2014
PFD Reports
Reports: 557
Areas: 71
55% response rate (below 63% average).
Samarjit Singh
Partially Responded
2014-0239
23 May 2014
Wirral
Department of Health and Social Care
NHS England
Wirral Clinical Commissioning Group
Concerns summary (AI summary)
The lack of a Specialist Community Perinatal Mental Health Service and a Mother and Baby in-patient unit in the region resulted in sub-optimal treatment and declined referrals for mothers with severe postnatal depression.
Noted
(AI summary)
NHS Wirral CCG established a working group to review the perinatal mental health pathway. They are revising the Liaison Psychiatry service specification to include dedicated consultant psychiatrist time and requiring specialist staff in the new IAPT specification due to start in April 2015. The Department of Health acknowledges the coroner's concerns regarding perinatal mental health services in the Wirral and Liverpool. They state that commissioning of local services is the responsibility of Clinical Commissioning Groups and that regional mother and baby units are sufficient, but will raise awareness with CCGs.
Clive Clinton
Historic (No Identified Response)
2014-0238
23 May 2014
North Wales (East & Central)
European Care
Concerns summary (AI summary)
A care home's complaints procedure failed, preventing family concerns about poor care (e.g., hygiene, medication) from reaching senior management and placing residents at risk of harm.
Ross Boyd
All Responded
2014-0313
23 May 2014
Milton Keynes
Concerns summary (AI summary)
An inadequate assessment of the deceased's needs resulted in an inappropriate placement at a care home, failing to meet his specific requirements.
Noted
(AI summary)
Milton Keynes Council reviewed the case and believes the placement was appropriate given the information available at the time. They will ensure managers discuss the use of respite beds with their teams and the need for clear assessment and support planning.
Simon Haines
Historic (No Identified Response)
2014-0236
22 May 2014
Norfolk
Norfolk County Council
Concerns summary (AI summary)
There was no clear protocol for signposting individuals struggling to accept decisions or outcomes, and little consideration was given to re-signposting to other support agencies.
Mark Bartholomew
Historic (No Identified Response)
2014-0237
21 May 2014
Manchester (North)
Broudie Jackson Canter
DAC Beachcroft
Department of Health and Social Care
+1 more
Concerns summary (AI summary)
Inadequate emergency response included missing patient details and lost documentation. Critical delays occurred because ligature cutters were not readily available and observation records lacked detail, hindering timely intervention and oversight.
Rainer Wickens
All Responded
2014-0234
20 May 2014
Surrey
St George’s Healthcare NHS Trust
Concerns summary (AI summary)
Significant delays in clot treatment and CTPA scans were caused by poor communication during handovers and between medical staff. Additionally, medical notes had gaps and vulnerable patients had unsupervised access to stairs.
Action Taken
(AI summary)
St George's Healthcare NHS Trust apologized for sub-optimal care and delays in a Serious Incident investigation. They have shared the investigation's learning outcomes, now investigate all cases of hospital-acquired thrombosis, and have completed some actions from the SI panel's report, with the rest due by 31 July 2014.
Denise Parramore
Historic (No Identified Response)
2014-0247
19 May 2014
South Yorkshire (West)
NHS England
NHS Sheffield Clinical Commissioning Gr…
Concerns summary (AI summary)
A lack of open, two-way communication and inability to access shared documentation between primary and secondary care meant psychiatric services were unaware of critical medication prescriptions.
Peter Franklin
All Responded
2014-0230
19 May 2014
Mid Kent & Medway
Kent and Medway NHS and Social Care Par…
Maidstone and Tunbridge Wells NHS Trust
Concerns summary (AI summary)
Confusion in terminology and lack of information sharing between health teams and the CRISIS team hindered effective care. Significant delays in documentation meant the GP was unaware of crucial hospital admissions and mental health involvement.
Action Planned
(AI summary)
Kent and Medway NHS Trust has developed a joint action plan with Maidstone and Tunbridge Wells NHS Trust, extending Liaison Psychiatry service hours, introducing a recovery card for patients on discharge, and holding monthly meetings to review frequent presenters. Tunbridge Wells Hospital is implementing a SMART tool, working towards electronic discharge summaries by October 2014, holding frequent attenders' meetings, and adding a 3-hour Mental Capacity Act session to the junior doctor teaching program.
Gregg O’Reilly
All Responded
2014-0221
19 May 2014
London Inner (North)
Barts Health
Concerns summary (AI summary)
The coroner noted a missed opportunity to refer the deceased to critical care, and the lack of observation records during a critical period before the deceased suffered a second bleed and cardiac arrest.
