2014
PFD Reports
Reports: 557
Areas: 71
55% response rate (below 63% average).
Margaret Connor
All Responded
2014-0215
9 May 2014
Norfolk
Heathers Nursing Home
Concerns summary (AI summary)
Inadequate procedures for wheelchair checks resulted in faulty equipment, while communication breakdowns led to doctors being misinformed about a patient's injury despite staff and family concerns.
Action Taken
(AI summary)
The nursing home asserts it already meets required standards for equipment maintenance and staff training. They are implementing weekly wheelchair checks and providing staff with updated guidelines, including a wheelchair safety checklist to be used each time a resident uses a wheelchair.
Ann Bennett
Historic (No Identified Response)
2014-0233
9 May 2014
West Yorkshire (East)
Leeds Teaching Hospitals NHS Trust
Concerns summary (AI summary)
The coroner endorsed findings from a Trust investigation report that identified serious issues contributing to a potentially avoidable death, necessitating a robust response.
Abiola Dosunmu
All Responded
2014-0209
9 May 2014
London (Inner South)
Kings College Hospital NHS Foundation T…
Concerns summary (AI summary)
Critical test results were not communicated effectively between departments, to the patient, or to the GP, resulting in a missed diagnosis and suboptimal care, which was inadequately reviewed by a serious incident investigation.
Action Taken
(AI summary)
The Trust will refer the case to be included as a reminder in the formal teaching of Foundation doctors and has already shared the incident at departmental governance meetings. ED has revised the transfer checklist for patients being admitted to include results of tests done in ED, and consultants will be notified within 12 hours when their patient discharges themselves from the hospital.
Anthony Lapping
All Responded
2014-0214
8 May 2014
Newcastle Upon Tyne
Indesit Company
Concerns summary (AI summary)
Highly flammable insulation material in a Hotpoint fridge freezer caused rapid fire spread, severely reducing escape opportunities and highlighting an urgent need for manufacturing review.
Noted
(AI summary)
The company outlines the safety standards in place at the time of manufacture and improvements made since. It describes assessments underway to reduce flammability further but describes constraints on introducing an aluminized cardboard covering.
Rajesh Parkash
Historic (No Identified Response)
2014-0207
8 May 2014
Surrey
Association of Ambulance Chief Executiv…
London Ambulance Service
Concerns summary (AI summary)
Failures in staff communication regarding updates and driving guidance, insufficient ongoing driver training, and inadequate supervision requirements for paramedics pose systemic risks.
Sopefoluwa Peters
All Responded
2014-0206
8 May 2014
County Durham & Darlington
Durham County Council
Concerns summary (AI summary)
Hazardous steps, poorly illuminated and without a handrail, combined with a low riverside safety barrier, created a dangerous environment, especially for intoxicated individuals.
Action Planned
(AI summary)
The Council will install a timber barrier in the riverside footpath adjacent to the wall opposite the exit of Drury Lane. The County Council will also be undertaking a risk assessment along sections of the river bank.
Frank Pope
Partially Responded
2014-0216
8 May 2014
London Inner (North)
Northern Medical Centre
Whittington Hospital NHS Trust
Concerns summary (AI summary)
There is no clear "back-up" process to ensure follow-up for patients lacking capacity, particularly when family members are not copied into correspondence, risking missed appointments.
Action Planned
(AI summary)
The Trust will send a communication to all GPs via the GP Bulletin to remind them to include any information with regard to vulnerable patients or patients who lack capacity in the referral letter. They will also remind them of the option to request that out-patient appointment letters be copied to either a nominated patient representative for patients who lack capacity to attend appointments.
Peter Brookes
All Responded
2014-0205
7 May 2014
London Inner (North)
University College London Hospitals NHS…
Concerns summary (AI summary)
Concerns include hospital administration of Parkinson's medication not following patient regimens, unavailability of doctors for weekend reviews, and an unresolved dispensing error causing wrong medication.
