2013

PFD Reports
Reports: 172 Areas: 55

47% response rate (below 63% average).

Clear 55 results
Barnabas Newlyn
All Responded
2013-0382 13 Nov 2013 London Inner (North)
NHS England
Concerns summary (AI summary) Road transfer times for time-sensitive critical care, particularly neurosurgical emergencies, are too long, necessitating earlier consideration and use of air transfer services.
Action Planned (AI summary) NHS England will issue interim guidance on protocols for time-sensitive critical care transfers, offer training to critical care staff in retrieval, mobilise commissioning arrangements for standardising protocols, and commission a report on the feasibility of building the air ambulance service more closely into the critical care neurosurgery pathway.
John Gwynfryn Morris
All Responded
2013-0295 11 Nov 2013 Hertfordshire
Care Quality Commission
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.
Timothy Clayton
All Responded
2013-0361-wp26757 11 Nov 2013 London Inner (North)
Kent Police
Concerns summary (AI summary) Police improperly pressured the grieving family regarding organ donation, and an officer subverted the coroner's judicial decision, leading to the loss of six organs.
1 response from Download2013-0558-Response.pdffile
Roshan Abbas Ladak-Ebrahim
All Responded
2013-0278 5 Nov 2013 London (North)
Department of Health
Concerns summary (AI summary) Inadequate guidance on assessing self-harm risk, confusion regarding safeguarding responsibilities, and insufficient patient consultation when prescribing high-risk medication contributed to safety concerns.
Noted (AI summary) The Department of Health acknowledges concerns about assessing self-harm risk and providing safety advice, referencing existing government action plans, NICE guidance, and GMC guidance on confidentiality and information sharing.
Susan Jill Hammond
All Responded
2013-0286 4 Nov 2013 Lincolnshire (Central)
United Lincolnshire Hospital Trust
Concerns summary (AI summary) Critical allergy information was overlooked due to inadequate flagging on patient files, and a poor handover during transfer by an uninformed nurse led to a communication breakdown.
Action Taken (AI summary) United Lincolnshire Hospitals NHS Trust revised antibiotic guidelines, developed a traffic light risk recognition system for penicillin allergic patients, incorporated allergy awareness into mandatory training, implemented SBAR for handovers between A&E and MEAU, and reviewed the nurse's practice involved in the incident, providing further training and competence assessment.
Wilhelmina Isobel Newton
All Responded
2013-0283 31 Oct 2013 Cumbria (North & West)
Cumbria County Council Carlisle Cumbria County Council Carlisle
Concerns summary (AI summary) The care home lacked clear written protocols and guidance for staff on responding to head injuries in elderly residents, particularly those on anti-clotting medication.
Action Taken (AI summary) Cumbria County Council has reviewed the issues regarding procedures to be followed when a resident sustains or is suspected of sustaining a head injury and updated their policy, embedding it throughout the organisation and with independent providers.
Peter Clive Higson
All Responded
2013-0277 24 Oct 2013 Surrey
Secretary of State for Health
Concerns summary (AI summary) Concerns arose regarding the detrimental effect of platelet transfusions following stem cell transplants, questioning if such transfusions might sometimes be contraindicated.
Noted (AI summary) NHS Blood and Transplant concludes that TRALI was unlikely in this case based on SHOT imputibility criteria, recent studies and current guidelines suggest that the benefits of platelet transfusion outweigh the risk, and they undertake measures to reduce the risk of TRALI. The Department of Health refers to a report from NHS Blood and Transplant which indicates that prophylactic platelet transfusion was appropriate in this case, and that the respiratory deterioration likely resulted from other causes, highlighting measures in place to minimise the risk of adverse outcomes from platelet transfusions.
Isabella Hope Hill
All Responded
2013-0281 23 Oct 2013 Liverpool
Liverpool Womens Hospital
Concerns summary (AI summary) Hospital guidelines for umbilical venous catheter insertion, specifically requiring an X-ray to confirm position, were not followed, indicating sub-optimal practice and a need for improved guidelines and staff training.
Action Taken (AI summary) The Trust has enhanced local education for staff on the Neonatal Unit regarding revised guidelines, reviewed and clarified the Service Level Agreement for Radiology to ensure X-rays are performed within 60 minutes, and is working to increase the use of the electronic patient administration system (Badger) through additional education sessions.
Robert Wilkinson
All Responded
2013-0269 21 Oct 2013 County Durham & Darlington
Durham Constabulary
Concerns summary (AI summary) The firearms certificate revocation process was inadequate, lacking a face-to-face meeting and personal service of the revocation letter, which contributed to the deceased retaining access to weapons.
