2014
PFD Reports
Reports: 557
Areas: 71
55% response rate (below 63% average).
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. 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. 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.
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.
Harold Penny
All Responded
2014-0507
24 Nov 2014
Manchester (South)
Tameside Hospital NHS Foundation Trust
Concerns summary (AI summary)
The radiology department lacked a system to urgently report critical findings, such as a displaced urinary catheter causing a blockage, or to rectify such issues themselves.
Action Planned
(AI summary)
The Trust is developing a 'Radiology Requesting and Reporting Policy' and has established a Results Governance Steering Group to improve patient safety related to radiology. The response details responsibilities for radiologists and consultants, including communication of critical findings.
Tracey Bannister
All Responded
2014-0506
21 Nov 2014
Black Country
Walsall Healthcare NHS Trust
Concerns summary (AI summary)
Patients discharged after ERCP surgery were not adequately advised to contact the surgical department directly for persistent symptoms, leading to delayed critical care.
Action Taken
(AI summary)
Walsall Healthcare NHS Trust revised the ERCP discharge leaflet to include clear instructions for patients to contact the department where surgery was performed if symptoms of pain or raised temperature continue for more than 24 hours. The revised leaflet has been approved by the Endoscopy Steering Group, shared with all staff, and is now in use.
Peter Dorney
All Responded
2014-0504
17 Nov 2014
Avon
Southmead Hospital
Concerns summary (AI summary)
Nurses lacked mandatory training on Early Warning Scores (EWS), resulting in non-adherence to protocols critical for patient well-being and timely intervention.
Action Taken
(AI summary)
North Bristol NHS Trust clarified that all new nurses receive mandatory Early Warning Score (EWS) training on induction and that 93% of all nurses have received EWS training. The directorate has reviewed which individuals have not received training, and measures are being put in place for those individuals to receive the training within the next 3 months.
Elsie Mallalieu
All Responded
2014-0501
17 Nov 2014
Manchester (South)
Tameside NHS Foundation Trust
Concerns summary (AI summary)
Inappropriate ward placement with untrained staff and inadequate nursing notes led to missed observations and an incorrect DNAR decision, hindering escalation for treatable infection.
Action Taken
(AI summary)
Tameside Hospital NHS Trust provided training to doctors in the Orthopaedic Department regarding patient transfer protocols and the involvement of senior medical staff. The training also forms part of the induction process for junior doctors, and the Trust's report was shared with the coroner's office previously.
Marcus Szigetvari
All Responded
2014-0503
14 Nov 2014
Powys, Bridgend & Glamorgan Valleys
Rhondda Cyon Taff Highways Department
Concerns summary (AI summary)
The busy road during rush hour presented a high risk of drivers misjudging motorcycle headlights for distant cars, especially in poor conditions, contributing to a history of multiple collisions and fatalities.
Disputed
(AI summary)
The Council argues that the junction complies with modern design standards and the layout was not a contributory factor in the collision. They state that poor weather conditions, the speed of the motorcyclist, and the actions of the driver pulling out of the junction all played a part in the collision, and therefore propose no further action.
Dolores Hubbert
All Responded
2014-0500
14 Nov 2014
Sunderland
Sunderland City Council
Concerns summary (AI summary)
Concerns were raised about the overall safety of a junction, specifically regarding speed restrictions and the frequency of grass cutting which could obscure driver visibility.
Action Planned
(AI summary)
The Council will undertake an assessment of possible measures for the A690/Durham Road, East Rainton junction in 2015. It intends to commence the statutory process to reduce the speed limit to 50mph on this section of road in January 2015, with the speed reduction potentially introduced in summer 2015.
Rowena Golton
All Responded
2014-0486
11 Nov 2014
Manchester (South)
Manchester Clinical Commissioning Group
Manchester Mental Health and Social Car…
Concerns summary (AI summary)
Critical shortages and significant waiting times for psychological services within crisis teams hinder adequate provision and timely access for vulnerable patients.
Action Planned
(AI summary)
The CCGs are working with colleagues to review service provision across all services and develop care pathways for service users. An external review of psychological therapies (IAPT) has been completed and commissioners and providers are working together to implement the recommendations.
Roseanne Cooke
All Responded
2014-0485
10 Nov 2014
Manchester (South)
5 Boroughs Partnership NHS Foundation T…
Concerns summary (AI summary)
Lack of inpatient psychological support, delayed/confused referrals, and critical communication breakdowns between family and care teams resulted in inadequate post-discharge support for a vulnerable patient.
Action Taken
(AI summary)
The Trust has looked into the concerns raised and has put an action plan in place after a period of no psychological input on the Grasmere Unit due to maternity leave, despite a patient's need. Actions include: All referrals to be written on specific form and recorded on electronic system, the manager to ensure annual leave handover forms are discussed within team meetings, and operation of an electronic patient record.
