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)
Clear 119 results
Oliver Robinson
All Responded
2026-0058 4 Feb 2026 Manchester North
Curaleaf Clinic
Concerns summary (AI 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 (AI summary) Curaleaf Clinic has implemented material changes to its clinical governance, communication, and shared-care processes, including requiring comprehensive up-to-date medical summaries from GPs. They have also reviewed their approach to complex psychiatric patients and reinforced coordination with external mental health services.
Joan Read Prevention of future deaths report
All Responded
2026-0055 4 Feb 2026 South Wales Central
[REDACTED}, Chief Executive Cardiff & V…
Concerns summary (AI summary) A single consultant lacking cross-cover for geriatric perioperative care creates a risk of urgent test results being missed during periods of absence.
Action Taken (AI summary) • The Health Board has undertaken a detailed internal Patient Safety Review and enacted several improvements. • Further actions are planned to reduce risk and strengthen system resilience.
Ryan Harding Prevention of future deaths report
All Responded
2026-0054 4 Feb 2026 South Wales Central
Governor of HM Prison Parc
Concerns summary (AI summary) Inadequate prison infrastructure allows illicit materials to enter. Scheduled welfare checks were also frequently delayed or missed due to staffing shortages.
1 response from HM Prison Parc
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 (AI 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 (AI summary) NHS England has provided £180,000 to University Hospitals Sussex NHS Foundation Trust to support the recruitment of additional mental health nurses. A new tri-funded short-term residential alternative to hospital admission is expected to open in 2026 to support young people in crisis.
Nathan Cyster
All Responded
2026-0051 3 Feb 2026 Staffordshire and Stoke-on-Trent
Department of Transport Moss Farm National Highways
Concerns summary (AI 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.
Noted (AI summary) National Highways will investigate road markings, signing, and carriageway layout on the A5, with a view to identifying mitigation measures to reduce injudicious overtaking. Implementation of any measures is subject to funding availability, with the investigation to be completed by 30/06/2026 and implementation in FY 2026-27. • Moss Farm Shop has asked Midland Signs to prepare a "no right turn" sign to be placed at the exit of the car park. • Moss Farm Shop will advise drivers leaving the shop not to turn right.
Scott Taylor
All Responded
2026-0092 2 Feb 2026 Essex
Association of Ambulance Chief Executiv… East of England Ambulance NHS Trust Essex Police
Concerns summary (AI 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.
Noted (AI summary) • All officers—regular and Special Constabulary—now receive the same level of training in relation to ABD. • ABD training has been moved from the First Aid Learning Programme refresher sessions into the College of Policing’s Scenario-Based Training programme.
Mia Lucas
All Responded
2026-0070 2 Feb 2026 South Yorkshire West
NHS England
Concerns summary (AI summary) A lack of national guidance for clinicians on considering and diagnosing Autoimmune Encephalitis creates a risk of missed diagnoses and future deaths.
Noted (AI summary) The Royal College of Psychiatrists has invested in the development of a national consensus guideline on the neuropsychiatry of autoimmune conditions. This guidance, which will provide clinical red flag features, investigation strategies, and referral thresholds, is anticipated to be formally released within the next six months. The British Paediatric Neurology Association confirmed the lack of specific current guidelines on Autoimmune Encephalitis for children and young people. They expressed a willingness to be involved if a NICE Guideline were commissioned and highlighted delays in NMDA receptor antibody testing across the UK. The Department for Health and Social Care considers the concerns about national guidance on Autoimmune Encephalitis more appropriately addressed by NHS England and has advised that NHS England will provide a direct response.
Heather Parkhill
All Responded
2026-0050 2 Feb 2026 North Wales (East and Central)
Welsh Ambulance Services University NHS…
Concerns summary (AI summary) Persistent ambulance delays and resource unavailability continue to put lives at risk, despite ongoing multi-agency efforts to address these long-standing issues.
