CQC
PFD Addressee
Reports: 188
Earliest: Aug 2013
Latest: 8 Apr 2026
61% 2-year response rate (below 83% average). 44% of classified responses show concrete action taken.
PFD Reports
188 resultsSheila Ridgway
Historic (No Identified Response)
2018-0229-wp26291
16 Jul 2018
Manchester (City)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A lack of systemic communication between specialty consultants prevents identifying and documenting potential ongoing risks when patients receive simultaneous treatments from different departments.
Ashley Notson
Historic (No Identified Response)
2018-0207
29 Jun 2018
Suffolk
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
There is no legal requirement for care home carers to have first aid training or to carry mobile phones, posing a risk in emergency situations.
Colin Johns
Historic (No Identified Response)
2018-0203
18 Jun 2018
Black Country
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
There was inadequate communication and history-taking during mental health assessments, failing to record critical self-harm attempts, and insufficient effort to find a suitable bed for a high-risk patient.
Rita Taylor
Partially Responded
2018-0225
12 Jun 2018
Surrey
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate management of hyponatraemia, including a consultant's failure to seek expert advice and non-adherence to national guidelines, resulted in a lack of a coherent patient care plan.
Action Taken
(AI summary)
The Trust has revised its procedures and processes to ensure that all patients with hyponatraemia will have a clear treatment plan to correct their sodium in line with recognised guidance. The case was also presented at the Epsom Hospital Grand Round meeting and circulated to all consultants within the Trust.
Kevin Freely
Historic (No Identified Response)
2018-0180
7 Jun 2018
London (West)
Community health care and emergency services related deaths
Concerns summary (AI summary)
Insufficient awareness and adherence to fire safety warnings regarding paraffin-based emollients, smoking in bed, and air-flow mattresses, combined with inadequate risk assessments, pose significant fire risks.
Doris Ridgwell
Partially Responded
2018-0151
15 May 2018
Surrey
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A critical communication failure meant an abnormally high INR result for a Warfarin patient was not effectively relayed or acted upon before discharge, leading to fatal complications.
Action Taken
(AI summary)
The Trust has revised its Standard Operating Procedure for telephoning coagulation results to ensure urgent abnormal blood results are communicated effectively, including escalation to the Site Manager if necessary. It has also re-issued guidance to clinical staff clarifying their responsibility to communicate clinically urgent abnormal blood results to patients and take appropriate action, even after discharge.
Gladys Rich
Partially Responded
2018-0149
14 May 2018
Northamptonshire
Care Home Health related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The care home failed in fall risk assessment and action plan implementation, while the under-resourced Falls Prevention Service lacked proactive follow-up and discharge mechanisms.
Action Planned
(AI summary)
The care home will contact the Falls Team after sending referrals and action plans to confirm receipt and intended actions, recording all contact in residents' care plans.
William Dickens
Partially Responded
2018-0137
8 May 2018
London Inner (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Hospital observation protocols for high-risk patients were not followed, and observation logs were retrospectively falsified, compromising patient safety and preventing timely intervention.
Action Planned
(AI summary)
The Director of Nursing will issue a safety alert, and ward managers will hold learning conversations with nurses regarding observation practices. The Therapeutic Engagement and Observation Policy will be reviewed, and new nurses and nursing trainees will receive a "Learning the Lessons" presentation. Six-monthly audits will be commissioned to establish compliance, and a timeline is being developed for transforming observations into an e-observation framework.
Barbara Haley
Historic (No Identified Response)
2018-0095
3 Apr 2018
Manchester (South)
Care Home Health related deaths
Concerns summary (AI summary)
Staff provided unsuitable food to a high-risk choking patient on a soft diet and left her unsupervised during meals, contrary to safety assessments.
David Sketchley
Partially Responded
2018-0069
9 Mar 2018
Gloucestershire
Care Home Health related deaths
Concerns summary (AI summary)
The investigation into a patient's death was inadequate, failing to determine supervision levels, collaborate with manufacturers, identify incident cause, or properly assess equipment suitability.
Noted
(AI summary)
The CQC is gathering evidence into this matter with a view to deciding whether there has been a failure by BUPA and/or the Registered Manager to comply with the Health and Social Care Act 2008 and will contact BUPA to request a copy of their response to the prevention future death report.
Vanessa Ferkova
Historic (No Identified Response)
2023-0414
26 Jan 2018
Inner North London
Child Death
Concerns summary (AI summary)
The walk-in centre's triage process was judged adequate by the CQC despite lacking vital clinical observations, unlike secondary care, creating an unacceptable safety risk for unscreened patients.
Ronald Farrington
Partially Responded
2017-0494
22 Dec 2017
Surrey
Care Home Health related deaths
Concerns summary (AI summary)
The care centre failed to implement specialist nursing advice, kept inaccurate records, and didn't seek medical attention for infection, exacerbated by inadequate tissue viability nurse staffing and poor CQC oversight.
