2014
PFD Reports
Reports: 557
Areas: 71
55% response rate (below 63% average).
Thomas Maher
All Responded
2014-0252
5 Jun 2014
Manchester (South)
Central Manchester University Hospitals…
Concerns summary (AI summary)
Missing medical records, unupdated risk assessments, non-functioning falls alarms, systemic delays in patient transfers, and incompatible paper/electronic record systems severely hampered patient care and safety.
Action Taken
(AI summary)
The hospital has implemented a new process to scan all records for deceased patients and those involved in high-level incidents into the electronic patient records system as a priority. Ward 16 now uses the EPR system.
Archie Hames
Partially Responded
2014-0259
5 Jun 2014
Surrey
Department of Health and Social Care
Surrey Community Health
Concerns summary (AI summary)
The combined use of a specific tracheostomy tube and a particular Velcro strap attachment compromised the tube's integrity, likely causing detachment and posing risks with similar devices.
Action Taken
(AI summary)
Following concerns about tracheostomy tubes and velcro straps, MHRA issued a Medical Device Alert, and manufacturers Arcadia Medical and Smiths Medical clarified instructions for use to warn against using velcro holders. Arcadia Medical also developed a nylon insert to reinforce the flange.
Sophie Allen
All Responded
2014-0256
5 Jun 2014
Sunderland
Department for Business Innovation and …
Concerns summary (AI summary)
Looped blind cords continue to pose a serious strangulation risk to young children, with existing installations in homes lacking the improved safety features of new standards.
Noted
(AI summary)
BIS acknowledges the concerns and describes existing campaigns and partnerships promoting blind cord safety led by the British Blind and Shutters Association (BBSA) and the Royal Society for the Prevention of Accidents (ROSPA).
John Day
All Responded
2014-0251
4 Jun 2014
Isle of Wight
Beacon Healthcare
Isle of Wight Clinical Commissioning Gr…
Concerns summary (AI summary)
Out-of-hours doctors lack crucial access to patient medical records, particularly allergy information, increasing the risk of incorrect medication prescriptions when patients provide inaccurate details or lack capacity.
Action Planned
(AI summary)
The Isle of Wight CCG is developing a system-wide IT strategy to move towards a universal, integrated, and readily accessible healthcare record, but notes there is still a long way to go. A reminder was sent to all out of hours GPs to consider trying to access Vision 360 if clinically indicated, and the Beacon out of hours service is working closely with primary care, the ambulance service and secondary care. The Adastra system has been integrated into the overarching hospital system ISIS.
Dean Hutchinson
All Responded
2014-0556
3 Jun 2014
Wiltshire and Swindon
Ministry of Defence
Concerns summary (AI summary)
The wording in the modification to the Fire Diary gives equal weighting to options when the evidence supports a preference for reviews to be undertaken before a change of use or structural alteration takes place; this wording should be reviewed.
Action Taken
(AI summary)
The Ministry of Defence has amended the Defence Fire Risk Management Organisation (DFRMO) Fire Diary, updated the Fire NCO course, and is reviewing the DFRMO Fire Risk Assessment template to emphasize recording sleeping arrangements. A Defence Instruction or Notice (DIN) has also been published covering these issues.
Robert Wood
All Responded
2014-0556-wp26758
3 Jun 2014
Wiltshire and Swindon
Ministry of Defence
Concerns summary (AI summary)
Fire risk assessment guidelines did not prioritise pre-alteration reviews, and Junior Fire NCOs lacked specific training on complex electrical overload risks, including high current draw appliances.
Action Taken
(AI summary)
• The Defence Fire Risk Management Organisation (DFRMO) Fire Diary has been amended to clarify that a competent fire risk assessor must be consulted before changes take place or if the fire risk assessment is no longer valid.
• The Fire Non-Commissioned Officer (NCO) course content has been amended to allocate more time and emphasis on the fire risks associated with electrical overloading.
• The DFRMO Fire Risk Assessment template has been updated to further emphasize the need to record if any sleeping is place on the premises regardless of its primary purpose.
Essa Shah
All Responded
2014-0250
2 Jun 2014
Bedfordshire & Luton
Luton and Dunstable University Hospital
Concerns summary (AI summary)
Crucial literature on the dangers of co-sleeping is only available in English, preventing non-English speaking mothers from accessing vital safety information.
Action Planned
(AI summary)
Luton and Dunstable University Hospital will ensure Feeding Packs are created containing a UNICEF leaflet in Bengali, Punjabi, and Urdu to advise of the dangers of co-sleeping. Community Midwives will also be equipped with iPads to facilitate communication.
Aimee Varney
All Responded
2014-0249
2 Jun 2014
Bedfordshire & Luton
Luton and Dunstable University Hospital
Concerns summary (AI summary)
NICE Guidelines for referring patients with suspected epilepsy to a Specialist Tertiary Centre were not followed, risking delayed or inappropriate specialized care.
