2013
PFD Reports
Reports: 172
Areas: 55
47% response rate (below 62% average).
Adrian John Pickard
All Responded
2013-0358
31 Dec 2013
West Yorkshire (East)
Lightwater Quarries Limited
Concerns summary
Company vehicles laden with aggregates are not routinely weighed before departing the premises, posing potential safety risks on public highways.
Action taken summary
Lightwater Quarries Ltd disputes the need to weigh all vehicles before departure, stating there is no legal requirement and their existing practice of spot-checking all vehicles is adequate and alread
Lynne Dring
All Responded
2013-0360-wp24087
30 Dec 2013
North Lincolnshire & Grimsby
North East Lincolnshire Council
Concerns summary
Street furniture obstructed motorists' views, and non-prescribed white lines may have falsely induced pedestrians to believe they had priority, creating a road safety risk.
Simon Sankey
All Responded
2013-0361-wp24075
27 Dec 2013
Manchester (West)
5 Boroughs Partnership NHS Foundation T…
Keith Samuel Peters
All Responded
2013-0378
20 Dec 2013
Manchester (West)
Bolton Council
Concerns summary
Inefficient case allocation and lack of prioritisation for assessments, combined with no system to reallocate cases when officers cannot meet deadlines, caused significant delays.
Action taken summary
Bolton Council has cascaded lessons learned throughout the organisation and implemented measures to improve systems, processes, and officer training. They will also oversee the full implementation of
Kate Louise Pierce
All Responded
2013-0363
20 Dec 2013
North Wales (East & Central)
General Medical Council
Concerns summary
A practicing GP failed to diagnose a patient and misled parents, with new evidence casting doubt on his fitness to practice. Previous GMC action stalled, posing a risk of future deaths.
Action taken summary
The General Medical Council acknowledges the concerns but states no action is proposed as their previous investigation was closed due to the five-year rule and they have received no further …
Christine Williamson
All Responded
2013-0371
18 Dec 2013
Shropshire, Telford & Wrekin
Telford and Wrekin Council
Telford and Wrekin Clinical Commission …
South Staffordshire and Shropshire Heal…
+1 more
Concerns summary
Failure to assess the deceased as a vulnerable adult at risk from domestic violence and a critical lack of information sharing between agencies hindered preventative measures.
Action taken summary
Telford & Wrekin Council has compiled and endorsed an action plan, with many actions already underway, building on recommendations from a Domestic Homicide Review. The implementation of this plan will
Sandra Wordingham
All Responded
2013-0373
17 Dec 2013
Cardiff & the Vale of Glamorgan
Springbank Care Home Limited
Concerns summary
A nursing home failed to seek timely medical opinion for an unconscious resident, delaying identification of a severe condition and risking unnecessary death if early intervention was possible.
Action taken summary
Springbank Nursing Home has developed and implemented new policies and protocols for managing residents who become unconscious, including a strict protocol for summoning emergency services and clear g
Clive Gould
All Responded
2013-0357
16 Dec 2013
Oxfordshire
South Central Ambulance Service NHS Fou…
Concerns summary
Ambulance service failures include inappropriate priority allocation for calls, insufficient system resilience leading to delays, and inadequate communication with callers about estimated arrival times and potential delays.
Action taken summary
SCAS has extended Rapid Response Vehicle cover to 24 hours in three counties and adjusted crew rotas to better match demand. They have also developed a Clinical Support Desk to …
Elsie May Treece
All Responded
2013-0376
16 Dec 2013
Staffordshire (South)
Burton Hospitals NHS Foundation Trust
Concerns summary
Hospital staff likely failed to report an incident where a patient fell during transfer, suggesting a need for better training and reminders on the requirement to report all inappropriate incidents.
Action taken summary
The Trust has arranged additional incident reporting training for Ward 6 staff and recently linked with a university to raise awareness for student nurses. They clarified that paper-based incident for
Joseph Drew Whiteside
All Responded
2013-0377
16 Dec 2013
Staffordshire (South)
East Staffordshire Borough Council
Concerns summary
Numerous drownings of intoxicated individuals in the River Trent highlight the need for improved safety measures, such as fencing and warning signs, at main access points.
Action taken summary
The Council appointed the Royal Society for the Prevention of Accidents (RoSPA) to conduct inland water safety reviews across Burton-upon-Trent and Uttoxeter, which was completed in late 2013. The Cou
Stephanie Daniels
All Responded
2013-0353
13 Dec 2013
Manchester City
NHS England
Care Quality Commission
NHS North Western Deanery
+4 more
Concerns summary
Significant deficiencies exist in internal SUI investigations, with errors and omissions, along with concerns about the thoroughness and independence of inquiries. Additionally, patient information handover between staff was often inadequate.
Action taken summary
The Trust is reviewing its Serious Incident Requiring Investigation (SIRI) policy to consider independent investigators and develop guidance. The Head of Nursing has issued instructions to Ward Manage
Felix Cembrowicz
All Responded
2013-0204
12 Dec 2013
Avon
Avon and Wiltshire Mental Health Partne…
Concerns summary
The electronic patient record system failed to migrate complete histories for discharged mental health patients, leaving current staff unaware of crucial past contact and relapse management plans.
Action taken summary
The Trust has updated its initial assessment/admission process to require staff to check for historic relapse management plans and other key documents (CPA, risk assessments) from previous electronic
Timothy Clayton
All Responded
2013-0361
11 Nov 2013
London Inner (North)
Kent Police
Concerns summary
Police improperly pressured the grieving family regarding organ donation, and an officer subverted the coroner's judicial decision, leading to the loss of six organs.
