2014
PFD Reports
Reports: 557
Areas: 71
55% response rate (below 63% average).
Audrey Kelly
All Responded
2014-0155
8 Apr 2014
Manchester (South)
Department of Health and Social Care
Concerns summary (AI summary)
The coroner reported that the attending doctor and nurse at the Out of Hours Service could not access the patient's GP electronic notes, describing this as a serious lapse in procedures that could lead to future loss of life.
Action Planned
(AI summary)
Stockport CCG is seeking formal assurance from Mastercall regarding processes for new starters and contingency plans when practitioners lack smartcards. They will also work with Mastercall to map and analyze processes for accessing shared records and to ensure fit-for-purpose mobile solutions with access to necessary information. Stockport CCG are investigating the attempted access to the patient's record at the time of the incident and are working with suppliers to understand the root cause and whether it was a human or system error. The CCG has also written to Mastercall to arrange a meeting to understand the issues more fully, and improve processes for the reporting of issues relating to the SHR.
Leslie Harding
All Responded
2014-0169
8 Apr 2014
Plymouth, Torbay & South Devon
Oak Side Surgery
Concerns summary (AI summary)
There was a failure to take prompt action and ensure robust treatment for a patient with a suspected life-threatening pulmonary embolus over a critical period.
Action Planned
(AI summary)
The doctor has decided to adopt a system of writing notes using the computer appointment system and a ring-bound notebook. The practice is composing a letter informing people of the risks of non-concordance with medication and has extended this review to patients receiving low molecular rate heparin and novel oral anti-coagulants; they have scheduled a further discussion of the case at the next significant event analysis meeting.
Andrew Horgan
All Responded
2014-0163
8 Apr 2014
Wiltshire & Swindon
Great Western Hospital
Concerns summary (AI summary)
Doctors lacked clear understanding and training on mental health referral procedures, leading to inadequate patient assessment processes.
Action Taken
(AI summary)
The Trust increased the number of Mental Health Liaison nurses from 2.6 to 6.8 and appointed a dedicated Consultant Psychiatrist. They also state that 82% of clinical staff had undertaken Mental Health Act training and 94% MCA and DoLS during 2013/14.
Roger Duggan
All Responded
2014-0157
7 Apr 2014
Exeter & Greater Devon
Royal Devon and Exeter Hospital NHS Tru…
Concerns summary (AI summary)
An agitated patient was left unsupervised in the Emergency Department, and staff failed to take responsibility for monitoring him, leading to his unnoticed departure.
Action Taken
(AI summary)
The staff nurse involved in the incident was reminded of the importance of contemporaneous record keeping. The Trust is using its Care Quality Assessment Tool (CQAT) to ensure that documentation is given a higher priority in scoring, and case notes are audited through various review processes. The incident reporting policy will be more explicit in relation to retaining equipment and devices. Following an investigation, the Trust upgraded its version of 'NHS Pathways' to version 6.5.1, including a dedicated Mental Health Pathway, and trained staff on its use; a Mental Health Group has also been established to monitor responses to patients with mental health concerns.
William Winter
Historic (No Identified Response)
2014-0154
7 Apr 2014
Kent (Central & South East)
East Kent Hospitals University NHS Foun…
Concerns summary (AI summary)
Understaffing and unfamiliarity with escalation procedures on a Clinical Decisions Unit led to missed patient observations and delayed surgical review.
Jamie Barlow
Historic (No Identified Response)
2014-0153
7 Apr 2014
Suffolk
Norfolk and Suffolk NHS Foundation Trust
Suffolk Constabulary
Concerns summary (AI summary)
There was a lack of effective inter-agency working, clear protocols for police assistance, and a joint mental health assessment framework for high-risk patients.
Eric Matthews
All Responded
2014-0151
4 Apr 2014
London Inner (North)
University College London Hospitals NHS…
Concerns summary (AI summary)
There is limited public awareness and insufficient research regarding the risk of positional asphyxia associated with baby slings.
Noted
(AI summary)
The Trust investigated a survey of 'cot deaths' in unusual scenarios but it did not prove feasible due to data protection and consent issues. They suggest coroners liaise with clinicians working on sudden infant death and release data from existing child death reviews.
Danuta Corbett
All Responded
2014-0150
3 Apr 2014
Brighton & Hove
Sussex Partnership NHS Foundation Trust
Concerns summary (AI summary)
The hospital's leave policy for informal patients was not followed, and inadequate risk assessment for escorted leave, using an untrained agency worker, resulted in critical safety failures.
