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
Martin Bryant
All Responded
2026-0030 19 Jan 2026 Essex
Essex University Partnership Trust NHS England
Concerns summary (AI summary) Mental health crisis patients face dangerously long waits in open reception areas due to a severe lack of local and national mental health beds, and inadequate facilities for appropriate waiting.
Action Taken (AI summary) NHS England is rolling out dedicated 24/7 neighbourhood mental health centres and specialist Mental Health Emergency Departments, and has reinforced patient flow improvement as a key priority in its 2025/26 operational planning guidance, with plans to reduce Out of Area Placements. EPUT has changed management processes to include risk assessments for patients waiting in reception, secured capital funding for Mental Health Urgent Care Department (MHUCD) refurbishment with approved plans for dedicated spaces, and implemented a Therapeutic Acute Inpatient Operating Model.
Wayne Walton
All Responded
2026-0028 16 Jan 2026 Coventry
Mental Health Directorate
Concerns summary (AI summary) Inpatient staff lacked awareness of Home Treatment Team policies, leading to inadequate risk assessments and safety plans. There is also no guidance for managing potential conflicts of interest when staff recognise patients outside of personal relationships.
Action Taken (AI summary) The Trust updated its patient transfer and discharge policy in February 2026 with clear guidance for inpatient teams on documentation for Home Treatment Team (HTT) discharges, implemented an 'end of shift' handover form, and developed scenario guidance for staff on professional boundaries while a new policy is being developed.
Matilda Pomfret-Thomas
All Responded
2026-0025 15 Jan 2026 Hampshire, Portsmouth Southampton
Department of Health and Social Care NICE Nursing and Midwifery Council
Concerns summary (AI summary) A lack of regulation, registration, and clear guidance for doulas creates confusion about their role, risks them working outside clinical boundaries, and poses challenges for midwives and patient care.
Disputed (AI summary) NICE acknowledged the concerns but stated that the registration, regulation, and training of doulas are not their responsibility and are better addressed by other bodies such as the NMC, RCM, and RCOG. Developing Doulas submitted a voluntary response, disputing the perception that the doula's presence negatively impacted midwifery services. They argued that the doula acted within a non-clinical support role and that difficulties highlight the need for strengthening communication and collaborative working with non-clinical supporters. The Department of Health and Social Care acknowledged concerns about unregulated doulas, clarified their current status as non-regulated professionals, and outlined the roles of other bodies like the NMC and NICE. They stated that NHS England will not be producing guidance for midwives' interactions with doulas. The NMC has updated its guidance and collaborated with Doula UK to launch a video resource clarifying the distinct roles of midwives and doulas to support positive maternity experiences. They stated that doula registration, regulation, and training are beyond their remit and a matter for government policy.
Ronald Nelson
All Responded
2026-0024 15 Jan 2026 Nottingham City and Nottinghamshire
Care Quality Commission Mulberry Court Care Home
Concerns summary (AI summary) Concerns remain regarding poor record keeping and inadequate compliance with care plans, which pose a risk to future patient safety.
Action Taken (AI summary) The CQC has taken regulatory actions by requiring the care home to submit an action plan, conducting a focused inspection, publishing an 'Inadequate' rating report, and issuing a Warning Notice regarding record keeping and care plan compliance. They will continue to monitor the service closely. Mulberry Court Care Home has implemented new systems and processes for record keeping and care plan compliance, including an enhanced staff training programme and updated care plan templates and risk assessments. They have also strengthened clinical oversight and communication processes following hospital discharge.
Margaret Grimsley
All Responded
2026-0022 15 Jan 2026 Shropshire, Telford and Wrekin
Shewsbury and Telford Hospital Trust
Concerns summary (AI summary) The apparent absence or non-use of an upper alarm setting on bedside oxygen meters risks over-oxygenation, with unclear policies on its implementation or whether it is standard practice.
Noted (AI summary) The Trust explained that while patient monitors have upper oxygen alarm functionality, it is not used as the greatest risk is low blood oxygen levels, with focus on lower alarms and regular monitoring. They apologised for a previous inconsistency between a consultant's evidence and a letter to the family, clarifying the consultant's information was correct.
Mark Turner
All Responded
2026-0065 14 Jan 2026 Staffordshire
Midlands Partnership Foundation Trust NHS England
Concerns summary (AI 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.
Noted (AI summary) • Midlands Partnership University Hospitals Trust has a Standard Operating Procedure (SOP) in place relating to clozapine. • The SOP sets out the criteria which need to be adhered to when using clozapine to ensure safe and effective practice and includes information and support to clinicians in relation to the prescribing, monitoring, administration and supply of clozapine. • Appendix 1 of the SOP provides a guide for clinicians to follow when assessing clozapine serum levels depending
Oliver Long
All Responded
2026-0021 14 Jan 2026 East Sussex
Department for Digital Culture, Media a… Department for Education Department of Health and Social Care +1 more
Concerns summary (AI summary) The self-exclusion scheme (GamStop) fails to protect individuals from unlicenced overseas gambling sites, which target vulnerable users. There is a critical lack of public health information regarding these risks.
