2013
PFD Reports
Reports: 172
Areas: 55
47% response rate (below 63% average).
Damion Stanley Joseph Henson
Historic (No Identified Response)
2013-0307
11 Dec 2013
Cumbria (South & East)
Riverview, 62 Lound Road, Kendal
Riverview, 62 Lound Road, Kendal
Concerns summary (AI summary)
A homeless unit, housing drug users, lacked 24-hour supervision, allowing unauthorized individuals to enter out of hours, thereby increasing risks in a facility not designed for drug rehabilitation.
Anthony Hughes
Historic (No Identified Response)
2013-0352
9 Dec 2013
Liverpool
National Crime Agency
Concerns summary (AI summary)
Police officers lacked awareness of "excited delirium," suggesting that training on this condition could improve responses in future incidents, despite appropriate actions in the specific case.
Keith Barton
All Responded
2013-0330
6 Dec 2013
Mid Kent and Medway
Ashley Gardens Nursing Home
Concerns summary (AI summary)
There was a lack of clarity in dysphagia supervision recommendations, insufficient training for all staff on dysphagia awareness, and a failure to complete incident reports, hindering further specialist reviews.
Action Taken
(AI summary)
Lifestyle Care booked dysphagia training for staff in February and March 2014 and a Nutrition and Hydration course in March 2014. They received confirmation from SALT that they will now be charging £125 per session and sessions can be booked from the end of March.
Kirk Duboise
Partially Responded
2013-0329
6 Dec 2013
County Durham and Darlington
Care UK
Prison Service
Concerns summary (AI summary)
There was a delay in summoning an ambulance and an inadequate self-harm risk assessment for a new prisoner, as essential forms were not reviewed during the reception process.
Action Taken
(AI summary)
Care UK has implemented protocols for summoning ambulances, disseminated to staff via a Governor's notice and staff briefings. NOMS has implemented ACCT training, with further training for healthcare staff commencing in January 2014, and refresher training on Self Harm Warning Forms is regularly undertaken.
Millie Elizabeth Thompson
All Responded
2013-0356
6 Dec 2013
Manchester (South)
North West Ambulance Service Trust
Department for Education
Department for Health
Concerns summary (AI summary)
Nursery staff lacked sufficient and updated paediatric first aid training. Ambulance call-takers misinterpreted breathing, causing incorrect triage, and emergency vehicles were inadequately equipped with paediatric life-saving kits.
Noted
(AI summary)
The Department for Education acknowledges the concern about paediatric first aid training and states that it is a statutory requirement for early years providers. They are consulting on reinforcing the need for a first-aid trained member of staff to be available at all times and expect to publish the results in February 2014. NWAS describes its recruitment and training processes for Emergency Medical Dispatchers (EMDs), including a six-week training course and continuing education requirements. All EMDs are required to undergo CPR recertification every two years. The Department of Health acknowledges the concerns, notes that training of nursery staff is the DfE's responsibility and NWAS is responsible for selection/training of call takers. They report that NWAS vehicles are equipped with paediatric equipment and they will share the report with the Association of Ambulance Chief Executives.
Karl Doran
Historic (No Identified Response)
2013-0328
5 Dec 2013
County Durham and Darlington
Beamish Museum
HSE
Concerns summary (AI summary)
The theme park failed to conduct appropriate risk assessments for volunteers, and there was a complete absence of direct or indirect managerial supervision over their activities.
Desmond Statton
Historic (No Identified Response)
2013-0379
5 Dec 2013
Plymouth, Torbay & South Devon
Derriford Hospital, Plymouth
Concerns summary (AI summary)
The provided text describes a procedural step (blood sampling) but does not detail any specific concerns.
Keith Thomas Graham
Historic (No Identified Response)
2013-0327
4 Dec 2013
North and West Cumbria
North Cumbria University Hospitals NHS …
Concerns summary (AI summary)
The report identifies a need to review procedures for seriously injured trauma patients arriving at the A&E, including summoning clinicians, CT scanning contraindications, and minimising time to surgery when indicated.
Marjorie Evelyne Keogh
All Responded
2013-0325
4 Dec 2013
Leicester City and South Leicestershire
Mymill Ltd. c/o Scraptoft Court Residen…
Concerns summary (AI summary)
The care home failed to assess suitability for a first-floor room, had staffing level concerns, and a manager was often absent. Conflicting risk assessments and non-compliant staircase furniture also posed safety issues.
Action Planned
(AI summary)
My Mil Ltd instructed a Structural Engineer to look into the balustrading at Syston Lodge and make recommendations to ensure they comply, which will be undertaken once the report is received. CQC is reviewing its approach to registration, considering checks to confirm compliance with building regulations for new or altered locations where providers seek to accommodate people. They will share the report with inspectors and managers within the Commission.
Yuki Ivy Norman-Knight
All Responded
2013-0321
4 Dec 2013
Norfolk
St Stephens Gate Medical Practice
Concerns summary (AI summary)
Concerns include fragmented patient record access, lack of clear guidelines for practice nurse referrals to doctors, and insufficient triggers for receptionists to book doctor appointments for young children and babies.
Action Taken
(AI summary)
St Stephens Gate has reviewed and reinforced the need for all clinicians to check patient past clinical history at each appointment. They are arranging laminated copies of the NICE Traffic Light guidance to be present on desks in all nurses' consulting rooms and have discussed the outcomes of this case at practice clinical meetings and reviewed policies and procedures accordingly.
Archibold Wellbelove
All Responded
2013-0324
4 Dec 2013
Warwickshire
Warwickshire County Council
Concerns summary (AI summary)
The Council failed to review its night-lighting policy for roads, creating unsafe conditions for pedestrians who regularly use unlit areas and may be unaware of footpath discontinuations.
