2014

PFD Reports
Reports: 557 Areas: 71

55% response rate (below 63% average).

Response Status
Responded 305 Historic 252
AI Classification
Action Taken 41%
Action Planned 36%
Noted 21%
Disputed 2%
Based on 383 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)
557 results
Helena Farrell
All Responded
2014-0309 3 Jul 2014 Cumbria (South & East)
Cumbria County Council Cumbria Partnership NHS Foundation Trust
Concerns summary (AI summary) The report identifies an inadequate referral system and staffing levels at CAMHS, a failure to recognise the escalation of incidents, unrealistic expectations of the school nurse, and a lack of verification of the school counsellor's qualifications.
Action Planned (AI summary) Cumbria Partnership NHS Foundation Trust has significantly redesigned the CAMHS referral system, with a 48-hour response target for urgent referrals. The recommendations from the Serious Untoward Incident report have been accepted and implemented in full. Cumbria County Council will remind schools of their duty to ensure counselors are appropriately qualified by the end of September and will undertake a sample audit later in the school year. They also plan to build changes into the new service specification commissioned from October 2015.
Esther Jones
Historic (No Identified Response)
2014-0296 2 Jul 2014 North Wales (East & Central)
Betsi Cadwaladr University Health Board
Concerns summary (AI summary) Significant delays in completing Serious Incident Reviews (SIRs) and disseminating lessons learned prevent timely improvements and risk further patient harm.
Gary Daltry
All Responded
2014-0295 2 Jul 2014 North Wales (East & Central)
Denbighshire County Council
Concerns summary (AI summary) An unmitigated tripping hazard poses a significant risk of falls and potential future deaths if not addressed.
Action Planned (AI summary) Denbighshire County Council will review the coastal risk assessment at Prestatyn, including the area near the Beaches Hotel, and carry out a joint boundary to boundary inspection of DCC coastal areas by the end of 2014.
Albert Flynn
All Responded
2014-0308 2 Jul 2014 Manchester (South)
HC-One
Concerns summary (AI summary) Care staff lacked adequate training to assess a deteriorating patient or administer prescribed medication, leading to a significant delay in treatment and neglect of critical medical history.
Action Taken (AI summary) HC-One Limited will re-emphasise the need to call for qualified assistance during individual supervision for staff and induction for new staff, and senior care staff involved in this incident will undergo additional training and competency assessment.
Ronald Perry
All Responded
2014-0302 2 Jul 2014 North Wales (East & Central)
Betsi Cadwaladr University Health Board
Concerns summary (AI summary) Inconsistent criteria for requesting CT scans based on time of day or weekend leads to varying levels of care and risks missed diagnoses for patients 'out of hours'.
Noted (AI summary) The University Health Board states that its radiology service operates a full service during weekday hours, with emergency on-call service at all other times, and a CT scan would have been performed had a ruptured abdominal aortic aneurysm been indicated. They are working to develop increased access outside of normal office hours.
Henry Marsh
All Responded
2014-0306 2 Jul 2014 London (North)
Department of Health and Social Care
Concerns summary (AI summary) The Home Treatment Team was overloaded with excessive patient caseloads, hindering effective multi-disciplinary meetings and compromising patient care.
Noted (AI summary) The Department of Health acknowledges the concerns about the Home Treatment Team's caseload and refers the Coroner to existing national guidance and resources for Crisis Home Treatment Teams. NHS England intends to map this best practice guidance on to the mental health intelligence network, but there is currently no set timeline.
Farres Ikken
Historic (No Identified Response)
2014-0310 2 Jul 2014 London (North)
Department of Health and Social Care
Concerns summary (AI summary) Hospital staff lacked the authority to refer patients directly to community psychology services upon discharge, creating a gap in post-hospital care.
Liam Hardy
Historic (No Identified Response)
2014-0307 2 Jul 2014 London (South)
South West London and St George’s Menta…
Concerns summary (AI summary) The electronic patient record system (RiO) failed to summarise critical patient history, preventing a comprehensive assessment and potentially altering care decisions.
