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
Geraldine Kilborn
All Responded
2014-0532 10 Dec 2014 County Durham & Darlington
Care UK National Offender Management Service Tees Esk Wear Valley NHS Foundation Tru…
Concerns summary (AI summary) There was a clear breakdown in mental health information sharing within ACCT reviews, where mental health input was not sufficiently weighted and members often relied on potentially misleading face-to-face assessments without reviewing documentation.
Action Planned (AI summary) An amended arrangement has been put in place to facilitate the presence of a member of the mental health team at ACCT reviews that take place at the weekend. Effective mental health input is now ensured in all cases in which a prisoner has mental health issues. Briefing sessions have been introduced to facilitate the sharing of information between prison staff and the mental health team. From April 2015 the health service delivery model will change from a Prime Provider model to a 7 Lot commissioning model. Daily reviews will be undertaken by a member of the mental health team, as on any patient allocated for, Healthcare with mental health issues: In addition all complex ACCT cases will be discussed at morning handover to increase staff awareness. A registered nurse with previous knowledge of the patient will be in attendance at an ACCT review. TEWV has already made changes to the availability of Mental Health Team staff over the weekend. Staff are on duty between 9.30 am - 1230pm Saturday and Sunday, with a priority role to ensure that the relevant ACCT reviews are attended and that those women in crisis are offered support. Staff were reminded to read all the relevant information in the ACCT document and on System One notes.
Garry Gilbey
All Responded
2014-0533 10 Dec 2014 Portsmouth & South East Hampshire
Department of Health and Social Care Ministry of Justice
Concerns summary (AI summary) The prison lacked a clear policy for calling ambulances or defining medical emergencies, leading to inadequate staff training for night-time assessments and inconsistent recording of critical healthcare information.
Noted (AI summary) The Department of Health provides context regarding healthcare contracts for prisons being performance managed by NHS England's Area Teams, and refers to DH and NOMS guidance issued in 2011 regarding emergency access for ambulance services. They note that the Ministry of Justice will address prison-related issues such as training for non-medical prison staff. Since the death, Prison Service Instruction 2013/03 Emergency Response Codes has been issued, reminding staff who can call a medical emergency and providing guidance on the use of medical emergency codes. Also, the new specifications for prison healthcare services have a contractual requirement for the management of appointments and referrals, including automatic referrals to secondary care services for those who Did Not Attend (DNA).
Paul Hyde
Partially Responded
2014-0527 5 Dec 2014 Brighton & Hove
Brighton and Hove City Council Community Governance Sussex Partnership Trust
Concerns summary (AI summary) Concerns arose regarding the effectiveness and timeliness of the mental health referral pathway for a patient with a deteriorating condition, despite anxieties being raised by community mental health workers.
Action Taken (AI summary) The trust recruited an additional administrator to the Triage team. GPs have been allocated named Consultant Psychiatrists and meetings have been arranged. Mr. Hyde's experience has been shared (anonymously) with staff and included in the Trust's Quarterly Quality & Patient Safety Report.
Peter Mackie
All Responded
2014-0528 5 Dec 2014 Buckinghamshire
Springhill Prison
Concerns summary (AI summary) Inadequate numbers of first aiders and healthcare staff were available across prison sites, compounded by a lack of clear guidance for staff on when and how to commence CPR.
Action Planned (AI summary) HMP Grendon and Springhill are working to increase the number of trained first aid staff, a new risk assessment will be completed to ensure appropriate levels of staff are identified to provide 24 hour cover and staff will receive written advice on when to commence CPR by 31 January 2015.
Elaine Giles
Historic (No Identified Response)
2014-0529 5 Dec 2014 South Lincolnshire
Peterborough and Stamford NHS Trust
Concerns summary (AI summary) An inaccurate pre-discharge assessment of a patient's functional ability, particularly with stairs, highlighted the need for more detailed home environment assessment and ensured adequate post-discharge support.
Jade Anderson
All Responded
2014-0530 5 Dec 2014
Department for Environment Food and Rur…
Concerns summary (AI summary) Concerns relate to inadequate dog management practices in a confined living space and fragmented, ineffective legislation on dog control that focuses on breed over behavior rather than public safety.
Action Taken (AI summary) The government extended the Dangerous Dogs Act 1991 to cover all places, including the owner's property, and increased penalties for fatal and non-fatal attacks. Compulsory microchipping of dogs will be introduced in April 2016.
James Stewart
All Responded
2014-0526 4 Dec 2014 Bedfordshire & Luton
Bedfordshire Clinical Commissioning Gro…
Concerns summary (AI summary) There was no system for new GP practices to verify medication with previous providers for nursing home patients, leading to prescribing errors and reliance on unqualified staff for medication initiation.
Action Planned (AI summary) The CCG developed a protocol for reconciliation of medications when people are transferred into care homes and are registered with a new GP. An action plan has been written to drive this work forward and progress will be monitored by their Patient Safety and Quality Committee.