Action Taken
(AI summary)
Surrey County Council has improved systems to identify long running adult safeguarding enquiries and take actions to bring them to a satisfactory conclusion, and has reduced the percentage of enquiries in progress for over 12 months. The care home has implemented structures and processes to avoid similar situations, including computerized care plans for wound and tissue care, regular reviews, and updates based on professional visits, audited by staff and SMT.
Anne Morris
Partially Responded
2017-0383
18 Dec 2017
London Inner (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Hospital staff did not contact friends and relatives after the patient consented, and there was no written plan identifying the responsible team for onward care in the community. The community team also did not proactively contact the hospital for a discharge plan.
Action Planned
(AI summary)
Priory Group has reviewed and re-launched its Admission, Transfer and Discharge Policy and plans a rolling programme of training webinars in 2018, where discharge planning and communication with family/friends will be highlighted. Oxleas Home Treatment Team now contacts the referring organisation to request discharge information within 24 hours if it's not received, and the 'Transfer of Care within Oxleas and externally' protocol has been reviewed to ensure standardisation across all Oxleas services.
Joseph Dune
Historic (No Identified Response)
2017-0371
12 Dec 2017
Isle of Wight
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Significant breaches in Information Governance allow clinicians to alter patient records under incorrect logins, making these critical changes invisible to treating clinicians and compromising data integrity.
Stephen Coulson
Partially Responded
2017-0307
27 Oct 2017
Manchester (City)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate systems for controlled drug management and patient observation policies, coupled with a failure to learn from investigations, posed risks to patient safety.
Action Taken
(AI summary)
The Trust has updated its Controlled Drug Policy, updated the Opiate Patch Monitoring Form, amended nursing admission documentation, developed education around delirium and neurological assessment, implemented a new electronic neurological observation chart, and educated doctors on fentanyl patch prescribing. The CDAO reports incidents into a reporting system to share lessons learned. CQC obtained and reviewed the Trust's revised action plan and will monitor its implementation during quarterly engagement meetings and future inspections. They also considered whether further regulatory action was needed but found no evidence of a systemic issue.
Sam Crick
All Responded
2017-0457
25 Aug 2017
Cambridgeshire and Peterborough
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Missed neuroradiological findings and a critical report's unavailability to the neurosurgeon led to undetected brain herniation and rising intracranial pressure. The absence of a Serious Incident Report further hindered learning from this preventable death.
Action Planned
(AI summary)
The Trust will review externally reported deaths weekly as part of a Morbidity and Mortality session to identify lessons and feedback to referring hospitals, as part of the ongoing SIR investigation. They have developed a 'Learning from Deaths' policy to respond to and learn from deaths of patients under their management. The CQC has requested written confirmation and evidence from Barking, Havering and Redbridge University Hospital NHS Trust (BHRUT) regarding actions taken following the death and any additional actions they intend to take. They are planning to inspect specific core services at BHRUT in the first part of 2018, including a 3-day in-depth inspection of the leadership and governance of the trust. NHS England will work with the Society of British Neurological Surgeons (SBNS) and the Royal College of Emergency Medicine to produce and distribute a guidance statement nationally within the next 6 months, focusing on treating patients with raised intracranial pressure and urging extreme caution in relation to the use of opiates. NHS England will also seek assurances from the Trust that they have addressed the concerns raised and will suggest an independent review of the case management.
Francesca Whyatt
Partially Responded
2017-0248
21 Aug 2017
London Inner (West)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Key safety gaps include no risk assessment for ward configuration, inadequate guidance on agency staff observation competency, and the failure to automatically treat ligature incidents as Serious Untoward Incidents (SUIs), despite the rapid risk of death.
Action Taken
(AI summary)
The Priory Hospital Roehampton details environmental and health and safety risk assessments undertaken and coordinated with Policy H43 Observation and Engagement throughout the ward. The Incident Management; Reporting and Investigation Policy (OP4) has been updated to include a requirement that serious self-harm incidents will require an SBAR notification to be made and further investigation will be commissioned.
Helen Cannon
Partially Responded
2017-0260
16 Aug 2017
Manchester (City)
Community health care and emergency services related deaths
Concerns summary (AI summary)
Emergency responders failed to seek medical assistance for a patient with internal hemorrhage after a fall, misinterpreting her symptoms. A subsequent flawed investigation failed to identify critical inaccuracies in risk assessment completion and staff understanding.
Noted
(AI summary)
Illegible response.
Michael Bingham
Partially Responded
2017-0322
31 Jul 2017
Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Harbour Healthcare failed to implement alarms for insecure internal doors, highlighting a risk assessment "blind spot." The CQC must review regulations and inspection procedures for door safety, and Stockport NHS guidelines lack clarity on CT scan requirements.
Action Taken
(AI summary)
Harbour Healthcare has completed work on internal doors at Hilltop Court, installing screech alarms or box panels, and has fitted screech alarms to internal emergency exit doors at other care homes. They have also completed risk assessments and implemented new internal procedures with regular drills.
