2014

PFD Reports
Reports: 557 Areas: 71

55% response rate (below 63% average).

Response Status
Responded 305 Historic 252
AI Classification
Action Taken 41%
Action Planned 36%
Noted 21%
Disputed 2%
Based on 383 classified responses
Top Categories
Hospital Death (Clinical Procedure… (240) Community health care and emergenc… (69) Other related deaths (66) Road (Highways Safety) related dea… (57) State Custody related deaths (35)
557 results
Phyllis Barnes
Historic (No Identified Response)
2014-0138 24 Mar 2014 Surrey
Frimley Park Hospital NHS Trust North East Hampshire and Farnham Clinic… Royal College of Surgeons
Concerns summary (AI summary) A visiting GP failed to recognise the seriousness of the patient's condition. Post-operative telephone follow-ups were inadequate, and there was no effective communication channel for family concerns.
Kerry Jacobs
All Responded
2014-0133 21 Mar 2014 West Sussex
Surrey and Sussex NHS Trust
Concerns summary (AI summary) The hospital lacked a policy requiring doctors to document reasons for prescribing medication outside BNF guidelines. There was also no protocol for pharmacists and clinicians to discuss queried medication dosages.
Action Taken (AI summary) The Chief Medical Officer issued a directive for staff to record the rationale for prescribing medication outside of BNF guidance, and the Chief Pharmacist has reiterated the medication screening procedure to pharmacy staff, instructing direct discussion between prescribing doctor and dispensing pharmacist.
Derrick Plater
All Responded
2014-0130 21 Mar 2014 Norfolk
Cambridgeshire County Council
Concerns summary (AI summary) There was no protocol for visiting care homes before placing patients with complex needs, relying solely on assurances. A lack of clear guidelines for when visits should be undertaken during assessment poses a risk.
Disputed (AI summary) The council believes that a pre-placement visit by a social worker would not have provided any added assurance and is not and will not be part of the assessment and placement process.
Norma Sheppard
Historic (No Identified Response)
2014-0129 21 Mar 2014 Staffordshire South
Queens Hospital Burton Upon Trent
Concerns summary (AI summary) The report describes confusion regarding the terms of the deceased's discharge from hospital to the care home, specifically regarding the provision of sub-cutaneous fluids, which presented difficulties in finding a suitable placement.
Robert Jones
All Responded
2014-0190 20 Mar 2014 Carmarthenshire and Pembrokeshire
West Wales General Hospital Glangwili C…
Concerns summary (AI summary) CT scan results were not made available promptly to relevant departments, nor were they acted upon without delay and within a reasonable timeframe.
Action Planned (AI summary) The Radiology department will sample emergency CT scan report times. All staff will be reminded to document review of test results, and verbal results. A report on these actions will be presented to the Health Board's Putting Things Right Committee in September.
Christopher Williams
Historic (No Identified Response)
2014-0131 19 Mar 2014 Cheshire
St Mary’s Hospital Warrington
Concerns summary (AI summary) A critical defibrillator failed due to lack of daily checks and no cross-check system. The hospital also lacked a policy for managing sudden or unexpected deaths.
David Chatburn
Partially Responded
2014-0126 18 Mar 2014 Manchester (North)
Department of Health and Social Care Pennine Care NHS Trust Rochdale Heywood and Middleton Clinical… +1 more
Concerns summary (AI summary) The GP failed to refer the patient to psychiatric services, inappropriately managed medication, and had poor record-keeping. Systemic issues included bureaucratic barriers to mental health referrals and non-medical triage.
Noted (AI summary) The Department of Health acknowledges the concerns raised regarding the patient's care and referral process, and notes that patients with a mental health condition have the same legal rights as physical health patients regarding choice of provider.
Charles Bradley
Historic (No Identified Response)
2014-0118 17 Mar 2014 Liverpool
Arrowe Park Hospital
Concerns summary (AI summary) Inadequate record-keeping and communication failures at Arrowe Park Hospital led to the patient not being expected upon transfer and unclear documentation of a significant fall.