Joanne Nobbs
All Responded
2014-0560 4 Dec 2014 Norfolk
Norfolk and Suffolk NHS Foundation Trust
Concerns summary (AI summary) A correlation between the deceased's deteriorating physical and mental health was noted but not investigated, and a care plan was not revised despite the deceased no longer engaging with mental health services.
1 response from Norfolk and suffolk NHS Trust
Sandra Danks
Partially Responded
2014-0525 3 Dec 2014 Teesside
British Oxygen Philips Respironics
Concerns summary (AI summary) An electricity supply interruption to the main oxygen apparatus stopped oxygen provision, as there was no backup system in place to continue oxygen delivery.
Noted (AI summary) BOC states they followed all procedures and contractual obligations, and all equipment was in working order. They see no reason to take further action but will monitor procedures.
Moses McDonald
Partially Responded
2014-0524 2 Dec 2014 London (Inner South)
Russell-Cooke solicitors South London and Maudsley NHS Foundatio…
Concerns summary (AI summary) The Clozapine clinic failed to conduct mandatory and regular glucose testing for patients receiving antipsychotic medication, posing a significant safety concern.
Action Taken (AI summary) The Trust updated its physical healthcare policy to outline the responsibility of clinical staff to address patient's physical health needs and made it mandatory that all patients prescribed anti-psychotic medication should have a physical health check. The Trust will conduct a full review of the Clozapine clinics across the 4 boroughs within the next 6 months.
Anthony Williams
All Responded
2014-0523 2 Dec 2014 North Wales (East & Central)
Betsi Cadwaladr University Health Board
Concerns summary (AI summary) Staff lacked clear guidance on psychiatric assessment pathways for 'exceptional cases', medical records were inaccessible out-of-hours, and there was insufficient engagement with family/carers on care plans.
Action Taken (AI summary) The health board now has a larger number of psychiatric nurses present on the Heddfan Adult Unit out of hours so socially anxious patients could be assessed at the Unit. The adoption of an electronic case record is currently being explored.
David Greenfield
All Responded
2014-0518 27 Nov 2014 County Durham & Darlington
Priory Group Ltd
Concerns summary (AI summary) Staff lacked expertise in managing co-occurring drug and alcohol problems, internal reviews overlooked external research, and admission procedures for alcohol detox patients omitted drug screening, hindering proper risk assessment.
Action Taken (AI summary) The Priory Group audited the competencies of medical staff in specialist wards and provided additional training where needed. They are ensuring a full baseline physical health assessment is in place at the point of admission. They reviewed practices and will ensure that all hospitals have access to urine drug screening kits and that staff are aware that a test should be undertaken if there is any indication that the patient may be at risk of using illicit drugs.
Stephen Morris
Partially Responded
2014-0522 27 Nov 2014 Blackpool & Fylde
Cheshire and Wirral Partnership NHS Fou… Lancashire Care NHS Foundation Trust
Concerns summary (AI summary) Inadequate information exchange between mental health services when a patient moved areas led to a lack of detailed, up-to-date patient history, compromising risk assessment and response.
Disputed (AI summary) The MDU is responding on behalf of a member, arguing that the coroner's report was not based on clear evidence and that the doctor's actions were reasonable in the circumstances.
Freda Owens
Historic (No Identified Response)
2014-0559 27 Nov 2014 Blackpool & Fylde
Blackpool Teaching Hospital NHS Foundat… Croft House Rest Home Lancashire Teaching Hospitals NHS Found…
Concerns summary (AI summary) There was a significant breakdown in information gathering and exchange between medical professionals, leading to incorrect assumptions about patient injuries, delayed specialist involvement, and suboptimal care.
Anthony Huggan
All Responded
2014-0517 26 Nov 2014 Manchester (North)
Bury Metropolitan Borough Council
Concerns summary (AI summary) The lack of a suitable out-of-hours service for drug addiction placed an undue burden on emergency services, with insufficient timely follow-up for patients who self-discharged after overdoses.
Noted (AI summary) The council provides contextual information about commissioned substance misuse services and describes the services available, but does not outline specific changes in response to the concerns.
Amanda Hawkins
Partially Responded
2014-0516 26 Nov 2014 Staffordshire (South)
Walsall and Dudley Mental Health NHS Tr… West Midlands Police
Concerns summary (AI summary) Patient vulnerability was exacerbated by service changes and failures in coordinating care, including sending critical appointment letters directly to a patient unable to understand them, and a lack of follow-up on missed appointments.
Action Planned (AI summary) The Trust will ensure outpatient letters from CRS North medical teams are copied to the care coordinator. A working group led by the Head of Recovery Services is looking at long-term solutions.
Marjorie Ellery
All Responded
2014-0519 26 Nov 2014 Surrey
Frimley Park Hospital
Concerns summary (AI summary) Medication was administered to a patient with a known allergy without appropriate senior medical advice, and the consent obtained for this treatment was not informed consent.
