2013
PFD Reports
Reports: 172
Areas: 55
47% response rate (below 63% average).
Adrian John Pickard
All Responded
2013-0358
31 Dec 2013
West Yorkshire (East)
Lightwater Quarries Limited
Concerns summary (AI summary)
Company vehicles laden with aggregates are not routinely weighed before departing the premises, posing potential safety risks on public highways.
Disputed
(AI summary)
Lightwater Quarries Ltd disputes the need to weigh volumetric vehicles, arguing it's not legally required and weight wasn't a factor in the collision. They state that they would like to see such & test also introduced at the annual ministectest.
Lynne Dring
All Responded
2013-0360
30 Dec 2013
North Lincolnshire & Grimsby
North East Lincolnshire Council
Concerns summary (AI summary)
Street furniture obstructed motorists' views, and non-prescribed white lines may have falsely induced pedestrians to believe they had priority, creating a road safety risk.
Action Planned
(AI summary)
• The illuminated bollards at the roundabout will be replaced with non-illuminated bollards, positioned to offer the best guidance to motorists while avoiding restricting visibility to pedestrians.
• All sites where WBM 294 (elephants footprints) road markings have been installed have been identified.
• A program of removal has been compiled, with the intention of removing markings at 10 sites being the priority, including Hewitt's Circus roundabout.
Simon Sankey
All Responded
2013-0361
27 Dec 2013
Manchester (West)
5 Boroughs Partnership NHS Foundation T…
Concerns summary (AI summary)
The categorisation of mental health referrals was done by an unqualified administration assistant, with no subsequent review of the urgency category, and the electronic system for prioritising referrals was not available to all senior nurse practitioners.
1 response
from Download2013-0558-Response.pdffile
Kate Louise Pierce
All Responded
2013-0363
20 Dec 2013
North Wales (East & Central)
General Medical Council
Concerns summary (AI summary)
A practicing GP failed to diagnose a patient and misled parents, with new evidence casting doubt on his fitness to practice. Previous GMC action stalled, posing a risk of future deaths.
Noted
(AI summary)
The GMC acknowledges the concerns but states that statutory rules preclude them from investigating events that are more than five years old and they have not received any further complaints since 2007.
Adrian Johnson
Partially Responded
2013-0364
20 Dec 2013
London (Inner South)
HMP Belmarsh
National Offender Management Service
NHS England
Concerns summary (AI summary)
The coroner noted that initial screening did not assess for tobacco withdrawal, ACCT reviews lacked healthcare input, and there was a lack of consistency in case management, with no handover from case manager to case manager.
Action Planned
(AI summary)
NOMS and NHSE will give further consideration to the extent to which screening processes should identify tobacco dependence and potential withdrawal issues. ACCT refresher training will reinforce that prisoners subject to ACCT procedures should be located in segregation units only in exceptional circumstances.
Roy Frank Fletcher
Historic (No Identified Response)
2013-0362
20 Dec 2013
Blackpool & Fylde
Lancashire Care NHS Foundation Trust
Concerns summary (AI summary)
The Trust's post-incident review was inadequate, failing to interview a key witness or assess if similar events were persistent issues, thus hindering learning and preventing future deaths.
Keith Samuel Peters
All Responded
2013-0378
20 Dec 2013
Manchester (West)
Bolton Council
Concerns summary (AI summary)
Inefficient case allocation and lack of prioritisation for assessments, combined with no system to reallocate cases when officers cannot meet deadlines, caused significant delays.
Action Planned
(AI summary)
Bolton Council has cascaded lessons learned and has an action plan in place to improve systems, processes, and officer training, which they will oversee the full implementation of.
Kenneth Smalley
Partially Responded
2013-0367
19 Dec 2013
Manchester (West)
Eschmann Holdings Limited
Medicines and Healthcare Products Regul…
Wrightington, Wigan and Leigh Teaching …
Concerns summary (AI summary)
A malfunctioning operating table and emergency stop, potentially linked to a damaged, improperly positioned handset, highlight inadequate pre-operation checks and a lack of training or hospital-wide review for similar equipment.
Action Taken
(AI summary)
The Trust has reviewed operating tables and handsets, changed pre-operative checks and inspections, implemented a more robust system and matrix for training theatre staff, and expanded the data base within theatres to cover all medical devices. The Trust has also contacted the MHRA to request a discussion to strengthen communication and sharing of information.
