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 results
Mary Waldron
Historic (No Identified Response)
2014-0127 10 Jan 2014 Coventry
Care Home Health related deaths
Concerns summary (AI summary) Nursing home staff failed to recognise and act on an acutely unwell resident due to inadequate ongoing training and poor internal investigation. Communication issues during ambulance transfer also posed a risk.
William Andrews
Partially Responded
2013-0368 17 Dec 2013 South Yorkshire (West)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Surgical equipment design flaws, including the lack of a brightly coloured detachable cap on a bulb syringe, led to a retained tip. A national safety recommendation for such caps was ignored, and no cap counting procedure exists.
Action Taken (AI summary) The manufacturer of syringes has agreed to supply syringes without caps, has issued a safety notice to all UK customers, and will make syringes without caps available for stock exchange. The Director of Patient Safety at NHS England has written about the taskforce to look at surgical never events and highlighted Royal College of Surgeons (RCS) revision of their practice guidance.
Stephanie Daniels
All Responded
2013-0353 13 Dec 2013 Manchester City
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Significant deficiencies exist in internal SUI investigations, with errors and omissions, along with concerns about the thoroughness and independence of inquiries. Additionally, patient information handover between staff was often inadequate.
Noted (AI summary) Manchester Mental Health NHS will be reviewing its SIRI policy to consider the engagement of an independent investigator in complex cases and will develop further guidance for investigators regarding learning from this case. Matrons will carry out weekly checks on compliance with the quality of documentation on handover forms. The Head of Nursing is writing to all Ward Managers to instruct nursing staff to read recent admission records and risk information and compliance with this system will be monitored through audit. The Citywide Commissioning, Quality and Safeguarding Team has developed a revised governance process and the Trust now attends an established Citywide Patient Safety Committee. An inpatient capacity management plan has been developed and implemented. The Commissioner Assurance Plan for Quality Improvement (CAP-QI) was agreed by the Joint Commissioning Management Board in September 2013 and is monitored monthly. The Department of Health acknowledges the concerns and states that local healthcare organisations should ensure that all staff are trained to the appropriate standard. Concerns have been sent to the National Trust Development Authority (NTDA) which is in contact with MHSC Trust and has received an action plan.
Doris Phoebe Miller
Historic (No Identified Response)
2013-0318 28 Nov 2013 Milton Keynes
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Patient medical records were unavailable to the GP surgery after a practice closure, indicating a failure in transferring and making accessible essential patient information.
John Gwynfryn Morris
All Responded
2013-0295 11 Nov 2013 Hertfordshire
Care Home Health related deaths
Concerns summary (AI summary) Inadequate security measures at a residential dementia unit failed to prevent a resident with a known history of wandering from leaving the premises, despite previous escape incidents.
Action Planned (AI summary) The CQC acknowledges concerns about care for people living with dementia and states that they are proposing to publish a report in May or June 2014 which will set out good practice and make recommendations about dementia care across different services.
Kathleen Rosemary Dixon
Partially Responded
2013-0292 11 Nov 2013 Cumbria (South & East)
Mental Health related deaths
Concerns summary (AI summary) Repeated critical incidents in the Trust, evident across multiple inquests, necessitate an independent assessment of its operations.
Noted (AI summary) The Department of Health acknowledges the concerns raised about mental health assessments at Cumbria Partnership NHS Foundation Trust and outlines existing measures and guidance in place to improve patient safety and mental health care, referring to CQC warning notices and actions following the Mid Staffordshire NHS Foundation Trust Inquiry.
Walter Gordon Powley
All Responded
2013-0251 4 Oct 2013 Leicester City & South Leicestershire
Care Home Health related deaths
Concerns summary (AI summary) Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded by a lack of specific room risk assessments and oversight failures by regulatory bodies.
Action Planned (AI summary) The CQC acknowledges the incident and will share the report's findings within the organisation. They are exploring ways to work more closely with the HSE and ensuring their new inspection methodology checks high-risk areas, though their inspectors do check that radiators are covered but will often only sample a selection of people's rooms. HSE will raise concerns about assessing risks from hot surfaces and pipe-work at the next GB Social Care Partners Forum meeting, scheduled for February 2014. They will also share the letter with local authority health and safety regulators and arrange for discussion at the next national local authority practitioner forum. The RNHA acknowledges the risk and states they regularly advise members of their responsibilities under the Health & Safety at Work Act, particularly regarding covering radiator pipes. They will continue to advise members on risk assessments and safe radiator temperatures.
Sally King
Historic (No Identified Response)
2013-0196 23 Sep 2013 Milton Keynes
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The provided concerns text is too truncated to identify specific safety issues.
Yvonne Sydney Annie Perry
Historic (No Identified Response)
2013-0195 23 Sep 2013 Milton Keynes
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A lack of robust processes for tracking radiology reports led to critical delays in patient care. Additionally, GPs in the intermediate care unit lacked access to electronic hospital notes, impeding effective treatment.
Daniel Onley
Partially Responded
2013-0208 19 Sep 2013 Gloucestershire
Care Home Health related deaths
Concerns summary (AI summary) Insufficient arrangements were in place to support the patient in taking anti-convulsant medication, and there was a failure to manage associated risks.
Action Taken (AI summary) The Trust has audited medicine administration, revised policies, implemented common paperwork for risk management, and shared the coroner's concerns with operational managers. The Safeguarding Board is monitoring the issues and requested regular audits.
George Renshaw Brown
Historic (No Identified Response)
2013-0230 16 Sep 2013 Manchester South
Care Home Health related deaths
Concerns summary (AI summary) A lack of efficient systems for reassessing and transferring care home residents with rapidly deteriorating conditions led to significant delays in moving a patient to more suitable accommodation.
Mohammed Chaudhury
Historic (No Identified Response)
2013-0193 20 Aug 2013 London (Inner South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The patient developed severe infected pressure sores due to the prolonged absence of an air mattress and insufficient turning, directly caused by nursing staff shortages.
Vera Lillian Steel
Historic (No Identified Response)
2013-0185 13 Aug 2013 Surrey
Care Home Health related deaths
Concerns summary (AI summary) A frail, bedbound resident fatally burned herself while smoking. Care homes should be encouraged to provide fire-protective aprons or smocks to residents who smoke to prevent similar incidents.