2014

PFD Reports
Reports: 557 Areas: 71

54% response rate (below 62% average).

Response Status
Responded 303 Historic 252
AI Classification
Action Taken 52%
Action Planned 24%
Noted 17%
Disputed 7%
Based on 29 classified responses
Top Categories
Hospital Death (Clinical Procedure… (240) Community health care and emergenc… (69) Other related deaths (66) Road (Highways Safety) related dea… (57) State Custody related deaths (35)
Clear 235 results
Frederick Pring
All Responded
2014-0024 21 Jan 2014 North Wales (East & Central)
Betsi Cadwaladr University Health Board
Concerns summary Current practices for patient handover at Emergency Departments lead to unacceptable delays, keeping ambulances occupied and unavailable for other critical calls.
Action taken summary The Welsh Ambulance Services NHS Trust and Betsi Cadwaladr University Health Board are completing an All Wales Handover Policy and have proposed becoming a 'Demonstrator Site' for the RCP's 'Future …
Mone White
All Responded
2014-0031 21 Jan 2014 London (North)
Department of Health and Social Care Northwick Park Hospital
Concerns summary There is no system to ensure specialist hospital advice for patients with complex clinical requirements is consistently communicated to all treating clinicians.
Action taken summary The Department of Health acknowledges the concern but states that developing a national flag system for patient care advice is a matter for local NHS Trusts to ensure existing information …
Julie Ann Camm
All Responded
2014-0023 17 Jan 2014 West Yorkshire (East)
Leeds City Council
Concerns summary A vulnerable tenant's property lacked smoke alarms because the housing association's policy only encouraged fire safety checks, failing to ensure installation and increasing the risk of death from fire.
Action taken summary Leeds City Council's Housing Leeds has updated its Electrical Specification to require hard-wired smoke detection during any major electrical works. They are installing hard-wired smoke detectors in 3
Michael O’Sullivan
All Responded
2014-0012 13 Jan 2014 London Inner (North)
Department for Work and Pensions
Concerns summary The DWP assessment process for fitness to work failed to incorporate vital medical information from the patient's treating GP, psychiatrist, and clinical psychologist, leading to decisions without comprehensive medical input.
Action taken summary DWP will issue a reminder to staff about the guidance for requesting further medical evidence in cases where claimants report suicidal ideation. They will also continue to monitor their policies …
Jason Nock
All Responded
2014-0013 13 Jan 2014 Black Country
Home Office
Concerns summary An entirely unregulated product is readily available without consumer information on safe dosage or potential consequences, leaving users unaware of the substance they are consuming.
Action taken summary The Home Office has requested advice from the Advisory Council on the Misuse of Drugs and is actively collecting evidence on AH-7921. They are also leading an expert panel review …
Albert James Hand
All Responded
2014-0010 9 Jan 2014 Bedfordshire & Luton
East of England Ambulance Service
Concerns summary Insufficient ambulance crews in the Luton and Bedfordshire area caused dangerously long wait times for head injury patients, and current emergency call protocols are putting patients at risk.
Action taken summary The Trust has reviewed and implemented an updated Demand Management Plan, recruited 100 new frontline clinicians, and commenced issuing a clinical manual. They are also commissioning an upgrade to the
Grace Mary Bates
All Responded
2014-0007 7 Jan 2014 London (North)
Department of Health and Social Care Barnet and Chase Farm Hospitals NHS Tru…
Concerns summary The hospital lacked a specialist diabetic nurse available over the weekend, posing a risk to patients requiring specific care.
Action taken summary Barnet and Chase Farm Hospitals NHS Trust has approved a business case for the appointment of at least one full-time specialist diabetic nurse to provide improved cover across the calendar …
Martin McGlasson
All Responded
2014-0001 6 Jan 2014 Cumbria (North & West)
British Precast Concrete Federation
Concerns summary Widespread use of an unsafe work method, failure to implement inexpensive safety measures despite known risks, and inadequate dissemination of risk assessments to operating staff were key concerns.
Action taken summary Thomas Armstrong Holdings Ltd has implemented a new system of work and adopted a new Risk Assessment and Method Statement for moving staircases. They have also provided health and safety …
Billy Paul Thomas Salton
All Responded
2014-0002 6 Jan 2014 Manchester (South)
Greater Manchester Police
Concerns summary GMP policy of not staffing the Prisoner Processing Unit overnight leads to unnecessary and prolonged custody times for individuals awaiting interview.
Action taken summary Medacs has introduced a new requirement for all new healthcare staff to sign off on policy awareness and has replaced handwritten assessment forms with an electronic record system. They are …
Daniel Williams
All Responded
2014-0009 6 Jan 2014 South Yorkshire (East)
Rotherham, Doncaster and South Humber N…
Concerns summary Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm items, and no central summary sheet for key patient information.
Action taken summary The Trust has completed 'personal safe care' training for all inpatient staff, altered handover practice, and developed a Standard Operating Procedure for room searches. They have also included a sear