Action Taken
(AI summary)
The Trust has a policy that all new patients should have their medication reconciliation completed within 24 hours and are looking to achieve 100% compliance. It also has measures in place to minimise the risk of dispensing errors including double checks, separate storage of similar drugs and mandatory reporting of errors.
Emma Lifsey
Historic (No Identified Response)
2014-0204
7 May 2014
Nottinghamshire
Network Rail
Concerns summary (AI summary)
The coroner noted that old-style filament bulbs in wig wag lights at the Beech Hill crossing were less than half as bright as they should have been and that the replacement of these lights with LEDs at level crossings was taking too long, given the known issue of sun glare affecting signal visibility.
Donald Spooner
Partially Responded
2014-0208
5 May 2014
West Sussex
Department for Transport
Royal Society for the Prevention of Acc…
Concerns summary (AI summary)
The absence of a compulsory protective helmet requirement for motorised bicycles traveling over 15 MPH significantly increases the risk of severe, unsurvivable head injuries.
Action Planned
(AI summary)
ROSPA will expand their online cycle safety advice to include motorised bicycles, and suggest specific advice about motorised bicycles is included in the next revision of the Highway Code. They will also include these messages in their safety journals and social media communications.
Darren Arnoup
Partially Responded
2014-0199
1 May 2014
Norfolk
Mundesley Medical Centre
NHS North Norfolk Clinical Commissionin…
Concerns summary (AI summary)
Concerns exist regarding the coordination and handover of care for a patient with known mental health issues and suicidal ideation following discharge and communication to the GP.
Action Planned
(AI summary)
The medical centre will develop clear lines of communication with NCH&C staff, alert GPs to referrals related to mental health or substance misuse, and ensure GPs fully document any areas of mental upset or instability discussed for the information of successive colleagues.
Elizabeth Cooper
Historic (No Identified Response)
2014-0197
1 May 2014
Cumbria (South & East)
General Medical Council
National Institute for Health and Care …
The Chief Coroner
Concerns summary (AI summary)
No specific safety concerns were detailed in the report text, only a general statutory duty to report matters of concern.
Sidney Martin
Partially Responded
2014-0196
1 May 2014
North Yorkshire (West)
North West Waterways Canal & River Trust
The Chief Coroner
Concerns summary (AI summary)
The dangerous condition of canal bridge steps and poor lighting in the area pose a significant risk to public safety.
Noted
(AI summary)
The Canal & River Trust acknowledges the coroner's report regarding a death at Gallows Footbridge in Skipton, extends condolences, and states that public safety is their highest priority. They describe the step surface as rough and not likely to be slippery when wet, and state that the surface is in good condition with little sign of wear.
Samiyo Farah
Partially Responded
2014-0202
30 Apr 2014
Manchester (North)
Affinity Healthcare Ltd
Central Manchester University Hospitals…
Department of Health and Social Care
+3 more
Concerns summary (AI summary)
Critical concerns include the absence of national observation guidelines for children in mental health units, poor communication protocols for inter-sector patient transfers, and inconsistent psychiatric referrals from A&E.
Noted
(AI summary)
The Department of Health acknowledges the concerns raised and highlights existing NICE guidance on self-harm and a government suicide prevention strategy. They note that Trusts develop their own transfer protocols with the private sector and refer to existing guidance from the Royal Pharmaceutical Society on patient transfer.
Beryl French
All Responded
2014-0198
30 Apr 2014
Nottinghamshire
Lifestyle Care PLC
Concerns summary (AI summary)
Nursing staff lacked understanding of DNACPR forms and End-of-Life Care planning was insufficient, risking patients not receiving appropriate dignified care in future similar circumstances.
Action Taken
(AI summary)
Life Style Care has provided updated training on DNACPR forms to staff across its remaining homes. An End of Life care plan has been piloted in 3 homes and is under consideration by the Quality Assurance team to be signed off by the end of September 2014.