Peter Banks
Historic (No Identified Response)
2014-0124 17 Mar 2014 Staffordshire South
Casualty Reduction Team
Concerns summary (AI summary) A pedestrian crossing point was positioned too close to the main road. Protective railings should be extended and the crossing moved further into Westhead Avenue to improve safety.
Daniel Taylor
Historic (No Identified Response)
2014-0125 17 Mar 2014 Staffordshire (South)
Casualty Reduction Team
Concerns summary (AI summary) A specific downhill road section preceding a right-hand bend lacked appropriate warning signs or markings, warranting a review to prevent future collisions.
David Oldfield
All Responded
2014-0117 14 Mar 2014 West Yorkshire (East)
West Yorkshire Police Force
Concerns summary (AI summary) Concerns were raised about the appropriateness and justification of tasering the deceased, given discrepancies in officer accounts. Unjustified tasering unnecessarily increases the risk of serious injury or death.
Noted (AI summary) West Yorkshire Police acknowledge the concerns raised, particularly regarding officer accounts, and state that the IPCC was informed. They also offer a visit to their training facilities to demonstrate Taser training and usage.
Michael Tarratt
All Responded
2014-0115 14 Mar 2014 Leicester City & South Leicestershire
Leicestershire Partnership NHS Trust
Concerns summary (AI summary) There was an unacceptable 18-month lapse in communication between the drug and alcohol team and the GP. Services failed to exchange information on inappropriate prescriptions for an opiate-dependent patient.
Action Taken (AI summary) An urgent memo was sent to the Drug & Alcohol team regarding GP communication standards (minimum every 3 months). Standard GP letter templates have been reviewed to ensure detailed updates are sent and are due to be uploaded within 14 days, with prompts and reminders by June 30th. A case note audit is due within 14 days, with follow-ups every 6 months.
Gavin Roberts
Historic (No Identified Response)
2014-0120 14 Mar 2014 Rotherham
Rotherham Metropolitan Borough Council
Concerns summary (AI summary) The current 60mph speed limit for a specific bend is too high, and warning signs are inadequate, particularly as the limit increases on approach, contributing to repeated incidents.
Matthew Simmonds
Historic (No Identified Response)
2014-0119 14 Mar 2014 Hampshire (Central)
NHS England
Concerns summary (AI summary) An effective local action plan for commissioning complex care pathways for ventilated patient discharges is not shared nationally, posing a risk that other Clinical Commissioning Groups may not adopt it.
Janette Sutherland
All Responded
2014-0114 13 Mar 2014 Gwent
Caerphilly County Borough Council
Concerns summary (AI summary) A drainage channel and concrete headwall present a significant hazard to road users. A safety barrier is needed to prevent vehicles from impacting the headwall.
Action Planned (AI summary) The council will investigate the site of the incident to provide recommendations for measures to alleviate future incidents. A Road Restraint Risk Assessment Process (RRRAP) survey was carried out on March 27th, and the council will complete the RRRAP in a timely manner and provide details of any findings/outcomes. Following a Road Restraint Risk Assessment Process (RRRAP), the council will demolish a headwall and re-profile the surrounding ditch, with works programmed for commencement in July.
Jean James
All Responded
2014-0112 13 Mar 2014 Sunderland
City Hospitals Sunderland NHS Foundatio…
Concerns summary (AI summary) Initial documentation delays and the unreviewed omission of prophylactic medication occurred. Pharmacy queries were poorly communicated, indicating that existing systems and protocols may be insufficiently robust to prevent human factor failures.
Action Planned (AI summary) The hospital information system is being updated to require completion of VTE prescriptions for at-risk patients, with alerts on medication administration records. A new format for clinical handover from the Acute Medical Unit to base ward has been introduced. The Trust will hold a clinical symposium in the autumn regarding VTE management.
