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
Craig Marren
All Responded
2014-0106 10 Mar 2014 West Yorkshire (East)
Tyersal Farm
Concerns summary (AI summary) Trees and foliage at a blind left-hand bend significantly impede driver visibility, creating a dangerous road hazard that requires cutting back.
Action Taken (AI summary) City of Bradford Council confirms that an order has been raised for a hedge to be flailed back to clear the highway obstruction.
Derrick Rivers
Historic (No Identified Response)
2014-0104 10 Mar 2014 Manchester (North)
Care Quality Commission Passmonds Care Home Rochdale Metropolitan Borough Council
Concerns summary (AI summary) The care home had an inadequate, unspecific drugs administration protocol and lacked audit processes, with management unaware of non-compliance. Regulatory bodies also failed to identify these critical issues during inspections.
Natasha Raghoo
Partially Responded
2014-0100 6 Mar 2014 West Sussex
Partnerships in Care South London and Maudsley NHS Foundatio…
Concerns summary (AI summary) The coroner identified concerns regarding staff training in cardiopulmonary resuscitation and defibrillator use, sporadic physical observations, the lack of routine ECGs for patients on antipsychotics with raised blood pressure, inconsistent communication during staff handovers, and unclear policies on family involvement in care planning.
Action Taken (AI summary) Partnership in Care reports improvements in information flow between PiC and SLaM, including a Liaison Nurse attending The Dene from SLaM several days a week utilizing a VPN link. PiC has also reviewed, revised and reissued its observation policy and handover protocols and are being regularly audited and spot checks are carried out.
Neil Carter
All Responded
2014-0103 5 Mar 2014 London (West)
Care Quality Commission Priory Group
Concerns summary (AI summary) There were repeated failures in basic nursing observations, chronic inadequate staffing and skill mix, and deliberate falsification of nursing records, compounded by management's failure to address reported issues.
Action Planned (AI summary) The CQC will include information held on deaths in psychiatric detention in all future annual reports. They will also work with partners in developing the Mental Health Crisis Care Concordat and deliver a thematic programme around the experiences and outcomes of people experiencing a mental health crisis, with a national report expected in the autumn of 2014. The organisation disciplined and dismissed a nurse for falsifying records and referred them to the NMC. They have also implemented changes to the staff induction programme and introduced daily monitoring visits, 'flash' meetings and monthly staff meetings to improve communication and patient care.
Stephen Ellis
Historic (No Identified Response)
2014-0102 5 Mar 2014 Manchester (South)
Department of Health and Social Care
Concerns summary (AI summary) A lack of warfarin home management kits for high-risk post-heart surgery patients leads to reliance on less efficient hospital monitoring.
Nellie Travis
Historic (No Identified Response)
2014-0101 5 Mar 2014 Manchester (South)
Tameside Hospital NHS Foundation Trust
Concerns summary (AI summary) The hospital's Falls Risk Assessment tool is ineffective due to its subjective nature and inconsistent application by nursing staff, highlighting the need for a more objective assessment method.
Barry Dillion
Historic (No Identified Response)
2014-0099 5 Mar 2014 Blackburn, Hyndburn & Ribble Valley
East Lancashire Healthcare NHS Trust
Concerns summary (AI summary) Insufficient resources are available to provide a comprehensive Speech and Language Therapy service at the hospital, potentially impacting patient care.
John Fox
Historic (No Identified Response)
2014-0098 5 Mar 2014 : London Inner (West)
St George’s Hospital
Concerns summary (AI summary) Reduced physiotherapy services on bank holidays and weekends increase the risk of post-operative complications for vulnerable patients.
Ryan Pettengell
Historic (No Identified Response)
2014-0096 4 Mar 2014 Norfolk
Borough Council of King’s Lynn & West N… Norfolk County Council Norfolk Police +1 more
Concerns summary (AI summary) Despite official closure and prior safety recommendations following multiple drownings, the site remains accessible to the public with damaged/missing signage and no implemented safety improvements.
Kathleen Border
All Responded
2014-0095 4 Mar 2014 Portsmouth & South East Hampshire
Northwood Square
Concerns summary (AI summary) Inadequate and unclear signage for parking areas led to a delivery vehicle reversing outside a designated zone, causing a fatal collision.
Action Taken (AI summary) Hanover has installed an extra sign to alert drivers to pedestrians and will remind residents and visitors to take care when walking behind parked vehicles via the estate newsletter.
Anne-Marie Katherine Ellement
Historic (No Identified Response)
2014-0181 4 Mar 2014 Wiltshire & Swindon
Armed Forces Minister Provost Marshall (Army)
Concerns summary (AI summary) The Armed Forces' victim support code lacks specific provision for serious sexual assault victims within the military, and staff managing suicide vulnerability risk assessments receive insufficient training and follow-up.
Lee MacPherson
Historic (No Identified Response)
2014-0097 3 Mar 2014 London (West)
HMP Wormwood Scrubs Metropolitan Police National Offender Management Service +1 more
Concerns summary (AI summary) Delayed police risk assessments and a lack of common understanding between escort and prison staff regarding critical handover documentation posed significant safety risks during transfers.
