2014
PFD Reports
Reports: 557
Areas: 71
55% response rate (below 63% average).
Rosemary Oladejo
All Responded
2014-0203
22 Apr 2014
London (West)
Central and North West London NHS Found…
NHS Hillingdon Clinical Commissioning G…
Concerns summary (AI summary)
A critical lack of communication between the GP and responsible clinician led to unauthorized and unrecorded changes in the patient's medication, including incorrect dosing and administration times for amitriptyline.
Action Planned
(AI summary)
Hillingdon CCG will review current processes for recording and communicating medication information by August 2014. They will discuss the possibility of developing one standard letter/form for use across all sectors in July 2014 and ensure practice pharmacists review and improve medicines reconciliation processes starting in July 2014. Central North West London NHS Trust will circulate a Clinical Risk Alert referencing this case in an anonymised form in the next few weeks to remind staff of the importance of communication. They will also take this to the Mental Health Partnership Board to highlight the communication lessons.
Andrey Wakefield
All Responded
2014-0186
22 Apr 2014
Staffordshire (South)
University Hospital of North Staffordsh…
Concerns summary (AI summary)
Poor communication of patient discharge information to GPs, especially for practices distant from the hospital, poses a significant risk to ongoing patient care.
Action Planned
(AI summary)
A solution is being rolled out in three phases to improve communication of discharge information between the hospital and GPs, including remote implementation, training, IT support and standard operating procedures. They are awaiting confirmation from Western Cheshire, South East Staffs and Seisdon; Shropshire and Vale Royal and South Cheshire to commit to the plan.
Michael Worrall
Historic (No Identified Response)
2014-0179
22 Apr 2014
London Inner (North)
Barnet Enfield and Haringey Mental Heal…
Concerns summary (AI summary)
The limited availability of psychological therapy at Avesbury House risks adverse outcomes for patients, particularly upon discharge to the community if prior therapy is discontinued.
Karen Peters
Historic (No Identified Response)
2014-0178
17 Apr 2014
Plymouth, Torbay & South Devon
Royal Cornwall Hospitals NHS Trust
Concerns summary (AI summary)
No specific concerns were detailed in the provided text, beyond broad categories of 'Nursing and Medical' matters.
Paul Millis
All Responded
2014-0176
17 Apr 2014
Leicester City & South Leicestershire
Leicester City Council
Concerns summary (AI summary)
The highway design features a very short and acutely angled lane merger near a junction, creating significant line-of-sight obstructions and danger for merging traffic.
Disputed
(AI summary)
Leicester City Council asserts the highway design at Troon Way complies with relevant standards and underwent multiple safety audits. They will forward the coroner's comments to the Road Safety Auditor for consideration during the final audit.
Muriel Dawson
Partially Responded
2014-0173
17 Apr 2014
West Yorkshire (West)
Optare
Transport Research Laboratory
Vehicle Operator Services Agency
Concerns summary (AI summary)
The bus design lacked restraints for seated passengers, especially in the aisle seat, leading to fatal injury during a sudden stop. Type-approval may not adequately consider the risk of death or serious injury.
Action Planned
(AI summary)
The Department for Transport will raise the coroner's concerns about bus seat design with bus manufacturers and at the next meeting of the International technical group to consider amending minimum specifications for new vehicles.
Sari Keen
All Responded
2014-0180
16 Apr 2014
Bedfordshire & Luton
Luton and Dunstable University Hospital
Concerns summary (AI summary)
Insufficient staffing levels overwhelmed healthcare professionals, and a lack of awareness among staff regarding 'un-recordable blood pressure' as a medical emergency led to delayed resuscitation.
Action Taken
(AI summary)
Luton & Dunstable University Hospital has increased night nursing staff on ward 22 following a staffing review. The hospital is evaluating current training for nurses and doctors, and will present the case at safety meetings to share learning.
Kathryn Sawyer
All Responded
2014-0177
16 Apr 2014
Norfolk
Roundwell Medical Centre
Concerns summary (AI summary)
A failure to adequately review and plan a reduction of high-dose addiction medications occurred, alongside a lack of detailed record-keeping regarding medication discussions and future plans.
Action Taken
(AI summary)
Roundwell Medical Centre has implemented several immediate actions regarding patients on addictive medications including assigning a single GP where possible, detailing clinical plans, adding read codes for easy identification, and a six-month medication review. They will design a bespoke "Addictive Medication Review" template within 3 months and include patients on weekly medication in risk profiling.
