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)
Clear 55 results
Dorothy Townley
All Responded
2013-0219 28 Aug 2013 Manchester (South)
Royal College of General Practitioners Royal College of Nursing
Concerns summary (AI summary) Significant communication breakdowns between District Nurses and the GP, inadequate burns treatment knowledge and training, and unclear procedures for urgent blood tests compromised patient care.
Noted (AI summary) The Royal College of General Practitioners provides context on its role, training, and advice to members, highlighting relevant sections of the GP Curriculum related to communication between professionals and patient safety.
John Walker
All Responded
2013-0213 21 Aug 2013 West Sussex
Sussex Partnership NHS Trust
Concerns summary (AI summary) Insufficient risk care planning, lack of rationale for decreasing observation levels despite deteriorating mental state, and delays in reporting missing patients raised serious safety concerns.
Action Taken (AI summary) The Trust has revised the documents clinicians are asked to complete to ensure they are less repetitive and better support succinct recording of relevant issues and the fences throughout Langley Green Hospital have been altered to make it much more difficult to get over.
Ann Margaret Spearing
All Responded
2013-0217 20 Aug 2013 Avon
Chair
Concerns summary (AI summary) Despite clear malnutrition and learning difficulties, the deceased was repeatedly assessed by mental health, hospital, and eating disorder services, yet consistently misdiagnosed or found not to have a treatable condition.
Action Taken (AI summary) Bristol has recently reviewed, redesigned and is currently re-procuring its specialist mental health and learning disability services and has piloted an enhanced advice and guidance support scheme to GPs.
Ronald Ellwood
All Responded
2013-0222 15 Aug 2013 Staffordshire (South)
Queen’s Hospital
Concerns summary (AI summary) The provided concerns text is too truncated to identify specific safety issues.
Action Planned (AI summary) The Trust plans to refurbish the Air Conditioning Systems within the hospital, re-evaluating environmental conditions and the system design to control the environment with additional heat loads, especially in the ITU unit.
Lucy Hannah Rose Bailey
All Responded
2013-0176 6 Aug 2013 Rutland & North Leicestershire
JRCALC East Midlands Ambulance Service South Central Ambulance Service
Concerns summary (AI summary) Concerns were raised regarding the adherence to or adequacy of guidelines for managing dystocia, which was identified as a known hazard.
Action Taken (AI summary) The South Central Ambulance Service has updated its clinical practice guidance on the management of shoulder dystocia, incorporating advice from specialists in obstetrics and midwifery, and issued it to Medical Directors of Ambulance Trusts across the UK.