2013
PFD Reports
Reports: 172
Areas: 55
47% response rate (below 63% average).
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.
Winston Llewellyn Johns
Historic (No Identified Response)
2013-0279
30 Oct 2013
Powys Bridgend and Glamorgan Valleys
Department of Health and Social Care
Welsh Ambulance Service NHS Trust
Concerns summary (AI summary)
Critical low blood sugar information was disregarded by the ambulance operator, and the computer system's inability to process clinical details led to inappropriate CPR advice.
Damion Anthony Andre Martin
Historic (No Identified Response)
2013-0280
30 Oct 2013
Liverpool
NOMS
HMP Liverpool
Rights and Responsibilities Group
Concerns summary (AI summary)
Inadequate prison risk assessment failed to identify a key suicide risk factor, first responders lacked CPR refresher training, and cell observation was compromised by restricted views and missed checks.
Harold Elvidge
Historic (No Identified Response)
2013-0274
24 Oct 2013
Nottinghamshire
Nottingham University Hospitals NHS Tru…
Concerns summary (AI summary)
A risk of fluid mix-ups exists due to inconsistent safety standards and storage policies across the trust, particularly in non-critical care settings, necessitating a trust-wide review of fluid management.
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)
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. 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.
Jacqueline Allwood
Partially Responded
2013-0275
23 Oct 2013
London (Inner South)
Bromley Healthcare
Cator Medical Centre
Beckenham Beacons UCC
+2 more
Concerns summary (AI summary)
The urgent care center lacked an agreed protocol for DVT management, and a consulting GP failed to meet normative practice standards for diagnosis, risking future missed DVT cases.
Action Planned
(AI summary)
NHS England has requested that the GP in question undertake a reflective report, attend a course on medical record keeping, and complete an audit of his medical record keeping, with specific deadlines for each action.
John Lansdowne
Historic (No Identified Response)
2013-0360-wp26756
23 Oct 2013
London Inner (North)
Camden & Islington NHS Foundation Trust
Concerns summary (AI summary)
Unclear observation records and inconsistent staff understanding of patient observation protocols during bathing, coupled with the use of baths instead of safer walk-in showers, posed risks.
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.
Brian Belfield
Historic (No Identified Response)
2013-0270
21 Oct 2013
Cumbria (North and West)
Fell Runners Association
Concerns summary (AI summary)
Failures in race management included an inaccurate system for tracking participants, lack of a single responsible person for checks, and unreliable communication between race control and marshals, leading to a missing runner.
Elsie Gibson
Historic (No Identified Response)
2013-0267
21 Oct 2013
South London
Bromley Council
Concerns summary (AI summary)
The Council, as Highways Authority, failed to promptly investigate and take action against an unlicensed scaffold tower that narrowed a pavement, leading to a fatal injury.
Lucy Kilvert
Historic (No Identified Response)
2013-0266
21 Oct 2013
Black Country
National Institution for Health and Cli…
Concerns summary (AI summary)
A significant delay occurred in performing a CT scan for an elderly patient on blood thinners after a fall, suggesting NICE Guidelines may not sufficiently emphasize the significance of medication in such cases.
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.
Mark Stephen Smith
Historic (No Identified Response)
2013-0268
21 Oct 2013
London (North)
London Ambulance Service
Concerns summary (AI summary)
Guidance is needed for emergency services on when to remain on the line with a person who has taken an intentional overdose and is alone.
Elizabeth Aurora Kerr
Historic (No Identified Response)
2013-0276
18 Oct 2013
Manchester City
All Party Parliamentary Gas Safety Group
Association of Chief Fire Officers
Department for Energy and Climate Change
+6 more
Concerns summary (AI summary)
The provided text is truncated, making it impossible to identify the specific safety concerns raised by the All-Party Parliamentary Gas Safety Group.
Jennifer Rushworth
Historic (No Identified Response)
2013-0264
18 Oct 2013
Manchester South
Stepping Hill Hospital
Concerns summary (AI summary)
Significant delays in cardiology reviews, lack of surgeon input in theatre booking, and insufficient surgeons contributed to surgical delays, potentially impacting patient outcomes.
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.
John James Jackson
Historic (No Identified Response)
2013-0260
16 Oct 2013
Black Country
Department of Health and Social Care
Concerns summary (AI summary)
The coroner notes a lack of readily available information about the dangers of consuming large quantities of caffeine, particularly from 'Hero Energy Mints', which are advertised as an alternative to energy drinks.
Janet Richardson
Partially Responded
2013-0261
16 Oct 2013
Cumbria (North & West)
Cruise and Maritime Services Internatio…
Newmarket Promotions Limited
Redningsselskapet
Concerns summary (AI summary)
The deceased fell into the sea during a rescue medical evacuation.
Noted
(AI summary)
CMSI states that they strongly believe that the Norwegian Rescue Service had appropriate procedures in place. However, they changed their procedures following the incident to prevent similar incidents from recurring, including following the new procedures adopted by the Norwegian Rescue Service. The changes will be implemented if there is a need to transfer a passenger from a CMSI vessel to a Norwegian Rescue Service vessel. Newmarket Promotions Ltd. states that they forwarded the Coroner's recommendations to their clients, however, disclaim responsibility as emergency procedures are the responsibility of the authorities.
Frederick Davidson
Historic (No Identified Response)
2013-0258
14 Oct 2013
Surrey
Department of Health and Social Care
Epsom and St Helier University Hospital…
Concerns summary (AI summary)
Inadequate note-keeping, inappropriate use of a nasogastric tube given the patient's history, unexplained gaps in clinical notes, communication breakdown between junior doctor and consultant, lack of pneumothorax recognition, premature authorisation of feeding, and delays in X-ray reporting were highlighted.
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.
Carol Ann Gibson
Historic (No Identified Response)
2013-0183
12 Oct 2013
Cheshire
Castlefields Health Centre
NHS England
Concerns summary (AI summary)
A GP ignored a critical adverse drug reaction alert, exacerbated by a culture of 'alert fatigue' and dismissive attitudes towards patient safety warnings within the medical practice.
James Edward Mansfield
Historic (No Identified Response)
2013-0288
10 Oct 2013
Cambridgeshire (South and West)
Nuffield Road Medical Centre
Concerns summary (AI summary)
Delays in the GP surgery reviewing hospital discharge letters for serious injuries, combined with prescribing strong painkillers without an in-person assessment, posed risks to patient safety.
Anthony Bernard Mcormick
Historic (No Identified Response)
2013-0255
8 Oct 2013
Manchester City
Consultant Physician and Gastroenterolo…
East Cheshire NHS Trust
Concerns summary (AI summary)
Urgent blood test results were not acted upon promptly, leading to a delay in necessary hospital admission.
Kuldip Singh Dhillon
Historic (No Identified Response)
2013-0254
8 Oct 2013
London (East)
Department for Transport
Concerns summary (AI summary)
Widespread common practice of unrestrained palletised loads on vehicles poses significant safety risks, compounded by insufficient enforcement and auditing of transport regulations by the Department of Transport.