2013

PFD Reports
Reports: 172 Areas: 55

47% response rate (below 62% average).

Response Status
Responded 80 Historic 72
AI Classification
Action Taken 58%
Action Planned 18%
Noted 8%
Disputed 16%
Based on 83 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) Care Home Health related deaths (14)
172 results
Neil Richard Clark
Historic (No Identified Response)
2013-0231 17 Sep 2013 Birmingham and Solihull
Jurys Inn Birmingham
Concerns summary A patient who had attempted overdose and undergone a mental health assessment was able to leave an Ambulatory Care Unit unnoticed, subsequently taking his own life.
Rachael Dallison
Historic (No Identified Response)
2013-0205 16 Sep 2013 Staffordshire (South)
Commissioner for Transport Staffordshire County Council
Concerns summary The provided concerns text is too truncated to identify specific safety issues.
Reggie John
Partially Responded
2013-0202 16 Sep 2013 Worcestershire
Worcestershire Health and Care NHS Trust HMP Bristol HMP Hewell
Concerns summary Poor communication and lack of written records between prisons compromised a high-risk prisoner's care. Failures included inadequate review processes and a nurse not accessing or updating crucial risk documents.
Action taken summary Following the inquest, the Lead for Offender Health set out clear expectations to all healthcare staff at HMP Hewell regarding ACCT documents for arriving prisoners, ensuring they are available to …
George Renshaw Brown
Historic (No Identified Response)
2013-0230 16 Sep 2013 Manchester South
Care Quality Commission Fentons Solicitors Manchester Clinical Commissioning Group +3 more
Concerns summary A lack of efficient systems for reassessing and transferring care home residents with rapidly deteriorating conditions led to significant delays in moving a patient to more suitable accommodation.
Matthew Dunham
Historic (No Identified Response)
2013-0229 12 Sep 2013 Norfolk
Norfolk and Suffolk NHS Foundation Trust
Concerns summary Failures in mental health care included delayed emergency referrals, unclear team roles, inadequate assessment of suicide risk, and critical breakdowns in information sharing and coordination among professionals.
Caroline Lee
Historic (No Identified Response)
2013-0228 11 Sep 2013 Coventry
University Hospital Coventry and Warwic…
Concerns summary Medical staff failed to recognise the significance of abnormal potassium results, compounded by the laboratory's failure to inform ward staff promptly, hindering timely intervention.
David Douglas Hackman
Historic (No Identified Response)
2013-0346 10 Sep 2013 Wiltshire & Swindon
NHS England
Concerns summary After a previous overdose attempt, a patient undergoing mental health assessment in a hospital unit was able to leave unnoticed, leading to his subsequent death by suicide.
John Michael Bailey
Historic (No Identified Response)
2013-0198 9 Sep 2013 South Yorkshire (West)
Department of Health and Social Care
Ricky Anderson
Historic (No Identified Response)
2013-0227 9 Sep 2013 Mid Kent and Medway
Kent and Medway NHS
Concerns summary Mental health services failed to inform the GP of hospital admissions, relied excessively on family for post-discharge monitoring, and discharged a patient early without a care plan.
Martin Daffydd Barker
Partially Responded
2013-0226 9 Sep 2013 Manchester South
Department of Health and Social Care Salford Royal Hospital NHS Trust Manchester Medical Service +1 more
Concerns summary There appears to be no national guidance on how independent medical service providers, particularly those covering large public events, should operate, posing a risk to patient safety.
Action taken summary North West Ambulance Service clarifies that for day-to-day services, they cannot and should not act as "gatekeeper" for NHS hospital standby numbers for independent medical providers. They state these
Peter Pattinson
All Responded
2013-0250 6 Sep 2013 Sunderland
European Care group
Concerns 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 summary European Care Group has implemented new procedures for bed rail risk assessments (within 24 hours of admission and monthly review), a daily checking system for bed rail condition, and staff …
Labhuden Amarshi Vaghadia
All Responded
2013-0201 5 Sep 2013 Leicester City & South Leicestershire
Leicestershire Partnership NHS Trust
Concerns 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 summary The Trust conducted extensive reviews of Mrs Vaghadia's death and current nursing practices, re-iterating vital communication principles through an implemented divisional strategy. They performed two
Karen Sutton
All Responded
2013-0223 4 Sep 2013 Leicester City & South Leicestershire
University Hospitals Leicester NHS Trust
Concerns 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 summary The Trust has written to all consultants reminding them of their duty to contact specialist teams for patients with complex needs. They also plan to implement new software by April …