Action taken summary
Kent Police disputes the Coroner's report, claiming it contains factual inaccuracies and questions its legitimacy regarding organ viability and the number of lives lost. They state an urgent review of
John Gwynfryn Morris
All Responded
2013-0295
11 Nov 2013
Hertfordshire
Care Quality Commission
Concerns summary
Inadequate security measures at a residential dementia unit failed to prevent a resident with a known history of wandering from leaving the premises, despite previous escape incidents.
Action taken summary
The CQC acknowledges concerns about dementia care staffing and underestimation of needs, clarifying their existing inspection methods. They plan to publish a thematic report on good practice in dement
Isabella Hope Hill
All Responded
2013-0281
23 Oct 2013
Liverpool
Liverpool Womens Hospital
Concerns 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 summary
The Trust has revised its UVC insertion guideline and proforma, enhanced staff education, clarified radiology service level agreements for neonatal X-rays to ensure a 60-minute turnaround, and provide
Robert Wilkinson
All Responded
2013-0269
21 Oct 2013
County Durham & Darlington
Durham Constabulary
Concerns 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 summary
Durham Constabulary states that face-to-face meetings will now be undertaken when they add value to firearms license reviews. They are also addressing weaknesses in record keeping by converting all ce
Rosa Anderson
All Responded
2013-0263
17 Oct 2013
Liverpool
Aintree Hospitals NHS Trust
Concerns summary
The patient was discharged without a summary, written information on her operation, critical advice, or emergency contact numbers.
Action taken summary
Aintree University Hospital has already implemented a discharge advice sheet for laparoscopic procedures, which is provided to all relevant patients prior to discharge. They are also implementing gene
Walter Gordon Powley
All Responded
2013-0251
4 Oct 2013
Leicester City & South Leicestershire
Care Quality Commission
Health and Safety Executive
Registered Nursing Home Association
Concerns summary
Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded by a lack of specific room risk assessments and oversight failures by regulatory bodies.
Action taken summary
The CQC acknowledges its inspector did not assess against relevant regulations for premises safety in this case. They are piloting a new inspection methodology that will focus on safety and …
Michael Joseph Hirrell
All Responded
2013-0247
1 Oct 2013
Leicester City and South Leicestershire
Ofgem
Npower
Energy UK
Concerns summary
Npower failed to recognise a clearly vulnerable person, disconnecting their power despite staff concerns. Systemic failures in consumer protection and inadequate industry-wide changes risk future deaths.
Action taken summary
Ofgem proposes that the Safety Net wording be made more explicit regarding vulnerable domestic consumers with non-domestic supplies, including a commitment for suppliers to maintain an audit trail. Of
Jared William McDowall
All Responded
2013-0245
27 Sep 2013
Avon
University Hospitals Bristol NHS Founda…
Concerns summary
Inadequate guidelines for identifying at-risk babies, including a lack of specific weight-for-gestation criteria and poor data presentation. Joint training for doctors and midwives on hypoglycaemia is also needed.
Action taken summary
University Hospitals Bristol has developed a composite action plan to address concerns regarding communication between neonatal and cardiac units for premature babies, and the cut-off weight guideline
Rose Jean Coles
All Responded
2013-0246
27 Sep 2013
Avon
University Hospitals Bristol NHS Founda…
Concerns summary
Inadequate communication and protocols between the neonatal intensive care and cardiac units hindered the safe care of premature babies, as the cardiac unit was not suited for their specific needs.
Action taken summary
University Hospitals Bristol has developed a composite action plan to address concerns regarding communication between neonatal and cardiac units for premature babies, and the cut-off weight guideline
Gwilym Pugh Jones
All Responded
2013-0239-wp23941
25 Sep 2013
North Wales (East and Central)
Betsi Cadwaladr University Hospital Boa…
Jude Augustus Gordon
All Responded
2013-0237
24 Sep 2013
South Yorkshire (West)
Department of Health and Social Care
Concerns summary
Failures in calculating and escalating Early Warning Scores, alongside a lack of national standardisation and automatic alert systems, led to delayed critical care referrals for a deteriorating patient.
Action taken summary
The Department of Health confirms that a National Early Warning Score (NEWS) system has already been advocated by the Royal College of Physicians, with guidance and e-learning materials produced to …
Michael Sweeney
All Responded
2013-0236
23 Sep 2013
London North (Inner)
London Ambulance Service
Metropolitan Police
Concerns summary
Police training on 'excited delirium' is not widely understood by other health professionals, risking miscommunication and missed diagnoses of underlying medical conditions. Standardising the term to 'extreme agitation' is needed.
Action taken summary
The Metropolitan Police Service (MPS) has adopted 'Acute Behavioural Disorder' (ABD) as common terminology, which is now incorporated into police officer training and a new joint agency call-handling
Joan Mary Jones
All Responded
2013-0234
20 Sep 2013
Leicester City and South Leicestershire
Manor Residential and Nursing Care Home
Concerns summary
Care home staff failed to escalate a patient's deteriorating condition and provide complete information to health professionals, resulting in inadequate care and putting the patient at risk.
Action taken summary
The Manor has issued a memo to all unit leads to ensure families are contacted after health professional visits, communication sheets are completed and shared, and visits are communicated to …