2013

PFD Reports
Reports: 172 Areas: 55

47% response rate (below 63% average).

Response Status
Responded 80 Historic 92
AI Classification
Action Taken 42%
Action Planned 33%
Noted 20%
Disputed 4%
Based on 99 classified responses
Top Categories
Hospital Death (Clinical Procedure… (62) Community health care and emergenc… (30) Road (Highways Safety) related dea… (15) Other related deaths (15) Mental Health related deaths (14)
172 results
Peter Galea
Historic (No Identified Response)
2013-0310 21 Nov 2013 City of Sunderland
Department of Health
Concerns summary (AI summary) Mental health services had limited mechanisms to break the 'ping pong' referral cycle between agencies, and GPs faced limitations in directly admitting patients to a place of safety for detailed assessment.
Lisa Jane Clayton
Historic (No Identified Response)
2013-0309 21 Nov 2013 Manchester North
Kennedy Wilson Europe (as Landlord) Public Protection, Oldham Council, Chad… Savilles Management Resources (as the L… +1 more
Concerns summary (AI summary) Inadequate physical deterrents on a car park wall, insufficient CCTV monitoring and understaffed security, coupled with a history of similar incidents, highlight serious failures in suicide prevention measures.
Daniel Maurice McMahon
Partially Responded
2013-0271 21 Nov 2013 London
Department of Health and Social Care LAS Legal Services Metropolitan Police +1 more
Concerns summary (AI summary) The report suggests improving information gathering by police when someone is trespassing on railway tracks; using feedback forms for patients on S17 MHA leave; amending the rule book to require trains to stop when a potentially unwell person is trespassing; and reviewing guidance on lung decompression needles for the ambulance service.
Disputed (AI summary) The London Ambulance Service reviewed the use of one-way valves on needle chest decompressions and concluded that their current approach of not using them is appropriate, citing expert opinions and consensus statements. The Department of Health is reviewing the advice in the 'Code of Practice Mental Health Act 1983', including the chapter on leave of absence under section 17 and references to care planning, using this case to assist that review.
Luke Jacob Goodwin
Historic (No Identified Response)
2013-0311 20 Nov 2013 West Yorkshire (Western)
House of Commons
Concerns summary (AI summary) The unrestricted sale of large helium canisters without flow control valves, combined with readily available online suicide guides, facilitates self-harm and raises serious safety concerns.
Annie Jones
All Responded
2013-0306 20 Nov 2013 North Wales (East & Central)
Abbeydale Residential Home, Princes Dri…
Concerns summary (AI summary) An inadequate mobility assessment led to the unsafe use of a stand aid for a non-weight-bearing resident. Staff lacked awareness of limitations and proper training, posing a significant risk of injury to vulnerable patients.
Action Taken (AI summary) Abbey Dale House created an updated document providing a snapshot of each resident's needs, including a summary person handling plan, readily available to all staff. The care home adopted the All-Wales Manual Handling Passport, an intensive manual-handling training programme.
Stuart Aaron Collins
Partially Responded
2013-0300 18 Nov 2013 Teesside
Cleveland Police Tees, Esk and Wear Valleys NHS Foundati… James Cook University Hospital, South T…
Concerns summary (AI summary) Inadequate patient assessment and a complete failure to conduct hourly observations or maintain accurate nursing notes for an epileptic patient. Furthermore, a hazardous item was left accessible to the patient.
Noted (AI summary) The Trust states that they have undertaken a full investigation and discussed the matter at a senior level. They maintain that the patient was assessed on arrival at A&E and observations were taken, but dispute the frequency of observations.
Andrew Phrydas
Historic (No Identified Response)
2013-0301 15 Nov 2013 London Inner North
London Underground
Concerns summary (AI summary) London Underground lacked a process for simultaneous dual-line shutdown at intersecting stations and failed to alert the train driver directly and effectively when a person was on the track.
David Cox
All Responded
2013-0355 15 Nov 2013 Derby & Derbyshire
The Peak District National Park Authori…
Concerns summary (AI summary) The narrow bridleway with acute, blind bends and no safety barrier poses a significant risk of vehicles leaving the track and falling into the river below.
Action Planned (AI summary) The Authority installed further permanent signage at both ends of the track in December 2013. They are investigating possible funding streams to implement further measures.
Anthony Brian Flynn
Partially Responded