Action Taken (AI summary) The Trust now requires registrar or higher authorisation and documented discussion with the patient for medication prescriptions when allergies are known. A new policy on allergy management is being developed and training for nursing staff has been reviewed to include the management of allergies.
Stephen Mayoll
All Responded
2014-0515 25 Nov 2014 Portsmouth & South East Hampshire
Portsmouth Hospitals NHS Trust
Concerns summary (AI summary) The hospital failed to re-assess out-patients for DVT risk according to policy and experienced delays in making fracture clinic notes available, risking patient safety.
Action Planned (AI summary) Patients returning to the fracture clinic with lower limb injuries will have a reassessment of their VTE risk factors. A scanner has been ordered to digitally save and record reviews by plaster technicians.
Michael Harman
All Responded
2014-0514 25 Nov 2014 Norfolk
Centra Support
Concerns summary (AI summary) Inadequate checks were made on Mr. Harman's personal hygiene, and clear indicators of his deteriorating condition, unsuitable for independent living, were not adequately addressed or reviewed.
Action Taken (AI summary) Centra Support conducted a full internal review of working practices and welfare checks. They drew up and rolled out local guidance protocols for reporting incidents, following up with service users after incidents, and making referrals.
Richard Turner
Historic (No Identified Response)
2014-0513 25 Nov 2014 Norfolk
FALCON CRANE HIRE LIMITED
Concerns summary (AI summary) Employees developed complacency regarding health and safety due to routine work, exacerbated by a lack of standard procedures to remind them of lifting plans, risks, and infrequent safety briefings.
Ryan Loughran, Katie Joyce, Muhanna Alhayany and Sophie Ryan-Palmer
All Responded
2014-0520 25 Nov 2014 London Inner (North)
NHS England
Concerns summary (AI summary) Deficient governance and lack of a national lead for autologous stem cell transplants, coupled with absent national benchmarking data and inaccessible international trial results, hinder optimal patient care.
Action Planned (AI summary) NHS England is reviewing service specifications, establishing a national expert group for oncology, enhancing reporting to the BSBMT registry, and commissioning its quality surveillance team to assure changes in governance.
Gaenor Moore
All Responded
2014-0512 24 Nov 2014 Surrey
Dolby Vivisol Invacare Rehabilitation Salter Labs
Concerns summary (AI summary) Oxygen flow was lost due to an improperly engaged humidifier screw cap, exacerbated by the absence of an alarm on the concentrator and insufficient training regarding equipment setup.
Action Planned (AI summary) Dolby Vivisol is liaising with Salter Labs and Invacare to update product instructions regarding humidifier cap engagement, and will update their own training materials and patient instructions accordingly. Proposed amendments will be sent to NHS contract managers for approval. Salter Labs has offered to review Dolby Vivisol's updated literature and will ensure it includes reference to the safety valve. They are waiting for the humidifier to be returned for examination and will provide an updated Vigilance Report to the MHRA. Invacare will update manuals provided to customers with concentrator units to include enhanced guidance on humidifier cap installation, with wording similar to confirming the cap is not cross-threaded. This update will be phased into all manuals within several months, with a technical update sent to customers in Europe.
William Hafele
All Responded
2014-0511 24 Nov 2014 Surrey
Surrey and Borders Partnership NHS Foun… Surrey Police
Concerns summary (AI summary) Inadequate training and communication between police and hospital staff on missing persons procedures led to critical information omissions, misclassification, and a complete failure to investigate Mr. Hafele's whereabouts.
Action Planned (AI summary) Surrey Police are reviewing and updating their Missing Person Policy to align with new ACPO guidelines, including clarifying risk assessment processes and responsibilities, and making information available on officers' MDTs. The TPT briefing training will be modified to ensure consistency with the Surrey Police Missing Person Procedure definition of 'Absent'. The Trust has emphasized the importance of the Missing Persons (MISPER) process and instructed staff to complete Appendix A. A member of the Clinical Assurance team is assigned to ensure compliance with the MISPER agreement.
William Jackson
All Responded
2014-0509 24 Nov 2014 Cumbria (North & West)
Newcastle Foundation NHS Trust
Concerns summary (AI summary) The hospital lacked a formal system to record specialist advice given during informal interactions, leading to critical advice being given without reviewing patient images, which risks lives.
Action Taken (AI summary) An electronic system is now in place within Cardiothoracic Surgery to record details of advice given when medical opinion is sought by a healthcare professional in another hospital.
Lara Mamula
Historic (No Identified Response)
2014-0508 24 Nov 2014 Isle of Wight
Isle of Wight Ambulance Service Isle of Wight NHS Trust
Concerns summary (AI summary) The ambulance service lacked critical understanding of Loeys-Dietz syndrome, failing to appreciate the severity of symptoms or stress the urgency of hospital transfer for a definitive diagnosis.