PFD Response Tracker

Malcolm Budd

Addressed to: Nottingham University Hospital NHS Trust

0 responses identified · 1 indexed addressee

Malcolm Budd

Addressed to: NHS England

1 response identified · 1 indexed addressee

Alan Hirst

Addressed to: College of Policing; National Police Chief’s Council

2 responses identified · 2 indexed addressees

Glyn Pressley

Addressed to: Chief Medical Officer for Welsh Government

1 response identified · 1 indexed addressee

Cody Stock

Addressed to: National Highways; North Northamptonshire; West Northamptonshire

1 response identified · 3 indexed addressees

Tia Birkitt

Addressed to: EPUT INQUESTS; [REDACTED] and [REDACTED]

1 response identified · 2 indexed addressees

Marie Bell

Addressed to: NHS England

1 response identified · 1 indexed addressee

Alison Thomas

Addressed to: The Grove Surgery

1 response identified · 1 indexed addressee

Philip Quelch

Addressed to: Care Quality Commission; Crouched Friars Residential Home; Essex Adult Social Care

3 responses identified · 3 indexed addressees

Gemma Robins

Addressed to: Foundation Trust; Chief Executive Royal Surrey NHS Foundation Trust; Chief Executive, University Hospitals Sussex NHS

3 responses identified · 3 indexed addressees

Eleisha Skinner

AI-generated concerns summaryThe coroner identified issues with the driveway's safety, including the absence of a protective barrier at a sheer drop and a lack of clear procedures for managing icy conditions. Concerns were also raised regarding the absence of instructions for safe vehicle unloading to prevent run-away incidents.

Addressed to: Howarth Properties LTD

1 response identified · 1 indexed addressee

Eden Henry

Addressed to: Department of Health and Social Care; London Association of Directors of Public Health

2 responses identified · 2 indexed addressees

Aylina Akhmadova

Addressed to: Institute of Health Visiting; Royal College of General Practitioners; Royal College of Midwives

3 responses identified · 3 indexed addressees

Scott Taylor

AI-generated concerns summaryThere are a limited number of tertiary centres for treatment-resistant OCD in the UK, predominantly in London and the South East, which limits access for complex cases due to capacity, criteria, and geographical distribution.

Addressed to: Department of Health and Social Care

2 responses identified · 1 indexed addressee

John Wetton

Addressed to: Alexander House Care Home; Department of Health and Social Care; Valorum Care Group

1 response identified · 3 indexed addressees

Bernadetter Roasario

Addressed to: Chief Constable, Devon & Cornwall Police; Head of Operations south-

1 response identified · 2 indexed addressees

Bethany Hewitt

Addressed to: Grove House Medical Practice; Secretary of State for Health & Social Care

4 responses identified · 2 indexed addressees

Graham Hollis

AI-generated concerns summaryThe Speech and Language Therapy service was unable to conduct assessments of care home residents due to staffing levels, which led to a decision to feed a resident with accepted risk without specialist assessment.

Addressed to: Staffordshire and Stoke-on-Trent Integrated Care Board; University Hospitals of Derby and Burton NHS Foundation Trust

2 responses identified · 2 indexed addressees

Johnpaul Digweed

Addressed to: HM Prison & Probation Service

1 response identified · 1 indexed addressee

Susan Dale

AI-generated concerns summaryThe care home had inaccurate record-keeping, did not follow its falls policy regarding moving a resident with a suspected head injury, and lacked proper handover between shifts concerning resident incidents.

Addressed to: Care Quality Commission; Westfield Residential Home

2 responses identified · 2 indexed addressees

Kerry Singh

AI-generated concerns summaryThe coroner noted insufficient early specialist centre involvement and patient consultation for a complex procedure. Concerns were also raised about William Harvey Hospital's systems for tracking critical test results and ensuring referral completion.

Addressed to: East Kent Hospitals University NHS Foundation Trust

1 response identified · 1 indexed addressee

David Joyce

AI-generated concerns summaryConcerns include the GP surgery's lack of follow-up and consideration of specialist mental health referral for deteriorating mental health. The coroner noted medication was prescribed without psychiatrist input, and there was a 15-week delay in adjusting the patient's medication.