Noted (AI summary) The Department of Health and Social Care acknowledges receipt of the report and states that the Department for Culture, Media and Sport is leading the development of a single cross-agency response, with DHSC contributing particularly in respect of public health considerations. The Department for Education acknowledges the concerns raised but states that responsibility for the matters lies outside its remit. The Gambling Commission acknowledges the concerns but states that the action proposed in the report falls outside of the Commission’s remit, but remains willing to share information and cooperate with relevant bodies. The Department of Culture, Media and Sport stated the government has pressed technology companies to prevent promotion of illegal gambling sites and the Gambling Commission developed guidance for consumers to identify licensed sites. They are also developing a new strategy, will publish a consultation response on financial risk checks, and are working to improve gambling-related harm education.
Stephen Taylor
All Responded
2026-0020 14 Jan 2026 Kent and Medway
Kent and Medway Mental Health Trust Vita health Group : Kent and Medway Tal…
Concerns summary (AI summary) Multiple services failed to coordinate risk escalation for escalating mental distress, relying on patient denial despite high-risk indicators. Urgent mental health referrals and family concerns were not actioned promptly or effectively.
Action Taken (AI summary) Vita Health Group updated its Duty Standard Operating Procedure in November 2025 to include explicit reference to managing routine referrals and considering family members’ information, and held a reflective session with the Duty Team to share learning from the case. Kent and Medway Mental Health NHS Trust has updated its Urgent Mental Health Helpline Standard Operating Procedure to clarify high-risk categories, mandates reviewing clinical records, and reduced urgent referral triage times to 24 hours. They have also implemented a visual aid for urgent 4-hour assessments and are delivering staff training on these new procedures and risk assessment.
Dorothy Hoyberg
All Responded
2026-0019 14 Jan 2026 Inner North London
Department of Health and Social Care
Concerns summary (AI summary) Extreme pressure on ambulance services, operating at REAP Level 4, resulted in severe delays, unmet targets, and inability to make welfare calls, demonstrating that demand consistently outstrips capacity.
Action Taken (AI summary) The Department of Health and Social Care highlighted the publication of the 2025/26 Urgent and Emergency Care Plan and the 10-Year Health Plan, committing to reducing ambulance response times and improving clinical validation. They noted that London Ambulance Service has implemented a new dispatch model and a recovery plan, including dedicated clinical support, to improve patient care and reduce delays.
Peter Thompson
All Responded
2026-0018 13 Jan 2026 Derby and Derbyshire
Bank Close House Residential Care Home
Concerns summary (AI summary) Care home staff failed to perform routine blood sugar tests on a diabetic resident, delaying critical diagnosis. A lack of formal shift handovers also prevents timely escalation of deteriorating conditions.
Action Taken (AI summary) Bank Close House has instructed staff to request a blood glucose test from external healthcare professionals if a diabetic resident shows signs of illness and has asked GP surgeries to provide each diabetic resident’s HbA1c level.
Heidi Williams
All Responded
2026-0017 13 Jan 2026 Northamptonshire
Essex Police
Concerns summary (AI summary) Evidence showed the deceased ordered numerous tablets from an individual linked to known addresses, but Essex Police have refused Northamptonshire Police's request to investigate the matter.
Action Taken (AI summary) Essex Police is now investigating the alleged drug supply, led by the Serious Violence Unit, and intends to take enforcement action including arrests and searches. They will also update the Essex Coroner regarding the concerns and share relevant learning and operational actions.
Rory Williams
All Responded
2026-0016 13 Jan 2026 North Wales (East and Central)
Betsi Cadwaladr University Health Board
Concerns summary (AI summary) The gastroenterology/endoscopy service suffers from critical staffing shortages, inadequate infrastructure, and excessively long waiting times. These systemic failures are not adequately reflected on the corporate risk register.
Action Planned (AI summary) Betsi Cadwaladr University Health Board is progressing work on developing an Integrated Digestive Disease Service, with shared clinical leadership, standardised pathways, coordinated workforce planning and strengthened governance, under executive sponsorship.
Jean Waldron
All Responded
2026-0009 8 Jan 2026 Worcestershire
Ignite Health and Homecare Services
Concerns summary (AI summary) An agency team leader disregarded clear instructions by providing inappropriate wound care, suggesting inadequate training on care limits and adherence to specialist medical advice for carers.
Action Taken (AI summary) The agency has reinforced guidance to staff clarifying that wound care is outside their scope, issued formal reminders about escalating clinical concerns, and reviewed supervision processes to ensure adherence to scope-of-practice boundaries.