Michael Longley
Historic (No Identified Response)
2013-0370
19 Dec 2013
Central & South East Kent
Kent Community Health NHS Foundation Tr…
Concerns summary (AI summary)
Difficulties in communication between Integrated Care 24 and the District Nursing Service highlight a need for improved oral and written communication methods.
Leo Deady
Partially Responded
2013-0369
19 Dec 2013
London (Inner South)
Department of Health and Social Care
Royal College of Obstetricians and Gyna…
Concerns summary (AI summary)
A significant proportion of breech presentations go undiagnosed nationally, yet there are no national guidelines for routine late-pregnancy scans to detect them, despite high risks.
Noted
(AI summary)
The Department of Health acknowledges the concerns regarding undiagnosed breech presentations but states that after consulting with the RCOG and taking account of existing research and guidance, it considers that there is no benefit to developing a national system of routine scanning in late pregnancy.
Christine Williamson
All Responded
2013-0371
18 Dec 2013
Shropshire, Telford & Wrekin
South Staffordshire and Shropshire Heal…
Telford and Wrekin Clinical Commission …
Telford and Wrekin Council
+1 more
Concerns summary (AI summary)
Failure to assess the deceased as a vulnerable adult at risk from domestic violence and a critical lack of information sharing between agencies hindered preventative measures.
Action Planned
(AI summary)
Telford & Wrekin Council has compiled a plan of action building upon recommendations made in the Domestic Homicide Review report, and the implementation of the action plan will be formally monitored by the Safeguarding Adults Board. The Adult Safeguarding Policy and Thresholds has been recirculated, domestic abuse leaflets and guidance has been circulated, and an education and training event for Telford & Wrekin GPs and Practice Nurses will be funded and delivered with a focus on safeguarding requirements and domestic abuse. West Mercia Police will provide a reminder regarding the requirement to complete DASH; Crime Reports and Vulnerable Adult documentation to all operational staff. The tactical equality and diversity advisor has recently attended a Dementia Friends workshop to scope the feasibility of additional awareness sessions, and the arrangement of a joint working group will be tasked by the Safer Communities Partnership to the Safeguarding Adults Board.
Sean Seabourne
Historic (No Identified Response)
2013-0374
17 Dec 2013
Worcestershire
Worcestershire Health and Care NHS Trust
Concerns summary (AI summary)
Systemic communication failures and unclear roles between mental health teams led to an urgent referral for a high-risk patient with suicide plans not being acted upon, preventing a crucial face-to-face assessment.
Sandra Wordingham
All Responded
2013-0373
17 Dec 2013
Cardiff & the Vale of Glamorgan
Springbank Care Home Limited
Concerns summary (AI summary)
A nursing home failed to seek timely medical opinion for an unconscious resident, delaying identification of a severe condition and risking unnecessary death if early intervention was possible.
Action Planned
(AI summary)
Springbank Nursing Home has produced a protocol for managing unconscious residents, including training for staff, clearer risk assessments, and mandatory summoning of emergency services in cases of doubt. The protocol has been provided for all staff working at Springbank Nursing Home.
John Morgan
Partially Responded
2013-0372
17 Dec 2013
Cardiff & the Vale of Glamorgan
Cardiff and Vale University Health Board
Welsh Government Health and Social Care
Concerns summary (AI summary)
Over-reliance on whiteboards rather than patient notes, the potential for human error to input incorrect information, and the use of a misleading DNR "red star" system pose risks to patient care.
Action Planned
(AI summary)
The Welsh Government requested that Health Boards and Trusts review the incident and make changes as appropriate. The Chief Medical Officer and Chief Nursing Officer will write to all Health Boards and Trusts in Wales to reinforce the need for robust systems where PSAG boards are in use. Welsh Government officials will also bring this to the attention of the 1000 Lives improvement service.
William Andrews
Partially Responded
2013-0368
17 Dec 2013
South Yorkshire (West)
Care Quality Commission
Department of Health and Social Care
Secretary of State for Health
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.
Cynthia Fretwell
All Responded
2013-0366
16 Dec 2013
Nottinghamshire
HAMA Medical Centre, NHS Commissioning …
Concerns summary (AI summary)
The GP practice had an ineffective system for telephone referrals, lacking timely consultation, proper assessment of patient mental capacity for refusing treatment, and clear communication between staff and doctors.