Noel Williams
Historic (No Identified Response)
2014-0123 13 Mar 2014 Teesside
South Tees NHS Trust
Concerns summary (AI summary) The coroner noted a failure to communicate haemoglobin level test results, which are an important factor in considering a patient's fitness for surgery, to the anaesthetist and surgeon, potentially affecting treatment plans.
Wendy Brown
All Responded
2014-0113 12 Mar 2014 Wiltshire & Swindon
Swindon Borough Council
Concerns summary (AI summary) Significant delays in implementing care packages and providing respite support for vulnerable carers, compounded by inadequate signposting of adult care services, complicated funding routes, and lengthy application processing times, put carers under severe strain.
Action Taken (AI summary) Swindon Borough Council recognises complexity and potential delays in decision making are real issues. An immediate action taken is that; were services over and above the indicative budget are requested, the indicative budget can be agreed pending any additional information required to ensure that some services are in place in a timely manner.
Stephen Tilbury
Historic (No Identified Response)
2014-0109 12 Mar 2014 London (East)
London Borough of Havering
Concerns summary (AI summary) Excessive vehicle speed in a residential area, despite an existing trief curb, poses a significant risk as the curb can deflect speeding vehicles onto the pavement. Physical speed reduction measures are needed.
Andrew Hall
Partially Responded
2014-0122 12 Mar 2014 Teesside
National Offender Management Service North Tees and Hartlepool NHS Trust Tees, Esk and Wear Valleys NHS Foundati…
Concerns summary (AI summary) Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within the prison healthcare unit were identified. Training gaps for staff in risk assessment and ACCT procedures also contributed to concerns.
Action Taken (AI summary) Cameras have been removed from cells in the healthcare centre and any prisoner assessed as requiring high levels of observation is located in a constant observation cell. A system is now in place to ensure post-closure reviews of ACCTs take place within seven days, and a local policy for an additional review after one month has been introduced.
Teresa Lonergan
Historic (No Identified Response)
2014-0110 11 Mar 2014 London (Inner South)
Eltham Park Surgery
Concerns summary (AI summary) The patient accumulated a dangerous hoard of prescribed controlled drugs due to a lack of monitoring by healthcare professionals, enabling a fatal overdose.
Saleh Ali Dalie
Partially Responded
2014-0108 11 Mar 2014 Birmingham & Solihull
Birmingham City Council West Midlands Police
Concerns summary (AI summary) This residential road has a history of multiple incidents and two fatalities, yet requested road calming, parking restrictions, and pedestrian crossing measures have not been implemented, posing ongoing safety risks.
Action Planned (AI summary) Birmingham City Council will install Vehicle Activated Speed Signs on Kyotts Lake Road, with completion anticipated by the end of July 2014. The City Council will consider further works as part of the Local Safety Scheme element of its Capital Programme for 2014/15.
Afifa Qaisar
Historic (No Identified Response)
2014-0107 11 Mar 2014 Manchester (South)
Tameside Hospital NHS Foundation Trust
Concerns summary (AI summary) Critical issues included inaccurate drug administration records, missing emergency equipment, delays in urgent platelet transfusions, and a failure to properly monitor fluid balance, indicating systemic clinical procedural shortcomings.
Lorna Cullen
Historic (No Identified Response)
2014-0105 11 Mar 2014 Mid Kent & Medway
NHS Medway Clinical Commissioning Group NHS Swale Clinical Commissioning Group
Concerns summary (AI summary) The coroner raised concerns about long-term liaison psychiatry nurse staffing levels covering hospital emergency departments, after evidence indicated patients needing mental health assessments were regularly waiting in excess of 2 hours due to staffing shortages.
Christopher Shapley
Historic (No Identified Response)
2014-0121 11 Mar 2014 Cardiff & the Vale of Glamorgan
HM Prison Cardiff Home Office
Concerns summary (AI summary) Critical medical and self-harm risk information from police custody failed to transfer securely to the prison via the PER form, leading to inadequate assessment and observation of the prisoner.