2013
PFD Reports
Reports: 172
Areas: 55
47% response rate (below 63% average).
Luke Lyons
All Responded
2013-0203
17 Sep 2013
Exeter & Greater Devon
Devon County Council
Action Taken
(AI summary)
The Council addressed drainage issues on a road, including undertaking works. They also plan to continue using intelligence gathering and inspection processes, and will use the media to disseminate messages about safe travel in severe weather.
George Renshaw Brown
Historic (No Identified Response)
2013-0230
16 Sep 2013
Manchester South
Bromleys Solicitors
Care Quality Commission
Fentons Solicitors
+3 more
Concerns summary (AI 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.
Reggie John
Partially Responded
2013-0202
16 Sep 2013
Worcestershire
HMP Bristol
HMP Hewell
Worcestershire Health and Care NHS Trust
Concerns summary (AI 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
(AI summary)
The trust reiterated expectations regarding ACCT documents for prisoners arriving at HMP Hewell, and reviewed Prison Service Instruction 64/2011 to identify and address areas of non-compliance. HMP Bristol introduced a system to contact receiving establishments about prisoners on open ACCTs, and HMP Hewell issued a notice reminding staff to report information indicating a change in a prisoner's potential for self-harm. Operational Orders reinforce multi-disciplinary ACCT reviews.
Rachael Dallison
Historic (No Identified Response)
2013-0205
16 Sep 2013
Staffordshire (South)
Commissioner for Transport
Staffordshire County Council
Concerns summary (AI summary)
The provided concerns text is too truncated to identify specific safety issues.
Matthew Dunham
Historic (No Identified Response)
2013-0229
12 Sep 2013
Norfolk
Norfolk and Suffolk NHS Foundation Trust
Concerns summary (AI 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 (AI 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 (AI 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.
Martin Daffydd Barker
Partially Responded
2013-0226
9 Sep 2013
Manchester South
Department of Health and Social Care
Manchester Medical Service
North West Ambulance Service
+1 more
Concerns summary (AI 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.
Noted
(AI summary)
The Ambulance Service clarified the difference between organised events and day-to-day operations, stating they cannot be the "gatekeeper" for NHS hospital standby numbers for private ambulance services. They suggest guidance from the Department of Health may assist. The Department of Health will share the case with the Care Quality Commission to consider whether access to emergency departments needs to be part of the inspection portfolio for independent ambulance providers. They also intend to write to the Health and Safety Executive to bring the case to their attention.
Ricky Anderson
Historic (No Identified Response)
2013-0227
9 Sep 2013
Mid Kent and Medway
Kent and Medway NHS
Social Care Partnership Trust
Concerns summary (AI 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.
John Michael Bailey
Historic (No Identified Response)
2013-0198
9 Sep 2013
South Yorkshire (West)
Department of Health and Social Care
Peter Pattinson
All Responded
2013-0250
6 Sep 2013
Sunderland
European Care group
Concerns summary (AI 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
(AI summary)
The care group has implemented new bed rail risk assessment and checking systems, along with staff training on safe bed rail usage. They also numbered daily statement documents to prevent misplacement.
Labhuden Amarshi Vaghadia
All Responded
2013-0201
5 Sep 2013
Leicester City & South Leicestershire
Leicestershire Partnership NHS Trust
Concerns summary (AI 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
(AI summary)
The Partnership NHS Trust reviewed the case, assessed the nurse's competence, and arranged medicines management and emotional resilience training along with additional clinical supervision. They are also implementing a mobile working solution for community staff.
Michael Irlam
Historic (No Identified Response)
2013-0224
4 Sep 2013
Manchester South
Improving Access to Psychological Thera…
Trafford Crisis Resolution and Home Tre…
Concerns summary (AI 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.
Karen Sutton
All Responded
2013-0223
4 Sep 2013
Leicester City & South Leicestershire
University Hospitals Leicester NHS Trust
Concerns summary (AI 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
(AI summary)
The Medical Director reminded consultants of their duty to contact specialist teams for patients with complex needs, and the hospital expects to have software by April 2014 to alert consultants about patients with specific needs.
May Gibson
Historic (No Identified Response)
2013-0199
30 Aug 2013
South Yorkshire (West)
LNT Software Helios 47
Herries Lodge Care Home
Concerns summary (AI summary)
The report identifies failures in obtaining and accounting for a community care assessment, performing pre-assessments, developing adequate care plans, conducting risk assessments, and implementing risk reduction plans at the care home.
Jessica Ashton-Pyatt
Historic (No Identified Response)
2013-0200
30 Aug 2013
South Lincolnshire
United Lincolnshire Hospitals NHS Trust
Concerns summary (AI summary)
The emergency response was uncoordinated, lacked consultant leadership, and critical equipment like the defibrillator was uncharged with missing pads, compromising immediate patient care.
Jack William Payton
All Responded
2013-0220
30 Aug 2013
West Somerset
Avon and Somerset Constabulary
Concerns summary (AI 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 Planned
(AI summary)
The police are commissioning an independent assessment of current shift patterns and their effects on staff, anticipated to commence in January 2014, with recommendations to be considered at Force level.
Martin Leslie Brown
Partially Responded
2013-0209
29 Aug 2013
Gloucestershire
British Board of Agreement
Fletcher's Solicitors
Gloucestershire Constabulary
+4 more
Concerns summary (AI 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 Planned
(AI summary)
The BBA has revised paragraph 3.1 of Certificate 06/H120, removing the reference to rural roads, and will reissue the certificate with the revised wording by December 2013.
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.
Terence O’Connell
Partially Responded
2013-0218
28 Aug 2013
Bridgend, Glamorgan Valleys & Powys
ABMU Health Board
Grove Medical Centre
Monkstone House Care Home
Concerns summary (AI 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.
Disputed
(AI summary)
The care home disputes that there was a communication breakdown between the care home, district nurses, and the out-of-hours GP service, asserting that communication breakdown was between district nurses and the GP out of hours service. The University Health Board has implemented a clear and accurate message sheet, SBAR (Situation, Background, Assessment, Recommendation), for switchboard staff to record out-of-hours requests for District Nurses in greater detail.
Muniza Mehrban
Historic (No Identified Response)
2013-0216
27 Aug 2013
Blackburn, Hyndburn & Ribble Valley
Jesta Capital Corporation
Concerns summary (AI 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.
Jill Sinson
Historic (No Identified Response)
2013-0221
23 Aug 2013
West Yorkshire (East)
Beeston Health Centre
Concerns summary (AI 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.
Luna Lesko
Partially Responded
2013-0214
23 Aug 2013
London (Inner South)
NHS Lewisham Commissioning Group
University Hospital Lewisham
Concerns summary (AI 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 Planned
(AI summary)
The hospital plans to relocate elective lists to the main theatre unit by the end of January 2014, which would free up the obstetric unit theatre for emergencies and allow midwives and doctors to focus on labouring women.
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.
Derek Brierley
Partially Responded
2013-0244
20 Aug 2013
Manchester North
England & Wales
Pennine Acute Trust
Concerns summary (AI summary)
The suprapubic procedure was performed by a consultant after a long hiatus with inadequate preparation, likely incorrect insertion, and a lack of Trust guidelines for competence and training.
Action Taken
(AI summary)
The hospital has re-drafted the pathway for managing urinary retention, shared it with A&E staff, initiated a training program for inserting catheters outside of the urology division, and will continue to monitor catheter-related incidents.