Action Taken
(AI summary)
Hama Medical Centre has updated its Mental Capacity Act 2005 policy and updated its Telephone Consultation Protocol, in addition to discussing the Mental Capacity Act during medical meetings. They have also included a full assessment of the patient's mental capacity in a situation where they are refusing medical treatment or admission to hospital in accordance with guidelines in the Practice's mental capacity policy.
Joseph Drew Whiteside
All Responded
2013-0377
16 Dec 2013
Staffordshire (South)
East Staffordshire Borough Council
Concerns summary (AI summary)
Numerous drownings of intoxicated individuals in the River Trent highlight the need for improved safety measures, such as fencing and warning signs, at main access points.
Action Planned
(AI summary)
East Staffordshire Borough Council appointed the Royal Society for the Prevention of Accidents (RoSPA) to conduct inland water safety reviews across Burton-upon-Trent and Uttoxeter and will be acting upon their recommendations as soon as practicable.
Elsie May Treece
All Responded
2013-0376
16 Dec 2013
Staffordshire (South)
Burton Hospitals NHS Foundation Trust
Concerns summary (AI summary)
Hospital staff likely failed to report an incident where a patient fell during transfer, suggesting a need for better training and reminders on the requirement to report all inappropriate incidents.
Action Taken
(AI summary)
Burton Hospitals NHS has always provided training for staff in relation to incident reporting, and they have arranged to provide additional training and support for Ward 6. They have linked in with the University to raise awareness with student nurses surrounding the importance of incident reporting.
Clive Gould
All Responded
2013-0357
16 Dec 2013
Oxfordshire
South Central Ambulance Service NHS Fou…
Concerns summary (AI summary)
Ambulance service failures include inappropriate priority allocation for calls, insufficient system resilience leading to delays, and inadequate communication with callers about estimated arrival times and potential delays.
Action Taken
(AI summary)
South Central Ambulance Service has extended Rapid Response Vehicle cover to 24 hours in Oxfordshire, Buckinghamshire and Berkshire. Rota match versus demand has also been reviewed. They have developed a Clinical Support Desk (CSD) within Emergency Operations Centre to support patients with clinical advice until a response is on scene.
Sarah Shepherd
Historic (No Identified Response)
2013-0359
16 Dec 2013
Surrey
Surrey and Borders Partnership NHS Foun…
Concerns summary (AI summary)
The Trust lacked a clear referral process for PICU and its documentation, while nursing staff misunderstood resuscitation guidelines due to unclear training and misleading aide-memoires, risking inappropriate patient care.
Stephanie Daniels
All Responded
2013-0353
13 Dec 2013
Manchester City
APEX Nursing Agency
Care Quality Commission
Department of Health and Social Care
+5 more
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.
Jane Dyson Gabbitas
Historic (No Identified Response)
2013-0326
12 Dec 2013
West Yorkshire (Western)
South West Yorkshire Partnership NHS Fo…
The Chief Coroner
Concerns summary (AI summary)
An open residential unit lacked a formal system to record and monitor resident absences, leading to staff being unaware of a resident's prolonged disappearance until her body was discovered.
Rosemary Brownyn Ferguson
Historic (No Identified Response)
2013-0365
12 Dec 2013
South Yorkshire (East)
Doncaster and Bassetlaw Teaching Hospit…
Concerns summary (AI summary)
Poor communication between hospital staff and Social Services led to a discharge without support. Unclear instructions given to a friend regarding patient care, combined with scanty hospital notes, created significant misunderstandings and risks.
William McCourt
All Responded
2013-0383
12 Dec 2013
North Yorkshire (West)
1. David Bowe
Concerns summary (AI summary)
Local residents' reports of flooding were not recorded or acted upon, and maintenance staff failed to correctly identify land ownership, leading to significant delays in addressing a safety hazard.
Action Taken
(AI summary)
North Yorkshire County Council acknowledged concerns, clarified the context of some decisions, and circulated further advice to highways officers regarding recording of actionable defects and warning signs.
Felix Cembrowicz
All Responded
2013-0204
12 Dec 2013
Avon
Avon and Wiltshire Mental Health Partne…
Concerns summary (AI summary)
The electronic patient record system failed to migrate complete histories for discharged mental health patients, leaving current staff unaware of crucial past contact and relapse management plans.
Action Taken
(AI summary)
Avon and Wiltshire NHS Trust will establish if re-referred patients have historic relapse management plans and an additional check should be undertaken in the RiO clinical records/documents to establish if they have been migrated across. This requirement is included in the current initial assessment/admission process and the Trust is updating supervision processes and information governance packages.