2013-0297 14 Nov 2013 Manchester West
Department of Health and Social Care HMP Forest Bank
Concerns summary (AI summary) Seriously ill prisoners were inhumanely shackled during medical examinations, clinician concerns were ignored, and there was inadequate training for prison officers regarding hospital escorts and clinicians' powers over restraints.
Action Planned (AI summary) Sodexo is planning Safer Custody, Cell Sharing Risk Assessment (CSRA) and Escort & Bedwatch awareness days and a training programme for prison officers who conduct escorts, particularly during hospital visits. They have also re-issued an Operational Instruction regarding prisoner correspondence.
Dean Griffiths
Historic (No Identified Response)
2013-0299 14 Nov 2013 Kent (Central & South East)
House of Commons
Concerns summary (AI summary) Insufficient time allocated for exercises created pressure, preventing Range Conducting Officers from completing crucial final assurance checks.
Kevin Paul Sutton
Historic (No Identified Response)
2013-0375 14 Nov 2013 West Somerset
Somerset Partnership NHS Foundation Tru…
Concerns summary (AI summary) The Trust failed to prepare essential care plans for patients discharged from its wards to other establishments, risking inadequate ongoing care.
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.
William Joseph Wilkinson
Historic (No Identified Response)
2013-0294 11 Nov 2013 Manchester South
Royal Bolton Hospital
Concerns summary (AI summary) Deficient one-to-one nursing, computer system failures, incomplete medical records, and absence of direct orthopaedic input in A&E contributed to an unnecessary admission and subsequent death.
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
Kathleen Rosemary Dixon
Partially Responded
2013-0292 11 Nov 2013 Cumbria (South & East)
Care Quality Commission Department of Health
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.
Peter Patrick Adrian Barnes
Historic (No Identified Response)
2013-0291 8 Nov 2013 West Yorkshire (West)
Cygnet Healthcare Ltd.
Concerns summary (AI summary) Hospital systems were inadequate for communicating observed patient information and serious incidents from nursing staff to the Responsible Clinician, leading to incomplete or outdated data for care decisions.
Stanley Dobson
Partially Responded
2013-0303 7 Nov 2013 Surrey
ADC Surrey Harmoni
Concerns summary (AI summary) Locum doctors failed to report patient non-response to the operative, hindering further contact efforts. Protocols need extending to ensure non-responses are consistently reported.
Noted (AI summary) The Department of Health acknowledges the concerns about staff ratios in care homes, explains that there are no set ratios due to varying resident needs, and refers to existing regulations requiring sufficient qualified staff and the CQC's role in enforcing these regulations. It also outlines changes following the Mid Staffordshire NHS Foundation Trust Inquiry.
Henry McQuoid
Historic (No Identified Response)
2013-0348 6 Nov 2013 Worcestershire
Moundsley Hall Nursing Home
Concerns summary (AI summary) Insufficient staffing, particularly with high reliance on agency workers, meant some residents requiring eating assistance might not receive it.
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.
Ethel Cross
Historic (No Identified Response)
2013-0362-wp25883 5 Nov 2013 Blackpool and Flyde
Blackpool Teaching Hospitals NHS Founda…
Concerns summary (AI summary) Wheeled chairs accessible to elderly patients caused falls, and a shortage of alarms for high-risk patients meant they could mobilize unsupported.
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.
Andrew Cairns, Rachael Slack and Auden Slack
Historic (No Identified Response)
2013-0290 1 Nov 2013 Derby and Derbyshire
Association of Chief Police Officers Department of Health and Social Care Derbyshire Constabulary +2 more
Concerns summary (AI summary) Police failed to inform the Mental Health Team of an arrest for threats to kill despite knowing of a recent mental health assessment; an existing information-sharing policy was also undisclosed.
Joanne Manning
Historic (No Identified Response)
2013-0289 1 Nov 2013 London
The Practice The Practice Practice
Concerns summary (AI summary) A severe communication breakdown between GP and psychiatrist led to unsafe methadone prescribing without full patient information, compounded by the absence of a clear inter-agency information-sharing policy.
John William Wright
Historic (No Identified Response)
2013-0285 31 Oct 2013 London Inner North
North Middlesex University Hospital NHS…
Concerns summary (AI summary) A patient fall was not investigated as a Serious Untoward Incident, and there was unclear training for doctors on fall policy and incident recording.