Action Taken (AI summary) • All staff responsible for admissions have received one-to-one supervision regarding Ms George’s case, ensuring learning is embedded. • Information has been disseminated to all junior staff for awareness training, emphasising the importance of correctly processing admission and discharge documentation. • All hospital discharge summaries are now scanned directly into residents’ care plans upon receipt. • WAST is increasing its remote clinical support to ensure prioritization of available resources based on patient needs and to improve safety netting. • WAST is working to minimize the number of patients being transported to busy hospitals by enhancing staff knowledge, skills, and competencies and the alternatives available to them. • WAST is increasing resources available for use, completing roster changes to increase resource availability and improving levels of attendance levels.
Avery Hall
All Responded
2026-0048 2 Feb 2026 Sunderland
Riverview Surgery Royal College of General Practitioners
Concerns summary (AI 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.
Noted (AI summary) Riverview Surgery has implemented a new Standard Operating Protocol (SOP) for prescribing medication to women of childbearing age, which includes stopping contraindicated medication and advising patients if they become pregnant. The frequency of reviews for female patients on ARB medication has been increased to three-monthly. The RCGP outlined its role in setting prescribing standards and mentioned the mandatory Prescribing Assessment introduced in 2019. It suggested exploration with system suppliers regarding alerts for existing repeat prescriptions when a patient becomes pregnant, and highlighted the new Learning From Patient Safety Exercise reporting system.
Janet Daniels
All Responded
2026-0202 2 Feb 2026 Essex
East Suffolk and North Essex NHS Founda…
Concerns summary (AI summary) There was a failure to communicate effectively with the patient and her family regarding critical clinical decision-making and the basis for such decisions relating to her transition to end-of-life care; clinical and nursing staff were insufficiently familiar with the principles in the Trust's policies and guidance.
1 response from East Suffolk and North Essex NHS Foundation Trust
Simon Moss
All Responded
2026-0052 1 Feb 2026 Inner South London
[REDACTED] Chief Executive Officer (CEO…
Concerns summary (AI 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.
Action Planned (AI summary) • NHS England is supporting mental health trusts to strengthen both the effective use of clinical information and relational approaches to care, in inpatient settings through the Culture of Care national programme. • NHS England launched Staying safe from suicide guidance in June 2025 to address issues in terms of mental health assessments both in a crisis situation and when mental health nurses are undertaking detailed mental health assessments in mental health and acute physical health trusts.
Pamela George
All Responded
2026-0049 30 Jan 2026 Devon, Plymouth and Torbay
Cann House Premiere Health Ltd
Concerns summary (AI 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.
Action Taken (AI summary) • All staff responsible for admissions have received one-to-one supervision regarding Ms George’s case. • Information has been disseminated to all junior staff for awareness training, emphasising the importance of correctly processing admission and discharge documentation. • All hospital discharge summaries are now scanned directly into residents’ care plans upon receipt. • The organisation has enforced its formal Hospital Discharge and Clinical Follow-Up Procedure.
Nigel Feckey
All Responded
2026-0047 28 Jan 2026 Leicester City and South Leicestershire
Ministry of Justice
Concerns summary (AI 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.
Action Taken (AI summary) • HMPPS provides evidence-based guidance for governors and directors to support them to make safe and appropriate decisions on accommodation arrangements for people convicted of sexual offences (PCOSOs). • The guidance sets out that governors and directors have discretion over whether PCOSOs should be integrated or separated, and that consideration should be given to the specifics and facilities of each establishment.
Patricia Walker
All Responded
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 (AI summary) Suboptimal staffing levels on Ward 90, caused by recruitment difficulties, increase the risk of patient falls due to insufficient dedicated nursing care.