Drew Greaves-Pimblett
All Responded
2026-0008 8 Jan 2026 Sefton, St Helens and Knowsley
NHS England
Concerns summary (AI summary) National telephone triage pathways lack adequate guidance for call handlers on probing questions for critical symptoms like breathing and body temperature, hindering accurate assessment for CPR.
Noted (AI summary) NHS England acknowledges the concerns and notes that the North West Ambulance Service followed protocol, but also outlines national work taking place around Reports to Prevent Future Deaths, ensuring learnings are shared across the NHS.
David Dugdale
All Responded
2026-0007 8 Jan 2026 East Sussex
East Sussex Healthcare NHS Trust
Concerns summary (AI summary) Inadequate pain management, lack of nutritional support, and severe neglect of a pressure sore, exacerbated by nursing staff ignoring carers' concerns, led to significant deterioration.
Action Planned (AI summary) East Sussex Healthcare NHS Trust will implement measures for clinical teams to liaise with family members to understand how the patient typically expresses pain and what interventions have previously been effective, and a business case is being developed to explore additional support for the Learning Disability Nurse role.
Mohammed Choudhury
All Responded
2026-0005 6 Jan 2026 Bedfordshire and Luton
East London NHS Foundation Trust
Concerns summary (AI summary) Inadequate management of a patient's paranoid schizophrenia included failure to address non-concordance with anti-psychotic medication and withdrawal of medication support without GP checks, despite known risks.
Action Taken (AI summary) The Trust has reviewed and reinforced its policy on medication non-concordance, embedded an audit cycle to ensure compliance, and trained staff to access and use the NHS Summary Care Record to verify prescription issues.
Suzanne Pemberton
All Responded
2026-0003 5 Jan 2026 Essex
East Suffolk and North Essex NHS Founda…
Concerns summary (AI summary) The hospital lacks any specialist dietetic service outside weekday working hours, risking delays in crucial nutritional interventions like naso-gastric feeding and potential non-adherence to re-feeding guides.
Action Planned (AI summary) The Trust has undertaken a project to ensure all relevant ward areas receive consistent and compliant training related to dietetic care planning, will monitor adherence with dietetic care planning in real time, is carrying out a therapeutic review of processes, and is seeking to develop an escalation process for out of hours periods.
Adam Hussain
All Responded
2026-0002 5 Jan 2026 Nottinghamshire
East Midlands Ambulance Service NHS Tru… NHS England Nottingham and Nottinghamshire Integrat… +1 more
Concerns summary (AI summary) The urgent care pathway poorly serves serious systemic illnesses like sepsis, with critical patient information not reliably used by ambulance staff, leading to unnotified ambulance cancellations and unsafe call transfers.
Action Planned (AI summary) The ICB facilitated a system wide After-Action Review (AAR) to enable collaborative learning and improvement across all relevant partners, and improvement initiatives identified by the review will be taken through and monitored for assurance within the existing governance for the relevant systems. EMAS has worked with partners to develop a Sepsis Observation Safety Net, implemented enhanced clinical review processes prior to call transfer, and ceased manual ITK push transfers to NEMS. NEMS has stopped manually pushing calls, implemented a standardised Sepsis Observation Safety Net, and provided additional training and resources to clinicians; furthermore data sharing agreements are in place to share discharge summaries and admission avoidance alerts. The ICB facilitated a system wide After-Action Review, EMAS have stopped the ITK push of calls, a review and redefinition of the existing UCCH service specification has occurred, and analytics team have developed the ability to join up multiple data sets to understand patient journeys.
Jake Hartwright
All Responded
2026-0001 5 Jan 2026 Nottinghamshire
East Midlands Ambulance Service NHS Tru… NHS England Nottingham and Nottinghamshire Integrat… +1 more
Concerns summary (AI summary) The urgent care pathway poorly serves non-immediately life-threatening systemic illnesses, as detailed 111 information is unreliably used by EMAS, families are uninformed of ambulance cancellations, and transfer criteria between services are unclear.
Action Planned (AI summary) The ICB facilitated a system wide After-Action Review (AAR) to enable collaborative learning and improvement across all relevant partners, and improvement initiatives identified by the review will be taken through and monitored for assurance within the existing governance for the relevant systems. EMAS clinicians now review all available information prior to transferring calls, and clinically assessed calls are no longer pushed to any EMAS Clinical Assessment Service (CAS). Manual ITK push transfers to NEMS have ceased. NEMS implemented changes to clinical practice and referral processes, including revised sepsis screening tools, enhanced clinical oversight, and improved information sharing with system partners. They have also invested in staff training and equipment to improve the management of complex patient presentations. The ICB facilitated a system-wide After-Action Review, reviewed and redefined the UCCH service specification, and developed the ability to join up multiple data sets to understand the patient journey across the pathway. They also committed to sharing PFD learning and assurance actions across multiple committees and processes.