2014
PFD Reports
Reports: 557
Areas: 71
55% response rate (below 63% average).
Samuel Openshaw
Historic (No Identified Response)
2014-0280
20 Jun 2014
Suffolk
Congenital Heart Services Clinical Refe…
Coronary Heart Disease Review
Coronary Heart Disease Review’s Clinica…
+1 more
Concerns summary (AI summary)
Slow electronic transfer of echocardiograph studies to specialist centers and high workload of paediatric retrieval teams pose significant risks for urgent child transportation and care.
Redmond Johnson
Historic (No Identified Response)
2014-0279
20 Jun 2014
Suffolk
Ministry of Justice
NHS England
Concerns summary (AI summary)
Prison healthcare lacked robust processes for gathering detainee medical history, conducting medication reviews, documenting test results, and assessing fitness for transfer, risking inadequate care for those with complex needs.
Else Harvey-Samuel
Historic (No Identified Response)
2014-0278
20 Jun 2014
Suffolk
West Suffolk Hospital
Concerns summary (AI summary)
Doctors failed to provide adequate clinical information for imaging requests, and post-incident investigations lacked robustness to identify lessons learned effectively.
Peter Farebrother
Historic (No Identified Response)
2014-0274
20 Jun 2014
Shropshire, Telford & Wrekin
South Stafford and Shropshire Healthcar…
Concerns summary (AI summary)
Failures in patient transfer, handover of observation status, and returning a ligature risk item (belt) led to an unsafe environment. The effectiveness of the "sloping door" design against hanging was also questioned.
Shaun Maslin
Partially Responded
2014-0277
19 Jun 2014
Surrey
Department of Business, Innovations and…
Energy and Utilities Skills
Concerns summary (AI summary)
There are no specific qualifications for pressure testing gas pipelines and a lack of national requirements for regular retraining and re-testing of gas industry operatives.
Action Planned
(AI summary)
Energy & Utility Skills proposes a strategic industry standard approach to competence management, including demonstrating initial competence, registering on the EUSR database with a five-year expiry, and mandatory registration of the workforce by infrastructure asset owners. A total registration and competence management system is realistically achievable within two years.
M5 (Seven)
Historic (No Identified Response)
2014-0654
19 Jun 2014
Somerset (West)
Department for Transport
Directorate for Business Innovation and…
Directorate South West
+2 more
Concerns summary (AI summary)
A firework display adjacent to the M5 caused greatly reduced visibility and a fatal multi-vehicle collision, highlighting a lack of preventative measures for such events.
Sol Hadhasseh
Historic (No Identified Response)
2014-0272
17 Jun 2014
Norfolk
Coventry and Warwickshire Partnership N…
Concerns summary (AI summary)
A mental health Trust's reliance on a delayed GP referral, rather than a direct Trust-to-Trust transfer, for a patient with complex needs highlighted a systemic flaw in patient transfer procedures between Trusts.
Audrey Garland
Partially Responded
2014-0271
17 Jun 2014
Manchester (South)
Blackpool Teaching Hospitals NHS Founda…
North Shore Surgery
Concerns summary (AI summary)
Failures by GP and District Nursing services to recognize and appropriately treat severe ulcers, combined with a lack of arranged hospital transport, resulted in inadequate care and examination.
Action Taken
(AI summary)
Blackpool Teaching Hospitals NHS Foundation Trust held focus group meetings and discussed the Coroner's concerns with the District Nursing Team, resulting in an action plan monitored by the Head of Service. A training event focused on Mental Capacity Assessment and Deprivation of Liberty standards was held for the team.
Mrs Care
Historic (No Identified Response)
2014-0273
16 Jun 2014
Cornwall
Royal Cornwall Hospital Truro
Concerns summary (AI summary)
Unexplained extensive bruising, likely caused during hospital care and potentially related to hoist use, contributed to the deceased's death, with no clear explanation provided.
David O’Garro
Historic (No Identified Response)
2014-0270
16 Jun 2014
London Inner (North)
HMP Pentonville
Concerns summary (AI summary)
The report cites that a nurse did not complete a cell sharing risk assessment and staff lacked clarity and shared understanding regarding the assessment process for prisoners with epilepsy.
Alun Sheppard
All Responded
2014-0268
13 Jun 2014
North Wales (East & Central)
Betsi Cadwaladr University Health Board
Concerns summary (AI summary)
The Health Board struggles to balance patient confidentiality with the crucial need for familial support to optimize recovery, potentially hindering patient well-being.
Noted
(AI summary)
The Health Board agrees that familial support improves patient recovery and routinely encourages service users to engage with their families. The policy of the Health Board is to use a confidentiality form.
June Rose
Historic (No Identified Response)
2014-0267
11 Jun 2014
London (West)
Royal College of General Practitioners
Concerns summary (AI summary)
A lack of training on the correct dosage and morphine equivalent of fentanyl patches led to an erroneous prescription, contributing to the patient's death through respiratory depression.
Bridget Cahill
All Responded
2014-0266
11 Jun 2014
Black Country
National Institute for Health and Clini…
Concerns summary (AI summary)
The coroner questions how a patient prescribed morphine can overdose despite receiving less than the prescribed amount, suggesting attention be given to the maximum recommended dose and factors influencing morphine buildup in the body.
Noted
(AI summary)
The MHRA reviewed the post-mortem report and the pharmacokinetics/dynamics of morphine, concluding that the case does not prompt a review of the maximum permitted dose or a need to adjust it based on body weight or co-morbidities. They emphasize the importance of careful titration and review of opioid dosing, as recommended in current treatment guidelines.