Marco Lima De Araujo
All Responded
2014-0093 3 Mar 2014 Portsmouth & South East Hampshire
Queen’s Harbour Master Portsmouth
Concerns summary (AI summary) There is no formal protocol for reporting and coordinating rescue efforts during life-threatening incidents in Portsmouth Harbour.
Noted (AI summary) The Maritime Coastguard Agency outlines its existing protocols for maritime search and rescue, including communication and cooperation with the Queen's Harbour Master Portsmouth and participation in the SOLFIRE multi-agency response group.
Carl Morris
All Responded
2014-0092 3 Mar 2014 Cumbria (North & West)
Professional Association of Diving Inst…
Action Planned (AI summary) PADI will include an additional statement in the 'Learning Agreement' to further enforce the issue of medical illness to both the Instructor and student diver with regards to doctor's approval and medical fitness. This will be notified to instructors via quarterly training bulletins.
Margaret Easterfield
Historic (No Identified Response)
2014-0091 3 Mar 2014 Kent (South East & Central)
East Kent University Hospital
Concerns summary (AI summary) A rare anastomotic leak following surgery, leading to the patient's death, raises concerns about a potential technical error by the surgeon.
Kirabo Kiwanuka
Historic (No Identified Response)
2014-0088 3 Mar 2014 London (Inner South)
Royal College of Physicians Royal College of Psychiatrists
Concerns summary (AI summary) Significant disagreement among medical professionals on Neuroleptic Malignant Syndrome diagnosis and management, leading to unclear optimal care pathways and limited family involvement for sectioned patients with acute medical issues.
Kevin Pearson
Historic (No Identified Response)
2014-0086 3 Mar 2014 North Lincolnshire & Grimsby
John Somerscales Ltd
Concerns summary (AI summary) The company potentially failed to ensure full compliance with health and safety guidance for drivers and verify their understanding of critical instructions for specialized activities.
Richard White
All Responded
2014-0085 28 Feb 2014 County Durham & Darlington
700 Club
Concerns summary (AI summary) Hope House lacked a formal, documented policy or protocol for medication administration, which was unknown to prescribers and not made available to staff.
Noted (AI summary) The 700 Club clarifies that it does not store or administer medication to clients, emphasizing that responsibility for safeguarding clients regarding medication lies with GPs. They will receive medication if handed to them, but will not return it without GP authorisation.
Peter Norman Nott
All Responded
2014-0229 28 Feb 2014 Oxfordshire
Rush Court Nursing Home
Concerns summary (AI summary) Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks despite prolonged immobility and clear deterioration.
Action Taken (AI summary) Rush Court care home has reviewed its policies and procedures when dealing with a resident who has experienced an unwitnessed fall. Neurological observations will commence using the Glasgow Coma Scale and be incorporated into resident care plans; only a registered nurse or person in charge can handover clinical information to paramedics.
Nathan Douthwaite
Partially Responded
2014-0084 28 Feb 2014 County Durham & Darlington
County Durham and Darlington NHS Trust Department of Health and Social Care National Institute for Health and Care …
Concerns summary (AI summary) A rectal biopsy would likely have diagnosed Hirschsprung's disease, highlighting concerns about current diagnostic guidelines and the trust's practices in this regard.
Noted (AI summary) The Department of Health acknowledges the coroner's concerns but states that NICE has the statutory function of producing clinical guidelines. NHS England will disseminate the case to NHS learning networks to minimise recurrence.
Victoria Meppen-Walter
Historic (No Identified Response)
2014-0083 27 Feb 2014 Manchester (North)
Department of Health and Social Care Medicines and Healthcare Products Regul…
Concerns summary (AI summary) Concerns were raised regarding the easy online availability and regulation of chloroquine, along with the associated risks of its misuse.
Malcolm Potter
Historic (No Identified Response)
2014-0082 27 Feb 2014 Cambridgeshire (South & West)
Network Rail
Concerns summary (AI summary) The pedestrian crossing's warning light system is inadequately positioned and not synchronized for multiple trains, creating a significant re-crossing risk on a busy commuter line.
Maureen Leaver
Historic (No Identified Response)
2014-0036 27 Feb 2014 West Sussex
Sussex Partnership NHS Foundation Trust
Concerns summary (AI summary) Inadequate medical supervision and ineffective systems for investigating acutely ill elderly patients in a psychiatric ward were identified, alongside a lack of understanding of legal duties for patient transfers.
Sean Cunningham
Historic (No Identified Response)
2014-0087 26 Feb 2014 Lincolnshire (Central)
Martin-Baker the MOD
Concerns summary (AI summary) A persistent design flaw in ejection seats allows strap misrouting, posing a significant risk, and manufacturers lack a robust system for urgently disseminating safety-critical information.
Herta Woods
Historic (No Identified Response)
2014-0081 26 Feb 2014 Brighton & Hove
Brighton and Sussex University Hospitals
Concerns summary (AI summary) Multiple failures in patient care included apparent abandonment, poor documentation, lack of senior review, incorrect fluid management leading to overload, and inappropriate cannulation, all contributing to the patient's death.