Action Taken (AI summary) Durham Constabulary now includes face-to-face meetings with certificate holders as part of the structured review process when it would add value, and is rationalising and indexing the 8,500 live certificate files into a more efficient electronic format.
Rosa Anderson
All Responded
2013-0263 17 Oct 2013 Liverpool
Aintree Hospitals NHS Trust
Concerns summary (AI summary) The patient was discharged without a summary, written information on her operation, critical advice, or emergency contact numbers.
Action Taken (AI summary) Aintree University Hospital has implemented a discharge advice sheet for laparoscopic procedures and is providing generic leaflets for all discharged patients, with specialties developing individualized discharge information sheets by March 2014.
Brian Dorling and Philippine de Gerin-Ricard
All Responded
2013-0265 17 Oct 2013 London (Inner North)
Transport for London
Concerns summary (AI summary) Confusing unbordered blue strips for cyclists, insufficient education on safer riding techniques, and a dangerous junction contribute to increased road safety risks for both cyclists and motorists.
Action Planned (AI summary) The Mayor of London and TfL are spending almost £1 billion to improve cycling infrastructure, including segregated highways and remodelled junctions, and are committed to upgrading existing superhighway routes.
Yousef Shokri-Gharab
All Responded
2013-0239-wp23943 14 Oct 2013 Liverpool
Mersey Care, NHS Trust
Concerns summary (AI summary) An outdated and unreviewed policy for informal patient leave failed to reflect current practice, risking patient safety due to lack of multidisciplinary consensus and proper documentation.
Action Taken (AI summary) • The Corporate Governance Team have been tasked with ensuring that all policies are received and updated to ensure that reflect national best practice. • Of the 120 Corporate Policies and Procedures currently in place , 117 are now in date. • The policy that provided concern at the Inquest on 11th October 2013 was one of the first to be reviewed and updated.
Walter Gordon Powley
All Responded
2013-0251 4 Oct 2013 Leicester City & South Leicestershire
Care Quality Commission Health and Safety Executive, Head of He… Registered Nursing Home Association
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.
Michael Joseph Hirrell
All Responded
2013-0247 1 Oct 2013 Leicester City and South Leicestershire
Energy UK Npower Ofgem
Concerns summary (AI summary) Npower representatives did not recognise the deceased as a vulnerable person despite visible signs; personnel felt unable to halt disconnection; and Ofgem was not informed of the death until the coroner's office notified them.
Action Planned (AI summary) OFGEM will monitor suppliers' performance regarding non-domestic disconnections and work with the coroner on reviewing the Safety Net provisions, considering how to promote them to non-domestic suppliers. They also provided context about existing protections for domestic consumers facing disconnection. Energy UK revised the Energy UK Safety Net to clarify protections for vulnerable domestic consumers using a shared non-domestic supply, publishing the updated version on their website. Signatories aim to implement required systems and processes by the end of 2014, with ongoing reviews and audits planned. Npower has briefed affected teams on process changes, organized face-to-face training with annual refresher, and introduced a trial period ceasing disconnection of shared commercial and domestic supplies during winter months. These measures are in addition to existing safeguards for vulnerable customers.
Rose Jean Coles
All Responded
2013-0246 27 Sep 2013 Avon
University Hospitals Bristol NHS Founda…
Concerns summary (AI summary) Inadequate communication and protocols between the neonatal intensive care and cardiac units hindered the safe care of premature babies, as the cardiac unit was not suited for their specific needs.
Action Planned (AI summary) University Hospitals Bristol has created a composite action plan to address concerns raised in two Regulation 28 reports and will monitor the plan's implementation through the Trust's governance procedures.
Jared William McDowall
All Responded
2013-0245 27 Sep 2013 Avon
University Hospitals Bristol NHS Founda…
Concerns summary (AI summary) Inadequate guidelines for identifying at-risk babies, including a lack of specific weight-for-gestation criteria and poor data presentation. Joint training for doctors and midwives on hypoglycaemia is also needed.
Action Planned (AI summary) University Hospitals Bristol has created a composite action plan to address concerns raised in two Regulation 28 reports and will monitor the plan's implementation through the Trust's governance procedures.
Gwilym Pugh Jones
All Responded
2013-0239 25 Sep 2013 North Wales (East and Central)
Betsi Cadwaladr University Hospital Boa…
Concerns summary (AI summary) Clinician-requested tests were not conducted, resulting in a missed opportunity for diagnosis and treatment.