Action Taken
(AI summary)
The consultant psychiatrist now carefully reviews notes taken during ward review. The Trust has reinforced with staff that should extraordinary circumstances arise again, a retrospective note must be completed, and the nurse responsible will ensure proper handovers take place in the future.
Graham Watts
All Responded
2014-0149
3 Apr 2014
Brighton & Hove
Brighton and Sussex University Hospital…
Royal Sussex County Hospital
Princess Royal Hospital
Concerns summary (AI summary)
The hospital's discharge procedure was severely flawed, involving blank paperwork, lack of communication with family or care home, and discharging a medically unfit patient.
Action Taken
(AI summary)
A social worker has started attending daily "Board Round" meetings to assist in patient discharge planning. The Trust acknowledges shortcomings in the discharge planning process and is aiming to start a one year pilot scheme to focus on consistent multi-disciplinary management of frail elderly patients, in preparation for their discharge.
Melvin Bandtock
All Responded
2014-0147
3 Apr 2014
County Durham & Darlington
Durham Constabulary
Durham County Council
Concerns summary (AI summary)
A duty manager's decision not to grit roads based on inaccurate weather assessment led to dangerous conditions; improved information sharing and review of council procedures are needed.
Disputed
(AI summary)
The Council intends to meet with weather forecasters prior to the next winter season to determine whether notifications relating to changes in weather can be improved. Duty Managers have been reminded to ensure that appropriate action is taken and the safety of the highway network is the paramount consideration. The Constabulary disputes the coroner's concern, stating that their procedures for dealing with road incidents are not managed on an ad-hoc basis and that they have robust, well-managed procedures and good communication with Durham County Council.
William Watson
Historic (No Identified Response)
2014-0146
2 Apr 2014
Isle of Wight
Hampshire Constabulary
Island Roads
Isle of Wight Council
Concerns summary (AI summary)
Poor road layout and obstructing hedgerows at a specific location compromise driver visibility, creating a significant road safety hazard.
John Dodd
All Responded
2014-0145
2 Apr 2014
Black Country
Dudley Group NHS Foundation Trust
Concerns summary (AI summary)
Inadequate patient monitoring, including missed INR checks and unreported temperature rise, coupled with significant delays in A&E medical assessment, compromised patient safety.
Action Planned
(AI summary)
The Trust will develop a written guideline to include routine checking of INR for all patients presenting after a fall who are receiving vitamin-K antagonist anticoagulants. The Emergency Department will develop an audit process to review the appropriate referral of patients for senior review, and the electronic clinical information system will be reconfigured to create a visible alert to the consultant in charge when a patient's vital signs fall outside normal parameters.
Oliver Hiscutt
Historic (No Identified Response)
2014-0152
1 Apr 2014
Manchester City
Department of Health and Social Care
General Medical Council
Health Education England
+2 more
Concerns summary (AI summary)
Lack of mandatory formal paediatric child health training for GPs results in inadequate skills to assess and manage sick children effectively.
Vincent Gibson
Historic (No Identified Response)
2014-0148
1 Apr 2014
Gateshead & South Tyneside
Independent Police Complaints Commission
Northumbria Police
Concerns summary (AI summary)
Police incident management suffered from unclear leadership, inadequate communication protocols, ineffective resource allocation, and unreliable electronic aids, compromising response safety and efficiency.
Joseph Godfrey
Historic (No Identified Response)
2014-0143
31 Mar 2014
London (East)
BUPA Care Homes
BUPA UK Provision
Concerns summary (AI summary)
Care staff and paramedics lacked awareness of warfarin-related bleeding risks in elderly fall patients. Care home staff failed to follow observation protocols, document checks, or access medical history, and BUPA's investigation was insufficient.
Valerie Hancox
Historic (No Identified Response)
2014-0144
31 Mar 2014
Shropshire, Telford & Wrekin
AGCO Ltd
Concerns summary (AI summary)
Farm bale chutes are routinely left lowered and unmarked on public highways, contrary to manufacturer instructions, posing a significant, unlit obstruction hazard to other road users.
Deanne Smith
Partially Responded
2014-0141
31 Mar 2014
London (South)
Bromley Drug and Alcohol Service
United Pharmacy
Concerns summary (AI summary)
The practice of dispensing large quantities of methadone to drug-dependent individuals over public holidays increases the risk of future deaths and needs policy review.
Action Taken
(AI summary)
United Pharmacy pharmacists are working closely with patients' special workers, having regular meetings with Bromley Drugs and Alcohol services, and will encourage services to use pharmacies open at weekends for medication pick-ups.