Action Planned
(AI summary)
Luton and Dunstable University Hospital are commissioning a further report from an independent general neurologist to assess whether the individual clinician's practice regarding NICE guidelines on epilepsy referrals fell outside the threshold of reasonable practice.
Jennifer Morrison
All Responded
2014-0265
2 Jun 2014
Wirral
Arrowe Park Hospital
Concerns summary (AI summary)
Missing medical records hampered investigations, and bed shortages combined with inadequate staffing during peak holiday seasons led to prolonged assessment unit stays and treatment delays.
Action Taken
(AI summary)
Wirral University Teaching Hospitals NHS Foundation Trust describes measures to manage medical records, including a Health Records Management Policy and regular audits. The Surgical Division now holds daily management meetings to review staffing levels, and the Surgical Assessment Unit (SAU) underwent a 'Listening into Action' project, increasing junior doctor presence, introducing consultant rounds, and regular staffing reviews.
Denise Prior
All Responded
2014-0262
2 Jun 2014
West Sussex
Western Sussex Hospitals NHS Trust
Concerns summary (AI summary)
Inadequate hospital record-keeping for oxygen levels, prescription, and the application of the NEWS system poses a risk of future deaths.
Action Taken
(AI summary)
Western Sussex Hospitals NHS Trust has undertaken a thorough investigation and review and enclosed an action log setting out the action taken.
Matthew Purser
Historic (No Identified Response)
2014-0568
30 May 2014
Swansea & Neath Port Talbot
HMP Swansea
MINISTRY OF JUSTICE
National Offender Management Service
Concerns summary (AI summary)
A prison doctor lacked ACCT training, ACCT trigger event documentation was subjective and lacked detail for accurate assessment, and procedures for obtaining community mental health records were unclear.
Richard Jaeger-Forzard
All Responded
2014-0246
30 May 2014
Buckinghamshire
Terex Global Gmbh
Concerns summary (AI summary)
The inquest identified unresolved professional disagreements regarding the proper steps needed to prevent similar occurrences, which could not be adjudicated.
Action Taken
(AI summary)
Genie issued a mandatory Safety Notice requiring recalibration of Z135/70 machines and updated controller software to prevent instability due to miscalibration.
Stephen Ward
All Responded
2014-0248
29 May 2014
London Inner (North)
Camden & Islington NHS Foundation Trust
Concerns summary (AI summary)
The mental health crisis team lacked a clear protocol for following up with police after requesting a welfare check, leading to delays when police did not respond.
Noted
(AI summary)
Response is blank.
Mark Duggan
All Responded
2014-0182
29 May 2014
London (North)
Association of Chief Police Officers
Coroner's Society
Crown Prosecution Service
+4 more
Concerns summary (AI summary)
Insufficient intelligence gathering and a failure to exhaust all intelligence avenues regarding key individuals prior to the stop, impacting subsequent police actions.
Noted
(AI summary)
The IPCC acknowledges the coroner's concerns, particularly regarding access to intelligence materials, and states it is best placed to determine who within the IPCC investigation should have access. The IPCC considers that there should be a clear legal right of access by IPCC investigations to all relevant intelligence material. The Home Office acknowledges the concerns raised, particularly regarding the IPCC's resources at the scene and access to intelligence. The response explains the existing legal framework for investigations and information disclosure, highlighting the need to balance transparency with national security. The National Armed Policing Portfolio has commenced work to determine whether the introduction of body worn video (BWV), might be included in armed policing operations. The National Policing portfolios will ensure liaison with the College of Policing to incorporate, reiterate and reflect issues relating to cordon management and evidence preservation in its post incident management and operational training. The National Crime Agency notes the concerns raised and states it has undertaken a thorough internal review of its operating procedures regarding intelligence gathering, development, and dissemination. Following this review, the Agency believes that no more could have realistically been done to avoid the incident. The MPS will adopt a procedure for all future police shootings whereby a Garage Sergeant or Collision Investigator is called by the DPS to download the IDR at the scene, which will then be available to police; the IPCC and any subsequent legal proceedings
Magdalen Dwerryhouse
All Responded
2014-0244
29 May 2014
Manchester (West)
5 Boroughs Partnership NHS Foundation T…
Concerns summary (AI summary)
Poor communication led to a missed patient appointment. A health trust also failed to engage with the fire service, preventing vulnerable individuals from receiving crucial home safety checks due to a lack of information sharing.
Action Taken
(AI summary)
The Trust has reviewed and amended operational guidance for community teams, specifically regarding actions when service users miss appointments. They have also established an information-sharing agreement and reciprocal training arrangements with the Greater Manchester Fire and Rescue Service.
Loui Aspinall
Historic (No Identified Response)
2014-0243
29 May 2014
Manchester (West)
Federation of British Tour Operators
Concerns summary (AI summary)
Tour operator safety audits falsely indicated trained lifeguards and rescue equipment, with the lifeguard lacking child resuscitation skills, highlighting a critical gap between audit findings and actual safety provisions.