Kevin Scarlett
All Responded
2014-0174
15 Apr 2014
Milton Keynes
National Offender Management Service
Concerns summary (AI summary)
The prison service and healthcare failed to assess the deceased's suicide risk, as staff lacked access to proper risk assessment tools or protocols.
Action Taken
(AI summary)
HMP Woodhill reviewed the local ACCT process in December 2013, revised the case review process, and issued guidance to staff. A governor grade is appointed to manage the case of each prisoner subject to the ACCT process who is assessed as having complex needs.
Philip Dean
Partially Responded
2014-0172
15 Apr 2014
London (Inner West)
Clinical Commissioning Group for Wandsw…
South Wet London and St George’s Mental…
Concerns summary (AI summary)
Mental health services were underfunded and under-resourced, leading to fragmented care, inadequate recording of critical information, and delayed professional assessments for severely unwell patients.
Action Taken
(AI summary)
South West London and St George's NHS Trust has revised serious incident procedures so that initial findings from concise investigations are reviewed after ten working days to consider escalating to a comprehensive investigation if necessary. They have commissioned externally led training workshops to develop knowledge, skills and quality assurance processes for investigations and report writing.
Desiree Falvo
All Responded
2014-0171
15 Apr 2014
London Inner (West)
NHS England
Concerns summary (AI summary)
A&E departments lack sufficient clinicians skilled in emergency surgical tracheotomy, indicating inadequate training and cover for critical airway management procedures.
Action Taken
(AI summary)
NHS England highlights existing training for A&E staff in emergency airway procedures and a review of Emergency Departments. They have agreed that major trauma units have consultants on site 24/7 and all A&Es will have senior training doctors on site 24/7.
Francis Golding
All Responded
2014-0136
14 Apr 2014
London Inner (North)
Camden Council
Concerns summary (AI summary)
The junction design poses significant and repeatedly fatal risks to cyclists due to collisions with left-turning vehicles and inadequate space, with slow progress on promised safety improvements.
Action Planned
(AI summary)
Camden Council will issue a brief to traffic consultants by the end of May 2014 to invite tenders for traffic signal modelling in the Holborn area, including the Southampton Row/Vernon Place junction, with consultants expected to be appointed in mid-June 2014.
Paul Ashton
Partially Responded
2014-0170
14 Apr 2014
Manchester (West)
Department of Health and Social Care
Medicines and Healthcare Products Regul…
Concerns summary (AI summary)
There was a lack of consultation with the cardiac transplant team and no established protocol for managing heart transplant patients undergoing non-cardiac surgery, leading to insufficient awareness of specific risks.
Action Planned
(AI summary)
NHS England will task its Rare Disease Advisory Group to prepare recommendations within six months for practical steps to improve care for heart transplant patients. NHS England will also ensure, immediately, through Area Medical Directors, that all hospitals are made aware of the ISHLT guidelines for heart transplant patients.
Winifred Dennis
All Responded
2014-0167
14 Apr 2014
Kent (North-East)
Kent Community Health NHS Trust
Concerns summary (AI summary)
Patient transfers between community nursing teams lacked formal handover documents, resulting in critical information, like the need for specific equipment, not being communicated to new care homes.
Action Taken
(AI summary)
Kent Community Health NHS Trust has devised a formal process for transfer of care between community nursing teams. A working group has been established to revise policies and procedures, improve documentation and monitor through clinical audit. The training available to staff for holistic assessment and care planning has been revised and is being rolled out.
Nicos Michael
All Responded
2014-0168
14 Apr 2014
Kent (North-East)
East Kent Hospitals University NHS Foun…
Concerns summary (AI summary)
The coroner identified conflicting evidence regarding the deceased's recorded allergies, noting a lack of readily available and continuously updated allergy information for hospital staff, and that electronic prescribing was not compulsory.
Noted
(AI summary)
East Kent Hospitals University NHS Foundation Trust notes the coroner's concerns regarding the recording of a reported allergy to penicillin throughout the healthcare records, but states that concerns are based solely on the findings of the Root Cause Analysis undertaken into this case and the various statements provided by the staff involved in the care and treatment of Mr Michael.
Lalitaben Patel
All Responded
2014-0175
13 Apr 2014
Leicester City & South Leicestershire
Department of Health and Social Care
Concerns summary (AI summary)
A locum consultant surgeon, despite being restricted to routine procedures, operated without additional supervision, raising concerns about oversight for consultants with identified limitations.