Hywel Hughes
Partially Responded
2014-0311 2 Jul 2014 North West Wales
Home Office North Wales Constabulary Security Industry Authority
Concerns summary (AI summary) Police training on positional asphyxia is inadequate, and vehicle designs hinder monitoring detainees. The SIA also fails to review restraint-related deaths by door supervisors.
Action Taken (AI summary) North Wales Police amended their training materials on positional asphyxia to include snoring as a symptom and added an exercise to demonstrate the dangers of medical emergencies. They also designed and are testing a single cell compartment bubble car and considering auditory improvements.
Beryl Brinkman
All Responded
2014-0314 2 Jul 2014 Manchester (North)
Rochdale Metropolitan Borough Council
Concerns summary (AI summary) Poorly located parking near a junction severely reduces driver visibility, creating a serious risk of harm or death for road users and pedestrians.
Action Planned (AI summary) Rochdale Borough Council plans to remove parking bays and introduce 'At Any Time' restrictions on the A58 to improve visibility, with implementation expected within the next four months. They have no record of prior complaints about the location.
John Adams
Historic (No Identified Response)
2014-0293 1 Jul 2014 Brighton & Hove
Brighton and Sussex University Hospitals National Patient Safety Agency National Research Ethics Service
Concerns summary (AI summary) VERONICA HAMILTON-DEELEY, LLB.
Sindy Woodhall
All Responded
2014-0292 1 Jul 2014 Manchester (North)
Department for Business Innovation and … Oldham Metropolitan Borough Council Public Health England +1 more
Concerns summary (AI summary) A lack of regulation prevented intervention when retailers sold toxic gases to a known addict, highlighting a gap in the law and enforcement powers that poses a health risk.
Noted (AI summary) The Trading Standards Institute states that it is a professional body without powers to get involved and that the matter is for local authority trading standards departments. It highlights a workforce survey demonstrating severe cuts to trading standards services. Oldham Council will ensure the trader concerned is visited and spoken to by officers on the safety/health implications and moral obligations related to addictions, and about sales to minors of age-restricted products. Public Health England has been working with the Department of Health to restrict access to volatile substances, has refined information collected on VSA as part of the National Treatment Monitoring System, and is looking to improve national collection of drug-related mortality data. The Department of Health acknowledges the concerns and refers to the response from Public Health England, expressing full support for their views and advice.
Jessica Bond
Historic (No Identified Response)
2014-0297 30 Jun 2014 Essex
Southend University Hospital
Concerns summary (AI summary) Propess was inappropriately administered to a patient with a prior caesarean section, despite the known risk of uterine rupture and associated complications.
Ian Reid
All Responded
2014-0288 30 Jun 2014 Cumbria (North & West)
Department of Health and Social Care
Action Planned (AI summary) NHS England has established a reference group to develop standards for prosthesis identification, including details of all prosthesis use in the patient record, with a target completion date of early 2015. The government's Information Strategy encourages information to be recorded once and shared securely between those providing care.
Dayani Chauhan-Ahmed
All Responded
2014-0287 30 Jun 2014 Leicester City & South Leicestershire
University Hospitals of Leicester NHS T…
Concerns summary (AI summary) Ineffective communication systems and unclear escalation policies hindered timely intervention during labor, compounded by insufficient staff availability during periods of high demand.
Action Planned (AI summary) The trust plans to implement several changes, including a proforma for communications during labour, reinforcement of the escalation policy, consultant presence at the LRI, and an annual emergency drill to test the escalation policy. They will also include the informal 'SOS' system in the strengthened Escalation policy.
Jake Hardy
Historic (No Identified Response)
2014-0305 30 Jun 2014 Manchester (West)
HM Youth Offenders Institute Hindley Ministry of Justice National Offenders Management Service +1 more
Concerns summary (AI summary) Vulnerable young persons with complex needs face increased self-harm and suicide risks in Youth Offender Institutions due to staff lacking adequate training and understanding.