Rosemary Simpson
Historic (No Identified Response)
2014-0142
28 Mar 2014
London Inner (North)
London Borough of Camden
Concerns summary (AI summary)
The bus stop's location in a busy area creates poor visibility for buses, forcing unsafe lane changes and posing risks to pedestrians and vehicles.
Susan Poore
Historic (No Identified Response)
2014-0140
28 Mar 2014
Norfolk
NHS England
Concerns summary (AI summary)
Anti-depressant medication was associated with a deterioration in the patient's depression, leading to an uncharacteristic death, despite side-effect warnings.
Sebastian Davies
Historic (No Identified Response)
2014-0139
28 Mar 2014
Norfolk
Norvic Clinic
Concerns summary (AI summary)
Hourly night observations failed to check for patient immobility or movement, potentially delaying detection of unconsciousness, and lacked continuity among observing staff.
Lee Hollman
All Responded
2014-0135
26 Mar 2014
West Sussex
Horsham and Mid Sussex Clinical Commiss…
Royal College of General Practitioners
Concerns summary (AI summary)
The practice had inadequate systems for maintaining accurate medical records, removing outdated repeat prescriptions, and reviewing patients' medication within guidelines.
Action Planned
(AI summary)
The RCGP and Royal Pharmaceutical Society will convene a multi-stakeholder group and establish a joint working group, including patients, to explore recommendations and develop a work program focused on shared standards, education and training. Riverside Surgery met with the Horsham Community Mental Health Team to improve communication, discussed prescribing with the CCG, and has ongoing reviews for mental health patients, including specialist consultations, case review meetings, and face-to-face reviews, leading to modified policies and processes.
Margaret Walker
All Responded
2014-0134
25 Mar 2014
Manchester (West)
5 Boroughs Partnership
Concerns summary (AI summary)
Incomplete medication history, poor record-keeping, and failure to apply a defibrillator promptly by ward staff contributed to critical care delays.
Action Taken
(AI summary)
The Trust has reviewed its medicines policy, will issue further guidance on medicines reconciliation, has implemented Trust-wide initiatives for managing physical health and diabetes, developed diabetes guidelines, introduced Diabetes Link Nurses/Associates and provided the Hospital at Home service.
Caroline Pilkington
All Responded
2014-0269
25 Mar 2014
Manchester (West)
Department of Health and Social Care
North West Ambulance Service
Concerns summary (AI summary)
North West Ambulance Service staff lack control and restraint training, forcing reliance on police who are not clinically trained, leading to delayed patient care and inappropriate diversion of police resources.
Noted
(AI summary)
Greater Manchester Police expresses concern about the increasing demand on police due to gaps in health services, emphasises that officers are trained in restraint but that medical emergencies require different approaches, and offers support to NWAS in training initiatives. NWAS acknowledges the coroner's concerns but maintains that ambulance staff are not trained nor expected to restrain patients who are acting in a threatening or violent manner, as advanced control and restraint is a specialised skill best left to the police. The Department of Health acknowledges the coroner's concerns but supports the NWAS's collaborative approach with the police in handling patients requiring advanced control and restraint. The Department of Health acknowledges the coroner's concerns about NWAS training, but supports the NWAS position that ambulance staff are sufficiently trained and that more advanced restraint training is not needed or beneficial.
Sean Morley
Historic (No Identified Response)
2014-0132
24 Mar 2014
Warwickshire
Warwickshire County Council
Concerns summary (AI summary)
The A444 stretch lacks pedestrian/cyclist warning signs, street lighting, and protective barriers, despite regular use by vulnerable road users and a 70mph speed limit, creating a high risk of collisions.
Jackson Chadd
Partially Responded
2014-0137
24 Mar 2014
Surrey
Department of Health and Social Care
Frimley Park Hospital
Royal College of Paediatrics and Child …
Concerns summary (AI summary)
Concerns include inadequate supervision for junior paediatric staff, insufficient consultant oversight for out-of-hours admissions, failure to apply national guidelines for fever in children, and disregarding parental concerns.
Action Planned
(AI summary)
The Hospital updated sepsis guidelines to include tachycardia, changed practices to fast track children with PEWS scores of less than 4 to the Paediatric Assessment Unit, and now requires blood gases on all children presenting with fever or non-blanching rash; it also reiterates its philosophy of 'patient not to go home'. The RCPCH refers to existing guidance, standards and reports regarding supervision and training and notes their current review of standards to encourage higher levels of consultant supervision.