Action Taken
(AI summary)
Warwickshire County Council has brought forward its review of night-lighting policy and will implement a dropped crossing point, barrier rail, supporting signage, and keep the street light on throughout the night where the footway terminates.
Abdullahi Sharif Abokar
All Responded
2013-0323
3 Dec 2013
Inner North London
Camden & Islington NHS Foundation Trust
Concerns summary (AI summary)
Mental health staff failed to assess suicide risk due to misconceptions, and resuscitation efforts were critically compromised by inadequate airway management, unactivated oxygen, and staff abandoning the patient.
Action Taken
(AI summary)
The Trust implemented a "Rapid Improvement Plan" for Coral ward, including mandatory training in suicide risk assessment and in-hospital life support, simulation exercises every 6 months, revised resuscitation scene management, and specialist training in oxygen use. The nurse involved is being managed under the Trust's capability policy.
Agostino Costa
Historic (No Identified Response)
2013-0322
3 Dec 2013
Inner North London
The Whittington Hospital NHS Trust
Concerns summary (AI summary)
Staff confusion over patient falls risk classification and junior doctors' lack of training in post-fall management created significant safety concerns, exacerbated by inadequate sharing of root cause analysis findings.
Horace Cottom
Historic (No Identified Response)
2013-0351
3 Dec 2013
Manchester City
Secretary of State for Health
the NHS
HMPS
+3 more
Karl Olof Nilsson
Historic (No Identified Response)
2013-0332
2 Dec 2013
West Yorkshire (Western)
National Highways
Bradford Metropolitan District Council
Concerns summary (AI summary)
The junction's layout, gradient, and an obscured STOP sign created an optical illusion, making the sign difficult to perceive, which substantially contributed to the fatal accident and previous injury incidents.
Michael James Meyler
Partially Responded
2013-0320
2 Dec 2013
Manchester City
HMPS
HMP Manchester
Concerns summary (AI summary)
Prison systems failed to adequately circulate self-harm/suicide risk information to relevant staff and attach it to ACCT documents, leading to uninformed decisions and a lack of accountability for information review.
Action Taken
(AI summary)
HMP Manchester reception staff now record ROSH document existence and consideration of ACCT in NOMIS. Healthcare staff scan paper documents onto SystmOne. Weekly assurance checks of NOMIS entries are conducted by Supervising Officers and Custodial Managers.
John William Tugwell
Historic (No Identified Response)
2013-0319
1 Dec 2013
Surrey
Coombe Dingle Nursing Home
Concerns summary (AI summary)
The care home allowed a high-risk patient with a documented history of falls unsupervised access to stairs, despite the clear potential for serious injury.
Doris Phoebe Miller
Historic (No Identified Response)
2013-0318
28 Nov 2013
Milton Keynes
Care Quality Commission
NHS England Hertfordshire and South Mid…
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.
Edna Elsie Mary Eden
All Responded
2013-0317
27 Nov 2013
Berkshire
Wexham Park Hospital Trust
Concerns summary (AI summary)
Significant delays in providing prescribed antibiotics, infrequent observations with an incorrectly calculated risk score, and failures in escalating concerns about patient review delays compromised care.
Action Planned
(AI summary)
The hospital introduced a policy (TPP 231) for managing deteriorating adult patients, requiring verification of EDOD scores. A 24-hour Central Hub system will be introduced to improve patient tracking, manage bleeps and referrals, and allocate jobs to doctors.
Peter Jeffrey
All Responded
2013-0313
27 Nov 2013
Eastern District of London
Guys & St Thomas'NHS Foundation Trust (…
Concerns summary (AI summary)
Hospital staff failed to consider alternative diagnoses or treatments, did not take cultures from an infected blister, and overlooked intravenous antibiotics after negative DVT scans.
Noted
(AI summary)
The Trust reviewed records but states it is unable to respond fully to the concerns due to a lack of clarity regarding the patient's condition in the months before his death. They offer to remind medical teams about antibiotic administration options.
Christopher Scott
Historic (No Identified Response)
2013-0350
27 Nov 2013
Wiltshire & Swindon
House of Commons
Concerns summary (AI summary)
The 'legal high' AMT is readily available for purchase despite clear evidence of its deadly effects, raising concerns about its unregulated status and accessibility to the public.
Barry James Lewis
All Responded
2013-0314
26 Nov 2013
Manchester North
Pennine Acute Hospitals NHS Trust
Concerns summary (AI summary)
Critical deficiencies exist in the emergency department, including inadequate availability and consistency of emergency airway equipment, insufficient backup instruments, poor out-of-hours theatre access, and inadequate night staffing.
Action Taken
(AI summary)
The hospital updated emergency airway packs in A&E, ensuring availability of 'large' instruments. The role of night nurse practitioners was reviewed to ensure involvement in direct care of critically ill patients.
Alan Stanfield Browning
Historic (No Identified Response)
2013-0315
26 Nov 2013
Avon
Somewhere House
Concerns summary (AI summary)
A vulnerable patient was discharged from a care facility without family notification or proper accommodation arrangements, specifically on a Friday, highlighting a lack of robust discharge planning.
Garrett Joseph Franklin Elsey
Historic (No Identified Response)
2013-0316
22 Nov 2013
Avon
HSE's Waste and Recycling Sector Team
Concerns summary (AI summary)
A document on people in commercial waste containers ('Waste 25') may not have been read widely in the waste industry, and an alert system could improve awareness.
Christopher James Morgan
Historic (No Identified Response)
2013-0272
22 Nov 2013
Cambridgeshire
Cambridgeshire and Peterborough NHS Fou…
Concerns summary (AI summary)
The Trust lacks clear policies for communicating risk level changes and leave access with family, and has no defined staff-to-patient ratio for escorted leave from psychiatric wards.