Lucy Moffatt
All Responded
2014-0261
10 Jun 2014
South Yorkshire (West)
Care Quality Commission
Department of Health and Social Care
Concerns summary (AI summary)
Window restraints were found to be misleadingly insecure, easily defeated, and establishments lacked proper key restriction, further compounded by CQC inspectors' unawareness of a critical Department of Health alert.
Action Planned
(AI summary)
The CQC is reviewing its registration process to include specific questions on safety alerts, and piloting pre-inspection methodology to assess dissemination of safety alerts by providers. The Department of Health discussed the report with the CQC, who will take steps to improve the implementation of Safety Alerts, including Department of Health Alerts.
Audrey Daws
Historic (No Identified Response)
2014-0318
9 Jun 2014
Plymouth, Torbay & South Devon
Plymouth Hospitals NHS Trust
Concerns summary (AI summary)
Initial medical assessment failed to order a chest X-ray despite tender abdomen and potential cardiac symptoms, indicating an incomplete diagnostic approach for the patient's condition.
John Cook
All Responded
2014-0578
9 Jun 2014
Oxfordshire
NHS England
Concerns summary (AI summary)
Inadequate design and management of DNA CPR forms, including unclear validity wording and lack of clear hospital identification, caused significant confusion and communication failures.
Disputed
(AI summary)
NHS England will not add telephone numbers to DNA CPR forms, but highlights existing policy requiring specific review dates and clear cancellation procedures and has requested the CCG to share audit results and hold the Trust to account in relation to learning from the inquest; furthermore NHS England will write to all provider Trusts and CCGs to ensure they have adopted the DNACPR policy from NHS South of England.
Bradley Cockel
Historic (No Identified Response)
2014-0298
9 Jun 2014
Essex
The Advisory Council on the Misuse of D…
Concerns summary (AI summary)
The drug involved, and several of its chemical compounds, were not fully controlled by legislation, leading to regulatory gaps and potential public health risks.
Daniel McCallum Keane
All Responded
2014-0260
9 Jun 2014
Manchester (West)
Department of Health and Social Care
Concerns summary (AI summary)
The GP's inadequate record-keeping and inaction, despite being alerted to an "extremely worrying" and high-risk situation for a diabetic patient, critically failed to ensure appropriate care and follow-up.
Noted
(AI summary)
The Department of Health has passed concerns about a GP's conduct to the GMC and CQC; NHS England is addressing transfers of care with its patient safety expert group and considering the long-term implications of the role of GPs in managing Type 1 diabetes.
William Beckwith
All Responded
2014-0258
9 Jun 2014
Derby & Derbyshire
Chesterfield Royal Hospital
Concerns summary (AI summary)
A frail, elderly patient with a history of falls was discharged home in the early morning without formal assessment of his or his wife's abilities, home environment, or essential post-discharge care needs.
Action Planned
(AI summary)
The hospital is undertaking a multidisciplinary review of its guidance for assessing elderly patients after a fall, with a clear policy expected by the end of August.
Charles Hardiman
Historic (No Identified Response)
2014-0257
9 Jun 2014
Teesside
Stockton Public House
Concerns summary (AI summary)
An open front door created a wind tunnel, causing the back door of a public house to move forcibly and suddenly, leading to an accident.
Ryan Boyle
All Responded
2014-0263
9 Jun 2014
Surrey
Surrey Police
Concerns summary (AI summary)
Police force control lacked adequate training for pursuit operators, an efficient notification system for pursuits, and sufficient staffing on the 'Force desk' to manage incidents effectively.
Action Taken
(AI summary)
Surrey Police updated its pursuit management guidance to align with ACPO guidance, installed a 'Call Supervisor' button in the Force Control Room, and briefed staff that two people must monitor the Force Channel at all times; staff were also instructed to shout to alert supervisors to incidents.
James McArdle
All Responded
2014-0264
8 Jun 2014
Wirral
Arrow Park Hospital NHS Trust
Concerns summary (AI summary)
The withdrawal of a coloured wristband system for falls risk without replacement removed a vital protection, increasing the risk of falls for elderly patients.
Action Planned
(AI summary)
The Trust is developing a new policy specific to patient falls, providing clearer guidance on risk assessments and timescales, and will communicate changes to nursing staff and revise audit questionnaires to monitor compliance.
Frances Bell
Historic (No Identified Response)
2014-0299
6 Jun 2014
Essex
Southend Hospital
Concerns summary (AI summary)
The investigation lacked a Root Cause Analysis and senior clinical input, coupled with unacceptable delays in patient transfer to theatre for critical treatment.
Katie Davies
All Responded
2014-0255
6 Jun 2014
Manchester (West)
Department of Health and Social Care
Concerns summary (AI summary)
Undetected "blind spots" in the hospital bleeper system hampered emergency response, and inadequate protocols for transferring Cerebral Venous Sinus Thrombosis patients to specialist centers delayed appropriate care.
Action Planned
(AI summary)
The Department of Health will send a safety alert to all Trusts in England about potential 'blind spots' for bleepers and pagers, and the National Clinical Director for Stroke at NHS England has agreed to review concerns about stroke guidance as part of developing the next edition of the National Clinical Guidelines for stroke.
James Boylan
Partially Responded
2014-0253
6 Jun 2014
Cumbria (South & East)
Care Quality Commission
Cumbria Clinical Commissioning Group
Cumbria Partnerships NHS Foundation Tru…
+2 more
Concerns summary (AI summary)
Unidentified ligature points, inadequate patient searching for contraband, poor communication of escalating risks, and incomplete GRIST assessments contributed to the patient's death in a mental health unit.
Action Planned
(AI summary)
The Department of Health states that NHS England has identified the need for both a Mental Health Patient Safety Expert Group and an Expert Safety Primary Care Group to improve safety of patients in NHS funded care further.