Ahmad Khan
All Responded
2014-0291 28 Jun 2014 South Yorkshire (West)
Q-Park Limited Sheffield City Council (Planning) Sheffield County Council
Concerns summary (AI summary) Easy access to a low perimeter wall, facilitated by a nearby barrier, creates a dangerous fall hazard for individuals, including children.
Noted (AI summary) Sheffield City Council found no breach of planning control or building regulations at the car park. However, they have suggested alterations to Q Park Ltd to prevent similar incidents and are open to working with the company on a solution.
Ashley Ponsonby
All Responded
2014-0386-wp24600 27 Jun 2014 Manchester City
Secretary of State for Health
Concerns summary (AI summary) Poor communication by a locum SHO regarding observation plans and failure to suggest Naloxone for drug overdose led to inappropriate management and monitoring of a deteriorating patient.
Action Taken (AI summary) • Greater Manchester Police agrees that a mental disorder does not absolve individuals of the criminal consequences of their actions. • It is often appropriate and necessary for legal proceedings to be pursued alongside and in support of an individual who is mentally ill. • This action can often be necessary to support health workers, so that can carry out their duties as safely as possible.
Sadik Miah
Historic (No Identified Response)
2014-0290 26 Jun 2014 London (Inner South)
South London and Maudsley NHS Trust
Concerns summary (AI summary) Inadequate physical health monitoring for psychiatric inpatients, including inconsistent ECG review for antipsychotic risks and significant delays for urgent non-emergency medical opinions, creates ongoing patient safety risks.
Peter Hinchliffe
Historic (No Identified Response)
2014-0284 25 Jun 2014 South Yorkshire (East)
BMI Hospital Thornbury Department of Health and Social Care NHS England +1 more
Concerns summary (AI summary) Significant delays in diagnostic investigations across both private and NHS sectors, coupled with inconsistent advice and management for young athletes experiencing syncope, pose a continuing risk.
Wilfred Aspinwall
Historic (No Identified Response)
2014-0283 25 Jun 2014 Liverpool
Prison and Probation Ombudsman
Concerns summary (AI summary) Healthcare provider at HMP Liverpool did not receive critical PPO and Clinical Review reports, hindering effective implementation of recommendations for prison fatalities.
Ralph Goslin
All Responded
2014-0282 25 Jun 2014 London Inner (North)
University College London Hospitals NHS…
Concerns summary (AI summary) An incorrectly presented reference range for sodium valproate levels led a junior doctor to misinterpret a sub-therapeutic result, delaying the recognition of missed medication.
Action Taken (AI summary) The trust has commissioned specialist epilepsy training from the National Neurological Commissioning Support Unit, working with the National Epilepsy Society, across inpatient and residential services. The process for sharing recommendations has been changed to ensure follow-up and written communication with all members of the group.
Lloyd Butler
All Responded
2014-0281 25 Jun 2014 Birmingham & Solihull
West Midlands Police
Concerns summary (AI summary) A pervasive lack of professionalism, leadership, and appropriate training in the custody suite led to an unacceptable culture and inadequate control over staff behavior with vulnerable detainees.
Action Taken (AI summary) West Midlands Police instigated misconduct procedures against officers and staff involved, resulting in disciplinary sanctions. They have provided clear guidance on dealing with individuals arrested for being drunk and incapable, directing that they be treated as a medical emergency and taken directly to hospital.
Marion Turner
Historic (No Identified Response)
2014-0300 25 Jun 2014 Essex
North Essex Partnership NHS Foundation …
Concerns summary (AI summary) The report identifies that a message left for the deceased's CPN regarding concerns about her mental health was not read until after her death.
Joan Richardson
Partially Responded
2014-0276 23 Jun 2014 West Yorkshire (East)
Fountain Medical Centre Leeds West Clinical Commissioning Group
Concerns summary (AI summary) The GP practice failed to provide emergency care during training closure, delaying assessment of an obviously unwell patient by 24 hours, which contributed to her death.
Action Planned (AI summary) The CCG will send a letter to all GP practices reiterating their obligations regarding safe medical cover during training sessions and emphasizing the need for clear communication regarding access to urgent medical attention. A statement will be made at a centrally organised TARGET event reiterating the obligations and recommendations.