Addressed to: Foxhayes Surgery GP Practice

1 response identified · 1 indexed addressee

Naeem Ahmed

AI-generated concerns summaryConcerns exist that other Trusts might still use practices of disposing small volumes of drugs into sharps bins without denaturation and that doctors may work excessive hours across multiple providers due to unintegrated rostering systems.

Addressed to: Department of Health and Social Care; NHS England

2 responses identified · 2 indexed addressees

Nola-Reign Morgan

AI-generated concerns summaryThe coroner notes a lack of national and local guidance for antenatal fetal monitoring in suspected chorioamnionitis, insufficient staff training, and an unaddressed delay in patient transfer between wards.

Addressed to: Aneurin Bevan University Health Board; Cabinet Minister for Health and Care; Health Inspectorate Wales; National Institution for Health and Care Excellence; Royal College of Midwives; Royal College of Obstetricians and Gynaecologists

0 responses identified · 6 indexed addressees

Pauline Margerat Bradley

Addressed to: Hull University Teaching Hospital; NHS England; NHS Humber and North Yorkshire ICB

2 responses identified · 3 indexed addressees

Jacqueline O’Brien

Addressed to: Worcestershire Acute Hospitals NHS Trust

1 response identified · 1 indexed addressee

John Philips

AI-generated concerns summaryThe SystmOne electronic patient record system can deactivate a patient's active record when a previous organisation accesses it, removing current care plans and risking unsafe clinical care. A national technological solution is preferable.

Addressed to: NHS England

1 response identified · 1 indexed addressee

Isabelle Bridie Sapherson-Moralee

Addressed to: NHS England; Department of Health and Social Care

2 responses identified · 2 indexed addressees

Geoffrey Fuller

Addressed to: Department of Health and Social Care

1 response identified · 1 indexed addressee

Jake Read

AI-generated concerns summaryThe coroner noted a lack of national guidance and timelines for administering medication in mental health crises, which contributed to a significant delay in Jake receiving Diazepam. Additionally, Mental Health Liaison Team prescribers at the hospital lacked direct access to medication, causing further delays.

Addressed to: Department of Health and Social Care

1 response identified · 1 indexed addressee

Catherine Kirkham

Addressed to: Chief Executive of Tameside General Hospital; Secretary of State for Health and Social Care

1 response identified · 2 indexed addressees

Muluembet Yohanes

AI-generated concerns summaryThe coroner identified gaps in the NHS 111 Pathways system, noting the absence of a dedicated category for neurosurgery patients and that call handlers did not ask about post-surgical 'red flag' discharge advice.

Addressed to: NHS England

1 response identified · 1 indexed addressee

Saffron Cole-Nottage

Addressed to: Chief Constable JESIP National Police Strategic Lead and Senior Responsible Officer, JESIP Interoperability Board Chair; Chief Executive Officer, East of England Ambulance Service NHS Trust (EEAST); Chief Executive Officer, NHS England

3 responses identified · 3 indexed addressees

Trevor Ridd

AI-generated concerns summaryThe coroner identified issues with unclear procedures, training, and operator information for handling quick-succession sprinkler system signals, potentially affecting emergency calls. There was also no evidence of regular system testing or maintenance.

Addressed to: Birmingham City Council

1 response identified · 1 indexed addressee

Derek Burt

AI-generated concerns summaryThe report identifies insufficient awareness and training within ambulance services and careline companies for using careline systems for direct communication and handling third-party emergency calls. Critical information was also not fully relayed.

Addressed to: Appello Careline Operations Director; Association of Ambulance Chief Executives; NHS England; South East Coast Ambulance Service NHS Foundation Trust; Telecare Services Association

5 responses identified · 5 indexed addressees

Daniel Forrest

AI-generated concerns summaryThe coroner notes that NHS Pathways advises callers an ambulance is being arranged, but for lower priority calls, dispatch is delayed by clinical validation without informing the caller. Additionally, callers cannot be advised of estimated waiting times for an ambulance.