Dana Baker
All Responded
2014-0242
29 May 2014
Worcestershire
Worcestershire Safeguarding Children’s …
Concerns summary (AI summary)
Inadequate inter-agency communication and a lack of shared knowledge, exacerbated by confidential Individual Management Reviews, prevented a comprehensive understanding of mutual concerns.
Noted
(AI summary)
The WSCB acknowledges the concerns but states that national practice is followed and questions if the report should have been directed to the Department for Education. The guidance in place at the time of the EW Serious Case Review (SCR) was undertaken is outlined, that which is now in place and WSCB's response to this is set out.
Arnold Soulsby
All Responded
2014-0241
28 May 2014
Black Country
Department for Transport
Concerns summary (AI summary)
Current regulations do not mandate retrospective fitting of forward mirrors on lorries, leaving many vehicles without a crucial safety feature and increasing the risk of similar road deaths.
Action Planned
(AI summary)
The Department for Transport has asked officials to prepare a consultation about retro-fitting forward-facing mirrors on heavy goods vehicles first registered before 26 January 2007. The consultation will explore the potential benefits and costs associated with requiring retro-fit of these mirrors.
Laura Page
All Responded
2014-0254
28 May 2014
Leicester City & South Leicestershire
Leicester Partnership NHS Trust
Concerns summary (AI summary)
Inadequate clinician response to failed home visits included lack of client contact and failure to escalate issues. Policies for escalation, welfare checks, and auditing failed visits require urgent review.
Action Taken
(AI summary)
The Trust has notified teams of the outcome of the investigation, developed a clear process for handling failed visits, and updated the Crisis Resolution Team's Operational Procedure. They have also clarified time targets for action and the threshold for requesting a welfare check, and the Crisis Service Manager is undertaking weekly audit checks on failed visits.
Gerardo Tonogbanua
Historic (No Identified Response)
2014-0245
27 May 2014
Avon
British Standards Institution
Department for Transport
Maritime and Coastguard Agency
Concerns summary (AI summary)
A rescue boat's fall wire failed due to an overstressing winch, highlighting a lack of 'system' design consideration in regulations. An electronic safety switch also failed, exacerbated by vague guidance on safety device performance.
Michaela Christoforou
All Responded
2014-0285
25 May 2014
London (North)
Care UK
Concerns summary (AI summary)
All staff at the unit did not carry ligature cutters, posing a significant risk in preventing self-harm incidents.
Action Planned
(AI summary)
Care UK has now located nine sets of ligature cutters throughout Rhodes Farm. Clinical staff will carry ligature cutters for a six month trial period commencing in September 2014 and a protocol/procedure is being developed that covers all aspects concerned with the carrying and management of ligature cutters.
Liam Coleman
Historic (No Identified Response)
2014-0312
25 May 2014
London (North)
Department of Health and Social Care
Concerns summary (AI summary)
There was an insufficient number of ambulances available to adequately cover urgent Red 1 and Red 2 calls, indicating a critical resource shortage.
Komba Kpakiwa
Partially Responded
2014-0301
23 May 2014
Essex
Chartered Institute of Environmental He…
Institute of Occupational Safety and He…
Concerns summary (AI summary)
The pool had an inherently dangerous profile with inadequate risk assessments, no lifeguards, ineffective supervision (unmonitored CCTV), unclear signage, and untrained staff in aquatic rescue.
Action Planned
(AI summary)
IOSH will raise awareness among its 44,000 members regarding the deaths of hotel swimming pool users by including a summary of the key findings in the next issue of their magazine and a news item in their e-bulletin.
Josephine Foday
All Responded
2014-0301-wp24614
23 May 2014
Essex
Chartered Institute of Environmental He…
Concerns summary (AI summary)
The pool's inherently dangerous profile was not properly risk-assessed. A lack of lifeguards, unmonitored CCTV, unclear signage, and untrained staff in aquatic rescue created significant drowning risks, especially for non-swimmers.
Action Planned
(AI summary)
• IOSH will raise awareness among its 44,000 members by highlighting the facts of this case, the concerns raised, and the Health and Safety Executive guidance on this topic.
• A summary of the key findings will be included in the next available issue (September 2014) of the Institution's official member magazine the Safety and Health Practitioner.
• A news item will be included in the e-bulletin, Connect, on Monday 21 July, which is distributed to all members.
Christian Devereux
All Responded
2014-0240
23 May 2014
Rutland & North Leicestershire
RAC Motorsports Association
Concerns summary (AI summary)
A HANS type device likely would have prevented or reduced fatal head and neck injuries in a collision. Many drivers in the race were not using these affordable and beneficial safety devices.
Noted
(AI summary)
The Motor Sports Association details its history of considering frontal head restraints and insurance policies, and provides statistics on affiliated clubs, license holders, officials and authorised events.