Action Planned
(AI summary)
DHSC highlights recommendations from a 2013 working group to strengthen quality assurance of locum doctors, including strengthened GMC appraisal guidance, pre-employment standards, audit guides, and guidance for Trusts. DHSC continues to welcome progress against these recommendations.
Terence Dooley
All Responded
2014-0162
10 Apr 2014
Manchester City
North West Ambulance Service
Concerns summary (AI summary)
The call concerning the deceased was given a code green despite the fact that each different tablet could be fatal on its own, let alone together.
Disputed
(AI summary)
NWAS defends its call coding system and response times, stating that the call was coded correctly and all immediately life-threatening calls were responded to within national targets. They dispute there was a lack of communication and that the computer-generated codes were misleading.
Thomas Allen
Partially Responded
2014-0160
9 Apr 2014
Suffolk
Department for Environment, Food and Ru…
Suffolk Constabulary
Concerns summary (AI summary)
The illegal practice of 'fly grazing' is difficult to manage in England as it is not a criminal offence, and a necessary police/local authority protocol is not yet in force.
Noted
(AI summary)
Defra acknowledges the concerns regarding fly-grazing and the death of Thomas Allen, but states that existing legislation (Highways Act 1980, Animals Act 1971, Anti-social Behaviour, Crime and Policing Act 2014) is already in place to tackle the issue. They are encouraging joint working amongst authorities and monitoring the situation in Wales.
Stephen Bedford
Historic (No Identified Response)
2014-0159
9 Apr 2014
Cambridgeshire (South & West)
East of England Ambulance NHS Trust
Messrs Hempsons
Messrs Stewarts Law LLP
Concerns summary (AI summary)
Ambulance staff training and assessment for life support standards are inconsistent, leading to inappropriate crew deployment for critical patients and inadequate communication of crew capabilities.
Sally Perrons
All Responded
2014-0158
9 Apr 2014
Nottinghamshire
Association of Ambulance Chief Executiv…
East Midlands Ambulance Service NHS Tru…
Concerns summary (AI summary)
No specific concerns were detailed in the provided text for summarization.
Action Planned
(AI summary)
The National Ambulance Sector will require the use of either a digital ETC02 monitoring device or full waveform capnography for every intubation with immediate effect. Waveform capnography will be considered the gold standard and the sector is committed to having this in place on every responding vehicle crewed by a paramedic by July 2017.
Russell Long
All Responded
2014-0165
9 Apr 2014
Cumbria (North & West)
Cumbria County Council
Action Taken
(AI summary)
Works were carried out in the last month to raise the height to a consistent level with the top of the bridge and installation of edge restraint system on the North bound A596.
Ozan Atasoy
All Responded
2014-0166
9 Apr 2014
Hertfordshire
Care Quality Commission
Concerns summary (AI summary)
A detained patient repeatedly absconded from a psychiatric unit's smoking area, often while escorted, indicating insufficient supervision and inadequate security protocols.
Action Planned
(AI summary)
CQC will disseminate the coroner's report within the CQC, particularly in relation to inspections of hospitals, and feed the issues into intelligent monitoring systems and key lines of enquiry. They will also consider improvements that have been implemented by the trust.
Doris Taylor
Historic (No Identified Response)
2014-0164
9 Apr 2014
Manchester (South)
Borough Care Limited
Concerns summary (AI summary)
The coroner noted that staff training should include a full and clear understanding as to what constitutes a reportable incident and the managers should be aware of their duty to report such. The door-closers on all doors should be in a safe working condition.
Michael Anthony
Partially Responded
2014-0161
9 Apr 2014
London (Inner South)
Guy’s Hospital
Princess Street Practice
Concerns summary (AI summary)
The coroner noted that the deceased's Gabapentin level was five times the normal therapeutic level, the reason for which was undetermined, and that the drug is usually not prescribed in diabetics due to the risk of severe reaction.
Action Taken
(AI summary)
The trust has built a review of the case into their day to day practice and reported the case via the MHRA yellow card reporting system. The trust has also spoken to clinical leads regarding the use of the drug and side effects.
Frederick Hall
Historic (No Identified Response)
2014-0156
8 Apr 2014
Manchester (South)
Alexandra Hospital
Concerns summary (AI summary)
Widespread deficiencies included poor staff training for NG tube insertion, erratic patient monitoring, failure to follow consultant instructions, and significant communication breakdowns. Additionally, poor record-keeping and inadequate staffing compounded risks.