Addressed to: NHS England & NHS Improvement; South East Coast Ambulance Service NHS Foundation Trust

1 response identified · 2 indexed addressees

Aaron Hamer

AI-generated concerns summaryThe majority of prison officers do not receive mandatory refresher training in basic life support after their initial training, which could impact emergency response.

Addressed to: Prison, Probation and Reducing Reoffending

1 response identified · 1 indexed addressee

Alex Ganski

AI-generated concerns summaryThe coroner identified a lack of a designated lead or single point of contact for young people with complex health and drug issues, leading to fragmented information sharing among agencies. There is also an absence of a national mechanism to highlight significant historical health and drug misuse risks across patient record systems.

Addressed to: Department of Helath and Social Care; NHS England

1 response identified · 2 indexed addressees

Suzanne Fredericks

AI-generated concerns summaryConcerns were raised that non-specialist hospitals may not provide sufficiently up-to-date blood test results for transplant patients, impacting survival, and the processes for handling samples may need improvement.

Addressed to: Addenbrooke’s Hospital; East Suffolk and North Essex NHS Foundation Trust; NHS England

2 responses identified · 3 indexed addressees

Barry Davies

AI-generated concerns summaryNeurological observations for Mr Davies were not performed as frequently as they should have been, and a nurse discontinued them prematurely before his second CT scan.

Addressed to: Northen Care Alliance

1 response identified · 1 indexed addressee

Linda Green

Addressed to: Whittington Health NHS Trust

1 response identified · 1 indexed addressee

Linda Green

Addressed to: Association of Anaesthetists; Royal College of Anaesthetists

1 response identified · 2 indexed addressees

Ismaeel Islam

AI-generated concerns summaryThe coroner raises concerns that the monitor manufacturer has not yet made a decision regarding the hospital's request to lock or default alarm volumes to maximum, which could enhance patient safety.

Addressed to: Masimo UK

1 response identified · 1 indexed addressee

Linda Green

Addressed to: NHS England

1 response identified · 1 indexed addressee

Lesley Higginson

AI-generated concerns summaryThe coroner identified a need for clarity on the ambulance service's policy for declining welfare calls and how this aligns with the police's 'Right Care Right Person' policy, which creates uncertainty about responsibility for welfare checks.

Addressed to: North West Ambulance Service

1 response identified · 1 indexed addressee

Judith Marsland

AI-generated concerns summaryThere was an error in not escalating abnormal blood results, leading to patient deterioration, and key parts of the action plan for structured cross-team handovers and named responsible clinicians are not yet implemented.

Addressed to: Tameside and Glossop Integrated Care NHS Foundation Trust

0 responses identified · 1 indexed addressee

Edie Smart

AI-generated concerns summaryAmbulance Support Practitioners, who are often first on scene at out-of-hospital cardiac arrests, are trained to use i-gels for airway securement only under paramedic supervision.

Addressed to: North East Ambulance Service

1 response identified · 1 indexed addressee

Charlotte Saunders

AI-generated concerns summaryThe road layout around a busy supermarket and town centre encourages pedestrians to cross a busy ring road at an unguarded point, despite nearby controlled crossings, posing a risk of future collisions.

Addressed to: National Highways; Staffordshire County Council

1 response identified · 2 indexed addressees

Barbara Cope

AI-generated concerns summaryDelays in commencing critical medication stemmed from a lack of communication and follow-up on abnormal blood test results, which were not reviewed despite clinical deterioration. Concerns were also raised about unclear responsibility for ongoing patient care between departments.

Addressed to: Rotherham District General Hospital

1 response identified · 1 indexed addressee

Keith Gandy

AI-generated concerns summaryThe coroner noted a lack of guidance for GPs on prior cancer as a red flag for specialist referral without further tests. Waiting times for specialist evaluation in these circumstances are between six to twelve months.

Addressed to: NHS England

1 response identified · 1 indexed addressee