East Essex Integrated…
Concerns 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.
Nathan Cyster
Response Pending
2026-0051 3 Feb 2026 Staffordshire and Stoke-on-Trent
Moss Farm Department of Transport National Highways
Concerns summary Hazardous right-turn manoeuvres, absent "left turn only" signage, ineffective road markings, and ambiguous legal guidance for crossing double white lines collectively create a dangerous road environment.
Lyn Maher
Response Pending
2026-0053 3 Feb 2026 South Wales Central
London SE1 8UG NHS England [REDACTED] Chief Executive Officer (CEO) +1 more
Concerns summary Community pharmacists in Wales faced confusion regarding clinical checks and patient confidentiality, and had limited access to crucial drug history via the Welsh Clinical Portal, hindering safe prescribing.
Ellame Ford-Dunn Prevention of future deaths report
All Responded
2026-0056 3 Feb 2026 West Sussex, Brighton and Hove
NHS England & NHS Improvement
Concerns summary Insufficient Tier 4 Paediatric Mental Health beds lead to long waits, resulting in children with mental health needs being inappropriately held on acute paediatric wards unsuitable for their care.
Action taken summary NHS England has funded the recruitment of additional mental health nurses for paediatric wards and emergency departments at University Hospitals Sussex NHS Foundation Trust. They are also engaged in m
Avery Hall
Response Pending
2026-0048 2 Feb 2026 Sunderland
Royal College of General Practitioners Riverview Surgery
Concerns summary A GP failed to provide specific advice on Candesartan risks during pregnancy, and the medication remained on repeat prescription, approved without review or system alerts, risking foetal harm.
Action taken summary Riverview Surgery has implemented a new Standard Operating Protocol for prescribing medication to women of child-bearing age, which includes counselling patients and stopping contraindicated medicatio
Heather Parkhill
Response Pending
2026-0050 2 Feb 2026 North Wales (East and Central)
Welsh Ambulance Services University NHS…
Concerns summary Persistent ambulance delays and resource unavailability continue to put lives at risk, despite ongoing multi-agency efforts to address these long-standing issues.
Mia Lucas
All Responded
2026-0070 2 Feb 2026 South Yorkshire West
NHS England
Concerns summary A lack of national guidance for clinicians on considering and diagnosing Autoimmune Encephalitis creates a risk of missed diagnoses and future deaths.
Action taken summary The Royal College of Psychiatrists has established a national expert working group that has developed national guidance on the neuropsychiatric presentation of autoimmune encephalitis and autoimmune p
Scott Taylor
Response Pending
2026-0092 2 Feb 2026 Essex
East of England Ambulance NHS Trust Association of Ambulance Chief Executiv… Essex Police
Concerns summary Ambulance service triage for Acute Behavioural Disturbance suffered from incorrect call categorisation and confusing, inconsistent training. Police training for Special Constables on ABD recognition also needs addressing.
Simon Moss
Response Pending
2026-0052 1 Feb 2026 Inner South London
London SE1 8UG NHS England [REDACTED] Chief Executive Officer (CEO) +1 more
Concerns summary Mental health assessments failed to incorporate detailed ambulance records (EPRC) and family contact information, leading to inadequate risk evaluation for suicidal patients due to gaps in training and policy.
Pamela George
Response Pending
2026-0049 30 Jan 2026 Devon, Plymouth and Torbay
Premiere Health Ltd Cann House
Concerns summary The care home failed to conduct regular blood tests, inadequately managed infections, and lacked clear policies for medical escalation, capacity assessment, and documentation, despite patient needs exceeding capacity.
Patricia Walker
Response Pending
2026-0044 28 Jan 2026 City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Hull University Teaching Hospital NHS England
Concerns summary Suboptimal staffing levels on Ward 90, caused by recruitment difficulties, increase the risk of patient falls due to insufficient dedicated nursing care.
Action taken summary NHS England notes the concerns, stating some fall outside its usual remit and seeking clarification on 'TAG nursing care.' They report that Hull University Teaching Hospitals NHS Trust has presented …
Akhona Moyo
Response Pending
2026-0045 28 Jan 2026 Northamptonshire
Department of Health and Social Care Northampton General Hospital NHS England
Concerns summary Hospital doctors lack electronic access to primary care medical notes, hindering comprehensive patient treatment and preventing a holistic view of patient medical history, especially for vulnerable individuals.
Nigel Feckey
Response Pending
2026-0047 28 Jan 2026 Leicester City and South Leicestershire
Ministry of Justice
Concerns summary The 'Offence Neutrality' policy in prisons, mingling sex offenders with mainstream prisoners, fostered fear, bullying, and self-harm among vulnerable inmates, posing a risk of future deaths where still implemented.
Lucy Thornton
Response Pending
2026-0040 27 Jan 2026 Hampshire, Portsmouth Southampton
Isle of Wight NHS Trust
Concerns summary Ambulance call handler training was inadequate regarding Category 1 response criteria for hanging incidents, and procedures for obtaining further information from callers were not followed.
Pippa Gillibrand
Response Pending
2026-0042 27 Jan 2026 Cheshire
National Institution for health and car… Department of Health and Social Care NHS England
Concerns summary A critical lack of national guidance exists for home births, covering midwife training, competency, staffing, equipment, and transfer thresholds, alongside an absence of outcome data collection.
Haaris Bhatti
All Responded
2026-0043 27 Jan 2026 Inner North London
Fold Nightclub
Concerns summary Nightclub staff delayed calling an ambulance for a critically unwell patron, indicating systemic failures in training and culture regarding medical emergency management.
Action taken summary FOLD nightclub has reviewed and revised its welfare escalation procedures to ensure earlier ambulance calls for seriously unwell guests. They have also introduced enhanced monitoring, updated public a