2013
PFD Reports
Reports: 172
Areas: 55
47% response rate (below 62% average).
Daniel Maurice McMahon
Partially Responded
2013-0271
21 Nov 2013
London
Department of Health and Social Care
Metropolitan Police
RSSB
+1 more
Concerns summary
Concerns include inadequate police information gathering for railway trespassers, lack of a feedback form for MHA S17 leave, and an outdated railway rule book concerning stopping trains for unwell individuals on tracks.
Action taken summary
The London Ambulance Service disputes the concern regarding the use of needle chest decompressions without a valve, stating that a review by their Medical Director concluded their current practice is
Lisa Jane Clayton
Unknown
2013-0309
21 Nov 2013
Manchester North
Concerns 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.
Peter Galea
Unknown
2013-0310
21 Nov 2013
City of Sunderland
Concerns 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.
Annie Jones
All Responded
2013-0306
20 Nov 2013
North Wales (East & Central)
Concerns 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 summary
Abbey Dale House created an updated document with summary person handling plans for each resident, adopted the All-Wales Manual Handling Passport training programme, and improved documentation for sta
Luke Jacob Goodwin
Unknown
2013-0311
20 Nov 2013
West Yorkshire (Western)
Concerns 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.
Stuart Aaron Collins
Partially Responded
2013-0300
18 Nov 2013
Teesside
Cleveland Police
Tees, Esk and Wear Valleys NHS Foundati…
Concerns 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.
Action taken summary
The Trust disputes the concerns, stating Mr Collins was triaged on arrival and observations were taken according to policy, which did not trigger more frequent monitoring. They also reminded staff …
David Cox
All Responded
2013-0355
15 Nov 2013
Derby & Derbyshire
Concerns 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 taken summary
The Authority installed new permanent safety signage at both ends of the track and commissioned an independent Survey Report on the bends. They are also developing detailed specifications for future …
Andrew Phrydas
Historic (No Identified Response)
2013-0301
15 Nov 2013
London Inner North
London Underground
Concerns 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.
Kevin Paul Sutton
Unknown
2013-0375
14 Nov 2013
West Somerset
Concerns summary
The Trust failed to prepare essential care plans for patients discharged from its wards to other establishments, risking inadequate ongoing care.
Dean Griffiths
Unknown
2013-0299
14 Nov 2013
Kent (Central & South East)
Concerns summary
Insufficient time allocated for exercises created pressure, preventing Range Conducting Officers from completing crucial final assurance checks.
Anthony Brian Flynn
Partially Responded
2013-0297
14 Nov 2013
Manchester West
HMP Forest Bank
Department of Health and Social Care
Concerns 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 taken summary
Sodexo has re-issued an operational instruction to staff regarding handling prisoner correspondence. They have also planned awareness days and a new training programme for prison officers on escort an
Barnabas Newlyn
All Responded
2013-0382
13 Nov 2013
London Inner (North)
Concerns 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 taken summary
NHS England will issue immediate guidance and establish a training programme for critical care staff on retrieval within a month. They will also commission a report on the feasibility of …
Kathleen Rosemary Dixon
All Responded
2013-0292
11 Nov 2013
Cumbria (South & East)
Concerns summary
Repeated critical incidents in the Trust, evident across multiple inquests, necessitate an independent assessment of its operations.
Action taken summary
The Department of Health reports that the Care Quality Commission (CQC) has already issued two warning notices and published an inspection report identifying shortfalls at Cumbria Partnership NHS Foun
Timothy Clayton
All Responded
2013-0361
11 Nov 2013
London Inner (North)
Kent Police
Concerns 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.
Action taken summary
Kent Police disputes the Coroner's report, claiming it contains factual inaccuracies and questions its legitimacy regarding organ viability and the number of lives lost. They state an urgent review of
John Gwynfryn Morris
All Responded
2013-0295
11 Nov 2013
Hertfordshire
Care Quality Commission
Concerns 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 taken summary
The CQC acknowledges concerns about dementia care staffing and underestimation of needs, clarifying their existing inspection methods. They plan to publish a thematic report on good practice in dement
William Joseph Wilkinson
Historic (No Identified Response)
2013-0294
11 Nov 2013
Manchester South
Royal Bolton Hospital
Concerns 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.
Peter Patrick Adrian Barnes
Historic (No Identified Response)
2013-0291
8 Nov 2013
West Yorkshire (West)
[REDACTED]
Concerns 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
All Responded
2013-0303
7 Nov 2013
Surrey
Concerns 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.
Action taken summary
The Department of Health explicitly rejects the suggestion of establishing national staffing ratios for care homes, stating it is not practical and there is no intention to add them to …
Henry McQuoid
Unknown
2013-0348
6 Nov 2013
Worcestershire
Concerns summary
Insufficient staffing, particularly with high reliance on agency workers, meant some residents requiring eating assistance might not receive it.
Ethel Cross
Historic (No Identified Response)
2013-0362
5 Nov 2013
Blackpool and Flyde
Blackpool Teaching Hospitals NHS Founda…
Concerns summary
Wheeled chairs accessible to elderly patients caused falls, and a shortage of alarms for high-risk patients meant they could mobilize unsupported.
Roshan Abbas Ladak-Ebrahim
All Responded
2013-0278
5 Nov 2013
London (North)
Concerns 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.
Action taken summary
The Department of Health reports that NHS England has published a new Consensus Statement on Information Sharing, providing clear advice on sharing information for individuals at risk of self-harm. Th
Susan Jill Hammond
All Responded
2013-0286
4 Nov 2013
Lincolnshire (Central)
Concerns 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 summary
United Lincolnshire Hospitals NHS Trust has revised antibiotic guidelines, developed a traffic light risk recognition system for penicillin allergies, and updated prescription charts to include prompt
Joanne Manning
Historic (No Identified Response)
2013-0289
1 Nov 2013
London
Practice
Concerns 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.
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
Home Office
+2 more
Concerns 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.
Wilhelmina Isobel Newton
All Responded
2013-0283
31 Oct 2013
Cumbria (North & West)
Concerns 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 summary
Cumbria County Council has developed a new policy and guidance for staff on how to respond to potential head injuries in elderly residents, especially those on medication affecting blood clotting. …