Michael Irlam
Historic (No Identified Response)
2013-0224 4 Sep 2013 Manchester South
Trafford Crisis Resolution and Home Tre… Improving Access to Psychological Thera…
Concerns summary A significant 24-day waiting time between discharge from crisis mental health services and the first follow-up appointment creates a dangerous gap in care, risking patient abandonment.
Jack William Payton
All Responded
2013-0220 30 Aug 2013 West Somerset
Avon and Somerset Constabulary
Concerns 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 taken summary The Constabulary is commissioning an independent assessment of current shift patterns and their effects on staff, anticipated to be completed by January 2014. Recommendations will be developed and con
Jessica Ashton-Pyatt
Historic (No Identified Response)
2013-0200 30 Aug 2013 South Lincolnshire
United Lincolnshire Hospitals NHS Trust
Concerns summary The emergency response was uncoordinated, lacked consultant leadership, and critical equipment like the defibrillator was uncharged with missing pads, compromising immediate patient care.
May Gibson
Historic (No Identified Response)
2013-0199 30 Aug 2013 South Yorkshire (West)
Herries Lodge Care Home
Concerns summary The care home exhibited widespread systemic failures, including inadequate assessments, poor care planning, insufficient risk management, and a lack of cohesive management and staff training.
Martin Leslie Brown
All Responded
2013-0209 29 Aug 2013 Gloucestershire
British Board of Agreement
Concerns summary The certificate for a road resurfacing product (Milepave) contained ambiguous wording regarding speed limit applicability and road types, risking its inappropriate use on unsuitable roads.
Action taken summary The British Board of Agrément has revised paragraph 3.1 of Certificate 06/H120, removing the reference to rural roads and clarifying the product's suitability for highways with speed limits up to …
Terence O’Connell
Partially Responded
2013-0218 28 Aug 2013 Bridgend, Glamorgan Valleys & Powys
Grove Medical Centre Monkstone House Care Home ABMU Health Board
Concerns summary A severe communication breakdown between the care home, district nurses, and out-of-hours GP led to the patient not being seen, alongside a lack of vital clinical monitoring for two days.
Action taken summary The care home, through Gabbandco, disputes the coroner's finding of a communication breakdown involving them. They assert that any breakdown occurred between the district nurses and the out-of-hours G
Dorothy Townley
All Responded
2013-0219 28 Aug 2013 Manchester (South)
Royal College of General Practitioners Royal College of Nursing
Concerns 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.
Action taken summary The Royal College of General Practitioners clarifies its role in providing training and professional development to GPs, outlining existing curriculum sections relevant to inter-professional communica
Muniza Mehrban
Historic (No Identified Response)
2013-0216 27 Aug 2013 Blackburn, Hyndburn & Ribble Valley
Jesta Capital Corporation
Concerns summary This marks the fourth death in three years at the multi-storey car park due to individuals jumping, indicating an urgent need for suicide prevention measures at the location.
Luna Lesko
Partially Responded
2013-0214 23 Aug 2013 London (Inner South)
NHS Lewisham Commissioning Group University Hospital Lewisham
Concerns summary Delays in essential foetal monitoring and performing a Category 2 Caesarean section, coupled with insufficient out-of-hours theatre capacity, create a real risk of preventable maternal and infant deaths.
Action taken summary The Trust plans to move all planned elective Caesarean sections to the main theatre unit by the end of January 2014 to free up the obstetric unit theatre for emergencies. …
Jill Sinson
Historic (No Identified Response)
2013-0221 23 Aug 2013 West Yorkshire (East)
Beeston Health Centre
Concerns summary The GP failed to adequately monitor the deceased, prescribed large quantities of unsupervised medication despite a self-harm history, and staff neglected to review critical records or consultant advice.
John Walker
All Responded
2013-0213 21 Aug 2013 West Sussex
Sussex Partnership NHS Trust
Concerns 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 summary The Trust has revised clinical documentation for risk care planning and conducts regular audits to ensure standards are met. They have also altered fences throughout Langley Green Hospital to make …
Nicola Matthews
Historic (No Identified Response)
2013-0192 20 Aug 2013 London (South)
South London and Maudsley NHS Trust
Concerns summary Incomplete documentation and unclear, undocumented follow-up arrangements for a high-risk patient discharged from inpatient care led to staff confusion and potential for future harm.