Noted (AI summary) • The Trust has established daily operational controls to mitigate staffing pressures in real time. • Daily staffing meetings take place across all sites, where ward-level escalations relating to actual versus planned staffing, changes in acuity, and red flag indicators are reviewed by dedicated staffing representatives. • Information from these meetings feeds directly into twice-daily Trust-wide safe staffing meetings chaired by a Nurse Director, providing senior clinical oversight of staffing gaps, mitigations and risk management. NHS England stated the local staffing concerns for Ward 90 fall outside its usual role and remit, noting that Hull University Teaching Hospitals NHS Trust is best placed to respond and has presented a business case to increase nursing staff. NHS England also disputed the clarity of the term “TAG nursing care.”
Haaris Bhatti
All Responded
2026-0043 27 Jan 2026 Inner North London
Fold Nightclub
Concerns summary (AI 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 (AI summary) FOLD nightclub has reviewed and revised its welfare escalation procedures, introducing a protocol in late 2025 requiring earlier ambulance calls when serious symptoms are observed. The club also engaged Frontline Medical Response Ltd in February 2026 to support welfare teams and introduced enhanced monitoring procedures.
Pippa Gillibrand
All Responded
2026-0042 27 Jan 2026 Cheshire
Department of Health and Social Care National Institution for health and car… NHS England +1 more
Concerns summary (AI 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.
Disputed (AI summary) • On 26 November 2025, NHS England wrote to all NHS maternity providers in England asking them to urgently review the safety and quality of their homebirth services. • NHS England urged them to consider issues such as the operational running of their service and care planning and risk assessment. • NICE stated that home birth is covered in its guideline on intrapartum care (NG235). • The guideline covers eligibility, informed choice, and midwife support for home births. • The guideline includes recommendations that support further discussion with an appropriately trained senior or consultant midwife and/or a senior or consultant obstetrician (if there are obstetric issues) if such a discussion is wanted. • Officials made enquiries with NHS England to address the coroner's concerns. • NHS England will be issuing a substantive response addressing the specific matters of concern raised. • NHS England is asking for an urgent review of the safety and quality of homebirth services. • The review should consider the operational running of the service, care planning and risk assessment, and governance and oversight.
Lucy Thornton
All Responded
2026-0040 27 Jan 2026 Hampshire, Portsmouth Southampton
Isle of Wight NHS Trust
Concerns summary (AI 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.
Action Taken (AI summary) The Isle of Wight NHS Trust has addressed the call handler's actions and amended guidance to clarify the need for direct contact with individuals at risk, regardless of location. A comprehensive training programme for call handlers on risk assessment and categorisation for suicidal patients is being delivered from February to April 2026.
Roger Leadbeater
All Responded
2026-0041 23 Jan 2026 South Yorkshire West
Greater Manchester Police South Yorkshire Police
Concerns summary (AI summary) Inadequate and unrecorded handovers between police forces and a mental health trust meant critical risk information about a patient was lost, impacting leave decisions and risking public safety.
Action Taken (AI summary) • A new, purpose-designed form has been created to record the transfer of responsibility for a missing person. • A mandatory task has been embedded within Compact, our MFH management system, providing officers with an automatic prompt at the relevant stage of the investigation and includes a direct link to the new form. • A comprehensive communication has been circulated across the organisation, outlining the new process, the rationale for its introduction and the tragic circumstances that brought the issue to light.
Dennis Price
All Responded
2026-0037 23 Jan 2026 South Yorkshire East
Doncaster Royal Infirmary
Concerns summary (AI summary) Failures in inpatient post-fall reviews, unclear neurological observation plans, and inefficient electronic system escalations compromised patient safety.
Action Taken (AI summary) • The Trust has a Patient Falls Prevention and Management Policy (PAT/PS 11) in place and accessible via the Trust intranet. • Following Mr. Price's death, it was found that the Inpatient Post-Fall Review documentation was not fully completed, though healthcare professionals acted in accordance with the policy. • The Trust emphasizes the importance of accurate and comprehensive documentation following inpatient falls for patient safety and effective communication.
