2026
PFD Reports
Reports: 131
Areas: 47
19% response rate (below 62% average).
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
Welsh Ambulance Service NHS Trust
Anueron Bevan University Health Board
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.
Lauren Moret-Dell
Response Pending
2026-0059
4 Feb 2026
Suffolk
Suffolk and North East Essex Integrated…
West Suffolk NHS Foundation Trust
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
Department of Transport
Moss Farm
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.
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.
Scott Taylor
Response Pending
2026-0092
2 Feb 2026
Essex
Essex Police
Association of Ambulance Chief Executiv…
East of England Ambulance NHS Trust
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.
Akhona Moyo
Response Pending
2026-0045
28 Jan 2026
Northamptonshire
NHS England
Northampton General Hospital
Department of Health and Social Care
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.
Mark Turner
Response Pending
2026-0065
14 Jan 2026
Staffordshire
Midlands Partnership Foundation Trust
NHS England
Concerns summary
There is a critical absence of local or national guidance for managing the steps to be taken when a high serum level is returned in patients being monitored for clozapine.