Action Planned
(AI summary)
Barts Health NHS Trust has concluded an investigation and outlined recommendations including recruiting a Band 7 Sister, shortening the transition to an electronic patient record, establishing a Critical Care Board (meeting August 2014), and launching an education strategy to identify deteriorating patients.
Stephen Owens
Historic (No Identified Response)
2014-0222
19 May 2014
Powys, Bridgend & Glamorgan Valleys
Rhondda Cynon Taf County Borough Council
Concerns summary (AI summary)
The report identifies that a street lamp was unilluminated and another was obscured by foliage, which likely affected the driver's ability to see the deceased.
William Piercy
Historic (No Identified Response)
2014-0231
16 May 2014
Kingston upon Hull & the East Riding of Yorkshire
Royal Society for the Prevention of Acc…
Concerns summary (AI summary)
A disengaged seatbelt left a passenger unrestrained, leading to fatal injury; a seat belt alarm would have alerted carers to this safety risk.
Gary Bradshaw
All Responded
2014-0232
15 May 2014
Manchester (South)
Department of Health and Social Care
Stockport NHS Foundation Trust
Concerns summary (AI summary)
The hospital experienced significant delays in diagnosis, inappropriate medication prescribing before test results, inadequate patient monitoring, and poor communication/IT systems, leading to suboptimal care.
Noted
(AI summary)
Stockport NHS Foundation Trust has purchased the Patientrack electronic tracking system which is being piloted and evaluated, with phased rollout planned across the Trust, starting with vital sign input in January 2015. The Department of Health acknowledges the concerns and highlights existing national guidance (NICE, Royal College of Physicians) on early warning scores and the care of acutely ill patients, noting that clinical interpretation is still essential.
Arthur Shaw
Historic (No Identified Response)
2014-0593
14 May 2014
Portsmouth and South East Hampshire
Department for Transport
Concerns summary (AI summary)
The process for renewing driving licenses for individuals over 70 lacks specific assessment of mental fitness, relying only on sight and hearing tests, despite potential cognitive impairment like dementia.
Mitchell Clifton
All Responded
2014-0227
13 May 2014
Staffordshire South
Casualty Reduction Team
Concerns summary (AI summary)
The wide access way to a car park, shared by pedestrians and vehicles, has a potentially unsafe layout that could be improved with better markings or physical dividers.
Noted
(AI summary)
Staffordshire County Council reports that the Co-operative introduced road humps, lane markings, and a pedestrian route after the accident. The Co-operative has agreed to renew worn road markings, and the council will add further markings on the highway. The Department for Transport acknowledges the concerns but states that changes to vehicle requirements are not proposed, as they are not convinced that changes to existing requirements would necessarily prevent similar incidents.
Harold Henshall
Historic (No Identified Response)
2014-0217
12 May 2014
Stoke-on-Trent & North Staffordshire
Staffordshire County Council
Concerns summary (AI summary)
Inadequate street lighting and crossing facilities on Church Street, especially near St Edwards Church, increased the risk to elderly pedestrians crossing the road.
Amanda Richards
All Responded
2014-0228
12 May 2014
Coventry
Whitefriars Housing
Concerns summary (AI summary)
The absence of domestic sprinkler systems in special accommodation, like Ms Richards', significantly increased the risk of death from fire.
Action Planned
(AI summary)
Whitefriars Housing states that they will participate in a serious incident review led by the West Midlands Fire Service, and will commission and pay for the installation of domestic sprinkler system to an individual dwelling if it is agreed as the appropriate action.
Keiran Toman
Historic (No Identified Response)
2014-0225
12 May 2014
London Inner (West)
Hafod Community Mental Health Team
NHS England
Windsor and Maidenhead Community Mental…
+1 more
Concerns summary (AI summary)
Psychiatric services failed to adequately assess patient capacity to refuse family contact, leading to isolation and increased risk of deterioration, especially when patients disengaged without follow-up to next of kin.
Courtney Mills
All Responded
2014-0224
12 May 2014
Portsmouth & South East Hampshire
Portsmouth Hospitals NHS Trust
Waterside Medical Centre
Concerns summary (AI summary)
Repeated prescription errors and severe communication breakdowns between the GP surgery and hospital led to dangerous delays in obtaining critical medication, putting the patient at risk of withdrawal.
