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)
172 results
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.
Mohammed Chaudhury
Historic (No Identified Response)
2013-0193 20 Aug 2013 London (Inner South)
Care Quality Commission King’s College Hospitals NHS Foundation…
Concerns summary (AI summary) The patient developed severe infected pressure sores due to the prolonged absence of an air mattress and insufficient turning, directly caused by nursing staff shortages.
Nicola Matthews
Historic (No Identified Response)
2013-0192 20 Aug 2013 London (South)
South London and Maudsley NHS Trust
Concerns summary (AI 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.
Sadie Ann Jane McGrady
Partially Responded
2013-0189 16 Aug 2013 North Wales (East & Central)
Driver and Vehicle Licensing Agency Association of British Insurers Vehicle and Operator Services Agency
Concerns summary (AI summary) Substandard repairs to a Category D insurance write-off vehicle compromised its structural integrity, increasing injury risk in a collision, with no independent checks for repaired written-off vehicles.
Noted (AI summary) The Association of British Insurers provides context on the Code of Practice for the Disposal of Motor Vehicle Salvage and the categories used to classify damaged vehicles. The Department for Transport is reviewing the Vehicle Identity Check (VIC) scheme, analysing ideas from a consultation, with potential changes by 2015 subject to legal processes and government priorities.
Keward Guy Domonic Harding
Historic (No Identified Response)
2013-0190 16 Aug 2013 Dorset
Community Mental Health Team
Concerns summary (AI summary) An urgent mental health assessment was significantly delayed for over two weeks, potentially preventing detection of a decline in physical health that could have been treated.
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.
Jordan Buckton
Historic (No Identified Response)
2013-0187 14 Aug 2013 Dorset
Dorset Healthcare University NHS Founda… National Offender Management Service
Concerns summary (AI summary) Prison staff lacked awareness of a prisoner's self-harm history due to information sharing failures. Additionally, there was inadequate follow-up after prescribing anti-depressants and a mental health course was discontinued due to staff shortages.
Vera Lillian Steel
Historic (No Identified Response)
2013-0185 13 Aug 2013 Surrey
Care Quality Commission South East England Fire and Rescue Serv…
Concerns summary (AI summary) A frail, bedbound resident fatally burned herself while smoking. Care homes should be encouraged to provide fire-protective aprons or smocks to residents who smoke to prevent similar incidents.
Ronald Sherlock
Historic (No Identified Response)
2013-0181 9 Aug 2013 Norfolk
Serco
Concerns summary (AI summary) Older prisoners lacked appropriate access to speech and language therapists to assess and manage swallowing difficulties, including recommendations for diet and fluid intake.
Matthew Thomas Hamilton
Historic (No Identified Response)
2013-0180 8 Aug 2013 Cumbria (North & West)
Cumbria County Council
Concerns summary (AI summary) A narrow footpath lacked a barrier, allowing children to emerge suddenly into traffic, compounded by restricted vision from a fence and shrubbery.
Dimitar Shtarbov
Historic (No Identified Response)
2013-0178 8 Aug 2013 South Lincolnshire
East Lincolnshire Clinical Commissionin… South Lincolnshire Clinical Commissioni…
Concerns summary (AI summary) Seasonal agricultural workers lacked awareness of and access to GP and emergency services in the UK. Many also self-medicated with prescription-only medicines obtained from their home countries.
Jean Miller
Historic (No Identified Response)
2013-0191 7 Aug 2013 Manchester (West)
Pennine Care Trust
Concerns summary (AI summary) District nurses failed to baseline a patient's wound, did not involve tissue viability specialists, and did not routinely take temperatures, as they were not issued with thermometers.
Ethel Smith Leese
Historic (No Identified Response)
2013-0184 7 Aug 2013 South Staffordshire
Stafford Hospital
Concerns summary (AI summary) Chaotic address verification procedures by the hospital post-discharge led to significant issues with the monitoring of Mrs. Leese's warfarin levels after her move to a care home and new GP practice.
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.
Alan Smith
Historic (No Identified Response)
2013-0173 5 Aug 2013 North Wales (East & Central)
Carrington Doors
Concerns summary (AI summary) A co-worker lacked specific training for working at height, and generic risk assessment forms and method statements were not routinely used by employees.
Joseph Burrell
Partially Responded
2013-0194 5 Aug 2013 London (North)
Harrow Council Traffic and Harrows Network Management …
Concerns summary (AI summary) The road junction lacked adequate pedestrian safety features, including no clear view of traffic lights, no 'red man/green man' signals, and no pedestrian control buttons, making it unsafe to cross.
Action Taken (AI summary) Harrow Council, in partnership with TfL, completed the installation of new signal equipment and linking of signals via SCOOT (Split Cycle Offset Optimisation Technique) to improve traffic flow; they are now monitoring the performance and will review the feasibility of introducing a dedicated pedestrian phase.
Michael James Thornton
Historic (No Identified Response)
2013-0170 1 Aug 2013 West Somerset
Somerset County Council Taunton Couthy Hall County Surveyor
Concerns summary (AI summary) Vehicles leaving the carriageway and landing in a rhynne leads to death by drowning; however, retaining barriers may be too costly given the extent of roadway that would need protection.
David George White
Historic (No Identified Response)
2013-0172 1 Aug 2013 South Yorkshire (East)
Regeneration and Environment
Concerns summary (AI summary) The coroner requests consideration of specific measures to reduce road traffic injuries at or on the approach to a bend on the A19 at Owston.
Annie Rose Gibson
Historic (No Identified Response)
2013-0171 1 Aug 2013 West Yorkshire (East)
Saga Homecare
Concerns summary (AI summary) The coroner raises concerns about a lack of clarity in Saga Homecare's procedures, specifically regarding the recording and communication of observations after a client fall.
Derek Edward Bartlett Twivey
Historic (No Identified Response)
2013-0175 30 Jul 2013 West Sussex
Fairlight Nursing Home
Concerns summary (AI summary) The coroner's concern relates to circumstances that could create a risk of future deaths, and action should be taken to prevent such occurrences.
Phillip Pratt
Historic (No Identified Response)
2013-0174 30 Jul 2013 West Sussex
Western Sussex Hospitals NHS Trust
Concerns summary (AI summary) A Root Cause Analysis Investigation Report identified a number of areas of concern arising from the investigation.
Jack William Partington
Partially Responded
2013-0308 21 Feb 2013 Manchester North
Department of Health Pennine Acute Hospitals NHS Trust
Concerns summary (AI summary) Neonatal care suffered from inadequate nurse handovers, isolated treatment decisions, and a lack of routine exhaled carbon dioxide detector use. There were also no national policies for managing paralysing agents or neonatal ventilation.
Noted (AI summary) The Department of Health believes the issues are local and should be addressed by the Trust, noting existing guidance and the role of NHS England, but will notify the British Association of Perinatal Medicine.