Mary Wanya
Historic (No Identified Response)
2014-0192
30 Apr 2014
West Yorkshire (East)
Leeds Teaching Hospitals NHS Trust
Concerns summary (AI summary)
Significant delays in urgent psychiatric assessments, an inadequate system for mentally ill patients in medical units, and a flawed investigation report by unqualified staff raise serious safety concerns.
Sukbir Singh Rana & Mandip Singh
Historic (No Identified Response)
2014-0191
30 Apr 2014
Black Country
Sandwell Metropolitan Borough Council
Concerns summary (AI summary)
The appropriateness of a 60 MPH speed limit on a bending country lane with limited lighting is questioned, as the maximum theoretical safe speed for the bend is also 60 MPH.
Dafydd Watts
Historic (No Identified Response)
2014-0194
29 Apr 2014
Avon
British National Formulary
UCB Pharma
Concerns summary (AI summary)
Drug literature and the British National Formulary fail to adequately inform physicians about rare but potential fatal occurrences associated with medication.
Stephen Widman
Historic (No Identified Response)
2014-0189
29 Apr 2014
Plymouth, Torbay & South Devon
Department of Health and Social Care
Torbay Hospital
Concerns summary (AI summary)
The provided text does not detail any specific concerns.
Joanne Oliver
Historic (No Identified Response)
2014-0210
29 Apr 2014
Manchester City
The Faculty of Intensive Care Medicine
Intensive Care Society
Concerns summary (AI summary)
A severe lack of national guidance for critical patient transfer decisions results in insufficient risk assessment protocols covering patient fitness, staff seniority, journey logistics, and post-transfer care.
Janet Blackman
Historic (No Identified Response)
2014-0200
29 Apr 2014
West Sussex
Department of Health and Social Care
Sussex Partnership NHS Trust
Western Sussex Hospitals NHS Trust
Concerns summary (AI summary)
Psychiatric units fail to provide essential physical health care, including DVT prophylaxis, indicating a need for seamless, integrated care delivery for both physical and mental health.
Robert Perkins
All Responded
2014-0195
28 Apr 2014
Avon
North Bristol NHS Trust
Concerns summary (AI summary)
The coroner noted a failure to immobilise the patient's neck with a cervical collar, despite neurosurgeon's instructions, and that medical staff did not raise concerns about this. The prescribed cervical collar was also not readily available despite the hospital being a regional neuroscience centre.
Action Taken
(AI summary)
The ED matron discussed communication failures with the nursing team. The hard collar safety alert and other materials related to cervical immobilisation will be redistributed to medical directors, CDs and included in medical staff inductions. A place for central storage of these devices is being looked for within the Emergency Zone and the accessibilily of rigid collars for the purposes of cervical immobllisation is being readdressed since the move into the new Brunel building.
Yasmin Richards
All Responded
2014-0193
28 Apr 2014
Avon
Highways Agency
Concerns summary (AI summary)
The A46 "Hartley Bends" has an inappropriate speed limit and inadequate road signage, markings, and warning features, contributing to a high risk of fatal collisions.
Action Taken
(AI summary)
The Highways Agency has implemented local measures to highlight the nature of the road, including additional chevron signage, hazard warning signs, and high friction surfacing in strips. They are planning a peer review of the implemented scheme by the end of July 2014 and will gather data to ascertain its effectiveness.
Jennifer Tompkins
Historic (No Identified Response)
2014-0188
28 Apr 2014
London (Inner South)
Kings College Hospital NHS Foundation T…
Concerns summary (AI summary)
The coroner expressed concern about potential training issues related to the administration of IV medications, and that the stopping of IV vancomycin infusions early may not be routinely documented, raising risks in other cases.
Stephen Goodhall
Historic (No Identified Response)
2014-0184
24 Apr 2014
Manchester (South)
University Hospital of South Manchester…
Concerns summary (AI summary)
A lack of clear policy for determining ITU candidacy and contradictory messages from nursing and medical staff pose risks to patient care.