Noted
(AI summary)
Waterside Medical Centre acknowledges the concerns and details their prior communications with the hospital and pharmacy regarding the patient's medication, suggesting the delay was due to the medication's limited availability in the community. Portsmouth Hospitals NHS Trust states that the Clonidine medication was not prescribed by them and that the hospital would have supplied it if approached. They suggest that the Royal Pharmaceutical Society should consider the issue on a national level.
Terence Fernandes
Partially Responded
2014-0220
12 May 2014
Bedfordshire & Luton
Association of Train Operating Companies
Department for Transport
Concerns summary (AI summary)
Lack of basic first aid training among train and station staff prevented the recognition and proper management of a critical medical emergency, specifically airway occlusion.
Action Planned
(AI summary)
ATOC has been directed by the Council to write to its members to explicitly alert them to the circumstances of the death and suggest that they consider whether any changes should be made to the first aid arrangements and the importance of the recovery position. ATOC will facilitate a further discussion on first aid provision amongst the TOCs at the next Safety Forum.
Ernest Harper
All Responded
2014-0223
9 May 2014
Bedfordshire & Luton
Bedford Borough Council
Concerns summary (AI summary)
Design flaws allowed falling between the safety barrier and vehicle, compounded by the lack of formal assessment for passenger health and mobility for safe access.
Action Taken
(AI summary)
Bedford Borough Council has retro-fitted devices to block gaps on Ford Transit vehicles. A new assessment form designed with Occupational Therapists will be introduced by July 14, 2014, and a client-specific risk assessment will be conducted for non-ambulant clients. A written form has been produced to ensure information regarding the client is also provided in a written format.
Lisa Webb
Partially Responded
2014-0213
9 May 2014
London (Inner South)
Basildon Road Surgery
NHS England
Concerns summary (AI summary)
Sub-optimal asthma management by the GP involved failure to assess asthma history, unrecorded vital signs, lack of objective measurements (peak flow/oximetry), and an inappropriate Diazepam prescription.
Action Taken
(AI summary)
The GP now ensures that during consultations with significant problems, they check past reviews and previous consultations. They also check to see if any reviews are outstanding, and either complete them or ask the patient to make an appointment and record this advice within the patient's electronic record.
Gary Richards
All Responded
2014-0212
9 May 2014
London (Inner South)
South London and Maudsley Trust
Concerns summary (AI summary)
Psychiatric services failed to properly assess self-harm risk, communicate patient vulnerabilities, ensure follow-up due to unrecorded contact details, and implement crucial recommendations from a previous incident report.
Action Planned
(AI summary)
The Trust has secured funding for a mental health specific homeless project, linked to an existing scheme across hospitals. There is now an expectation that discharge summaries will be sent to GPs for all discharges.
Akua Anokye-Boateng
All Responded
2014-0211
9 May 2014
London (Inner South)
Medicines and Healthcare Products Regul…
Concerns summary (AI summary)
The report raises concerns about the use of NSAIDs in children with sickle cell disease, specifically regarding the potential for a single dose to cause GI damage and the lack of clear guidance on gastro-intestinal protection measures.
Action Planned
(AI summary)
The MHRA will publish an article in the September 2014 Drug Safety Update to remind healthcare professionals of existing SPC information regarding GI side-effects of NSAIDs. They will also strengthen the patient information for all NSAIDs regarding GI risk, with changes implemented within 12 months.
Linda Fisher
All Responded
2014-0226
9 May 2014
Blackpool & Fylde
Blackpool Teaching Hospitals NHS Founda…
Concerns summary (AI summary)
Inaccurate medication dosages resulted from doctors relying on patient-reported weight, and critical family medical history was not obtained or effectively communicated among staff.
Action Taken
(AI summary)
Blackpool Teaching Hospitals states that staff now perform a Mid Upper Arm Circumference calculation in line with the Malnutrition Universal Screening Tool (MUST) to assist is establishing an accurate weight, if it is not possible to weigh the patient.
Gianna Khan
All Responded
2014-0219
9 May 2014
Bedfordshire & Luton
Bedfordshire Clinical Commissioning Gro…
Concerns summary (AI summary)
The coroner raised concerns that a patient reporting a head injury was streamed to the GP clinic instead of being seen by a doctor in the A&E Department, and that the Clinical Commissioning Group had refused a full triage before streaming patients.
Action Planned
(AI summary)
Luton CCG will share findings with Luton Clinical Commissioning Group, LHS has accepted NICE Guidance CG176, LHS will cooperate with NHS England investigation and is resubmitting its 'Risk and Serious Incident Framework' for scrutiny, key priority will be review of emergency and urgent care commissioning arrangements.