Maureen Colclough
All Responded
2017-0318
27 Jul 2017
Cheshire
Care Home Health related deaths
Concerns summary (AI summary)
Care home staff received inadequate training to recognise emergency situations and relied on presumptions when encountering an unresponsive patient.
Action Taken
(AI summary)
CQC has raised the provider's failure to notify them of the death, conducted an inspection, found all staff received basic life support training in August/September 2017 with additional training in late September/early October, and is taking substantive enforcement action requiring an action plan to improve care. Unique Care Services has notified all employees and revised performance appraisals to include recognizing emergency situations, ensured new starters receive relevant information, and mandated extra Emergency First Aid training for all employees.
Percy Jacks
All Responded
2017-0329
27 Jul 2017
South Wales Central
Community health care and emergency services related deaths
Concerns summary (AI summary)
Communication breakdowns between hospital, GP, and care homes, including incorrect information transfer and inadequate medication review systems, led to poor DVT management.
Noted
(AI summary)
Healthcare Inspectorate Wales (HIW) has noted the inquest findings and will use the information to inform their ongoing review of discharge arrangements, focusing on communication and documentation between secondary and primary healthcare, and will discuss collaboration with CSSIW regarding communication between health services and care homes. Rhayader Group Practice has implemented a system to record and follow up DVT referrals, inform patients with positive DVT results and prescribe Rivaroxiban, and fast-track medical records for new patients registering from nursing/care homes; they will audit the process in 6 months. Hywel Dda Health Board has streamlined the process for managing potential DVT patients with a direct referral pathway to the Radiology Department, a pre-printed letter from on-call physicians to the GP, and a specific proforma completed on discharge for patients from care homes; they investigated and addressed an incorrectly addressed discharge summary, noting improvements in access to the Welsh Clinical Portal. CQC had no prior knowledge of the death. They contacted Pencombe Hall care home and Cantilupe Surgery in Herefordshire, reviewed information transfer procedures, and consider their current inspection methodology covers relevant elements of care, and is satisfied that no additional policy change is required.
Sheila Gaskin
All Responded
2017-0328
27 Jul 2017
South Wales Central
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Despite an identified risk of smoking in bed, carers regularly assisted the deceased to smoke, due to a lack of management oversight and a clear prohibition policy.
Noted
(AI summary)
CSSIW cannot impose a blanket ban on care workers assisting service users to smoke, but will issue general guidance to care providers on assessing and mitigating health and fire risks associated with smoking, and exploring alternatives. CQC acknowledges the concerns, notes the service falls under CSSIW jurisdiction, and states their current inspection process covers governance systems, supervision, and accident/incident reviews, but does not support a blanket prohibition on assisting with smoking, preferring a case-by-case risk assessment.
James Allbones
Historic (No Identified Response)
2017-0336
21 Jul 2017
Nottinghamshire
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A lack of consultant paediatrician review, inadequate sepsis training, poor handover protocols, and insufficient paediatric staffing levels put sick children at serious risk.
James Harris
All Responded
2017-0334
21 Jul 2017
Birmingham and Solihull
Care Home Health related deaths
Concerns summary (AI summary)
Care home staff failed to read care plans, adhere to falls protocols, and provide medical attention after a fall, compounded by poor record-keeping and an absent registered manager.
Noted
(AI summary)
Care First Class UK has implemented read and sign sheets for care plans, provided a falls protocol to all staff, maintained records of nightly checks, and addressed pain management procedures; management staff are also monitoring records to address any issues arising. CQC acknowledges the concerns raised regarding Cherry Lodge Care Home, details actions taken by the provider, and explains its regulatory role and monitoring of the situation, including the need for a registered manager and ongoing assessments.
Pauline Taylor
Partially Responded
2017-0330
21 Jul 2017
West Yorkshire (West)
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Emollient creams with paraffin pose an unrecognised fire hazard due to inadequate warnings and lack of awareness, alongside insufficient patient risk assessments.
Action Planned
(AI summary)
MHRA has liaised with ArjoHuntleigh to confirm risk mitigation factors are appropriate and are working to communicate important healthcare information to healthcare professionals and the public through established alert systems. MHRA were also aware of and highlighted the work undertaken by the National Patient Safety Agency (NPSA) in 2007 regarding emollients. PAGB will provide a written submission to the MHRA by September 30th, 2017 regarding paraffin-containing products and will work with the MHRA, fire brigades, and other stakeholders to ensure clear and consistent communication about the risks. Locala has shared learning from the case internally, raised awareness about paraffin-containing products in their monthly medicines management report, and is developing a flowchart, documentation, and training for staff to identify patients at risk and ensure further risk assessments are completed when circumstances change. NHS Improvement notified of the death in 2015 and included actions taken in response to the death in the Patient safety review and response report published in June 2017. The UK Homecare Association has provided information to homecare providers including a fact sheet prepared by the London Fire Brigade, an article in their magazine, and an email briefing regarding the fire risks of paraffin-based emollients.