Jean Groves
All Responded
2026-0036 23 Jan 2026 Norfolk
Careline365 Norfolk Swift Response
Concerns summary (AI summary) Emergency responders assisting ambulance services are not provided with crucial access details for vulnerable patients, potentially endangering lives during medical interventions.
Noted (AI summary) Norfolk County Council plans to issue a communication to all operational managers and reablement liaison officers to remind them to record every referral (accepted or declined) and all attempts to obtain access details in the Service User’s Liquid Logic record, to prevent recurrence of recording errors. Careline365 reviewed its internal procedures for recording and communicating property access information, confirming adherence to TEC Monitoring module standards and no operational failing on their part. They clarified that the ultimate provision of access details in multi-agency pathways is beyond their operational visibility once a call is escalated.
Tamara Logan
All Responded
2026-0035 22 Jan 2026 Manchester
Department for Work and Pensions
Concerns summary (AI summary) An incorrect benefits assessment, uncorrected by review, significantly impacted the deceased. Additionally, standard letters were sent despite recognised vulnerabilities, without attempting to reduce associated risks.
Action Taken (AI summary) • The department accepts that its initial decision to reduce Ms Logan’s benefits may have been unjustified. • The department investigated the decision and is taking steps to minimise such decisions in the future. • The department shares the coroner's concern that its decision may have influenced Ms Logan.
Clive Hyman
All Responded
2026-0034 22 Jan 2026 Inner North London
Association of the British Pharmaceutic… Medicines and Healthcare Products Regul… Medicines UK
Concerns summary (AI summary) Patient information leaflets for Apixaban do not adequately advise on actions following head trauma, risking delayed medical intervention for intracranial bleeds in patients taking anticoagulants.
Noted (AI summary) The ABPI, as a trade association without regulatory authority, has made the originator company, Bristol Myers Squibb (BMS), aware of the coroner's report and concerns regarding apixaban patient safety information and labelling. MedicinesUK states its member companies will comply with any future changes to product information regarding anticoagulants and head trauma warnings, should such changes be required by the MHRA. The MHRA has completed a preliminary assessment and initiated a full review across all Direct Oral Anticoagulants (DOACs) and warfarin regarding patient information leaflet warnings for head trauma, with plans to seek expert advice on potential updates.
George Ritchie
All Responded
2026-0039 21 Jan 2026 Worcestershire
Cardinal Healthcare
Concerns summary (AI summary) The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time staffing was not addressed, risking residents in this and other facilities.
Action Taken (AI summary) • The Home Manager was placed into disciplinary proceedings for failing to uphold policy, maintain effective oversight, and ensure compliance.
Dhananji Dona
All Responded
2026-0033 21 Jan 2026 Staffordshire
NHS England Royal Stoke University Hospital
Concerns summary (AI summary) The hospital failed to implement the specialist National Early Warning Score matrix for prenatal women across all departments, risking inadequate monitoring without plans for timely introduction.
Action Planned (AI summary) NHS England has published the Maternal Care Bundle (MCB) in January 2026, which includes a national mandate for implementing the Maternity Early Warning Score (MEWS) across all settings by March 2027, and has circulated draft MEWS specifications to digital suppliers. The Trust has established an operational group and plans to roll out a paper-based Maternity Early Warning Score (MEWS) process across the organisation by March 2027, supported by a robust training programme, and will also explore developing an in-house digital solution.
Linda Fury
All Responded
2026-0029Deceased 20 Jan 2026 Manchester South
Pennine Care NHS Foundation Trust
Concerns summary (AI summary) The Trust's investigation into Linda's discharge was insufficient, failing to adequately analyze the lack of local beds, decision-making process, and capacity assessment. Current ward rounds also prevent private disclosure of family concerns regarding risk.
Action Taken (AI summary) The Trust has made Carer Awareness Training mandatory for all frontline staff and implemented strengthened MDT documentation, patient and carer submission forms, enhanced ward-round communication pathways, and improvements to PARIS functionality to improve carer engagement and reduce risks.