Action Taken (AI summary) • The Corporate Governance Team was tasked with ensuring that all policies are received and updated to ensure that reflect national best practice. • Of the 120 Corporate Policies and Procedures currently in place , 117 are now in date. • Three policies are subject to fundamental review; this process will be completed by 31st March 2014.
Jude Augustus Gordon
All Responded
2013-0237 24 Sep 2013 South Yorkshire (West)
Department of Health and Social Care
Concerns summary (AI summary) Failures in calculating and escalating Early Warning Scores, alongside a lack of national standardisation and automatic alert systems, led to delayed critical care referrals for a deteriorating patient.
Noted (AI summary) The Department of Health acknowledges the concerns, noting existing work on a national early warning score (NEWS) and the use of computerised systems in some Trusts. However, it states that there are no current plans to mandate computerised EWS systems nationally due to IT infrastructure limitations, and emphasizes the importance of local training.
Michael Sweeney
All Responded
2013-0236 23 Sep 2013 London North (Inner)
London Ambulance Service Metropolitan Police
Concerns summary (AI summary) Police training on 'excited delirium' is not widely understood by other health professionals, risking miscommunication and missed diagnoses of underlying medical conditions. Standardising the term to 'extreme agitation' is needed.
Disputed (AI summary) The Metropolitan Police Service has addressed potential information gaps for civil staff with practice notes and in-house training, and developed a detailed joint agency call-handling protocol with the London Ambulance Service. The Medical Director will encourage the adoption of shared terminology and increase awareness in emergency departments. The London Ambulance Service does not agree with the recommendation to use the term 'extreme agitation', preferring 'acute behavioural disturbance' (ABD). They have engaged with police and reviewed guidance, and raised the issue of terminology with the national Ambulance Service Mental Health Working Group, which will issue a position statement after consulting the Royal College of Psychiatrists. They will also share their response with the Pan London Emergency Department Consultants Group.
Joan Mary Jones
All Responded
2013-0234 20 Sep 2013 Leicester City and South Leicestershire
Manor Residential and Nursing Care Home
Concerns summary (AI summary) Care home staff failed to escalate a patient's deteriorating condition and provide complete information to health professionals, resulting in inadequate care and putting the patient at risk.
Action Taken (AI summary) Following an inquest, the care home sent a memo to unit leads emphasizing communication protocols with families and healthcare professionals after GP visits. They also contacted the family and engaged a consultant to arrange a meeting to address outstanding questions.
Luke Lyons
All Responded
2013-0203 17 Sep 2013 Exeter & Greater Devon
Devon County Council
Action Taken (AI summary) The Council addressed drainage issues on a road, including undertaking works. They also plan to continue using intelligence gathering and inspection processes, and will use the media to disseminate messages about safe travel in severe weather.
Peter Pattinson
All Responded
2013-0250 6 Sep 2013 Sunderland
European Care group
Concerns summary (AI summary) Care home staff failed to act on family requests for bed rail use and repairs, did not conduct risk assessments, and maintained inadequate, unpaginated patient records.
Action Taken (AI summary) The care group has implemented new bed rail risk assessment and checking systems, along with staff training on safe bed rail usage. They also numbered daily statement documents to prevent misplacement.
Labhuden Amarshi Vaghadia
All Responded
2013-0201 5 Sep 2013 Leicester City & South Leicestershire
Leicestershire Partnership NHS Trust
Concerns summary (AI summary) A community nurse administered anticoagulant despite patient bleeding, failed to share critical information with other professionals, and demonstrated a lack of professional insight and adequate training.
Action Taken (AI summary) The Partnership NHS Trust reviewed the case, assessed the nurse's competence, and arranged medicines management and emotional resilience training along with additional clinical supervision. They are also implementing a mobile working solution for community staff.
Karen Sutton
All Responded
2013-0223 4 Sep 2013 Leicester City & South Leicestershire
University Hospitals Leicester NHS Trust
Concerns summary (AI summary) Hospital departments failed to share patient admission information, leading to discharge without prophylactic medication and inadequate follow-up arrangements due to a lack of Trust-wide communication policy.
Action Taken (AI summary) The Medical Director reminded consultants of their duty to contact specialist teams for patients with complex needs, and the hospital expects to have software by April 2014 to alert consultants about patients with specific needs.
Jack William Payton
All Responded
2013-0220 30 Aug 2013 West Somerset
Avon and Somerset Constabulary
Concerns summary (AI summary) Control room staff's judgement and handling of the matter were negatively affected by excessive working hours and heavy caseloads, raising concerns about operational capacity.
Action Planned (AI summary) The police are commissioning an independent assessment of current shift patterns and their effects on staff, anticipated to commence in January 2014, with recommendations to be considered at Force level.