Santosh Muthiah
All Responded
2014-0476
5 Nov 2014
London (North)
Association of British Insurers
Association of Manufacturers Of Domesti…
Beko Plc
+9 more
Concerns summary (AI summary)
The inability to identify appliance details after severe fire damage hinders accurate defect pattern recognition, and inconsistent information sharing among Fire & Rescue Services impedes product safety investigations.
Noted
(AI summary)
BSI Committees CPL/61 and PEL/33 reviewed the points raised and are submitting a proposal to the International Committee to add a warning about supply cords and portable socket-outlets to relevant appliances, and a new test for non-metallic material covering thermal insulation. AMDEA's Technical Manager on Refrigeration together with industry safety specialists prepared a basic proposal for change to the international standard IEC 60335-2-24. This proposal was placed before the BSI committee CPL61 and was accepted as a UK proposal for change at international level in 2014; the UK proposal was accepted by the International Electrotechnical Commission (IEC) meeting in Tokyo. The Society explains its role as a professional body for forensic science practitioners, noting that their reports are usually delivered directly to those who engaged them and may be sensitive or confidential. They state that forensic scientists are rarely involved in fire investigations unless they are serious, unexplained or suspicious, and that the fire service and/or police usually investigate. CFOA will engage proactively with DCLG to help develop the future IRS and the ease by which this type of information can be gathered, accessed and disseminated. CFOA will provide guidance to FRS by April 2015 to help ensure that the information provided on IRS is as accurate and meaningful as is possible to facilitate the ease by which DCLG could provide it to TS and manufacturers if they decided to do so. BIS will consider consistency of guidance and sharing of best practice as part of the independent review of consumer product recalls. The potential for a Code of Practice will also be considered as part of the independent review. BIS will continue to support AMDEA's Register my Appliance site.
William Davies
All Responded
2014-0475
5 Nov 2014
London Inner (North)
Care UK Limited
Concerns summary (AI summary)
Significant confusion exists among prison staff, including GPs, regarding emergency ambulance procedures and death verification, leading to inappropriate actions and potential fatal delays.
Action Taken
(AI summary)
Care UK has re-briefed control room staff, created a crib sheet for ambulance calls, launched a publicity campaign on emergency response codes, and improved intranet information and signage. The National Medical Director clarified GPs' responsibilities regarding verifying death, and guidance/training is being developed to support decision-making in unexpected collapse or death cases.
Mark Hudson
All Responded
2014-0478
4 Nov 2014
Blackpool & Fylde
Blackpool Teaching Hospitals NHS Trust
Concerns summary (AI summary)
Hospital procedures for urgent specialist care requests through the switchboard are insufficiently robust, risking unanswered or delayed responses that could harm patients.
Action Taken
(AI summary)
The Trust has undertaken training with senior members of the CICU Team, who are now competent in the placement of iGel tubes. A policy of using end tidal carbon monoxide monitoring for all intubated patients has been adopted. A review of the Out of Hours Anaesthetic Service was commissioned from the Royal College of Anaesthetists.
Sandra Higham
All Responded
2014-0479
3 Nov 2014
London (Inner South)
Department of Health and Social Care
Public Health England
The Heart Rhythm Society of the United …
Concerns summary (AI summary)
A highly fatal complication of atrial ablation, atrial-oesophageal fistula, is difficult to diagnose due to non-specific symptoms and low medical awareness within the wider profession.
Noted
(AI summary)
BHRS will include an article on avoidance and recognition of atrio-oespohageal fistula in its winter newsletter and remind members to ensure this complication is recorded in the national cardiac rhythm management database. BHRS will work with the AF Association and A-A to re-design the information relating to complications of AF ablation to include information on recognition of symptoms and a leaflet will be developed by the end of March 2015. Public Health England states that the case is not something they can directly assist with, but understand that the Department of Health will contact appropriate bodies. The Department of Health contacted the BCS who are considering circulating a letter to relevant surgeons. A copy of the coroner's letter and the response from the Department of Health will be sent to the BCS and the RCS.
Maureen Ellett
All Responded
2014-0473
31 Oct 2014
Brighton and Hove
Brighton and Sussex University Hospital…
Royal Sussex County Hospital
Concerns summary (AI summary)
Initial A&E documentation was flawed, with critical patient information like blood pressure and Glasgow Coma Scale omitted from the front sheet.
Action Taken
(AI summary)
Agreement has been reached with SECAMB that they will start calculating National Early Warning Scores (NEWS) and the triage nurse will note this when the patient arrives. The Trust is continuing to educate staff about avoiding the term 'Acopia'. Individual named emergency consultants have recently been given responsibility for each of the Short Ward and Clinical Decisions Unit.
Christopher Ajayi
All Responded
2014-0558-wp26761
31 Oct 2014
London (Inner South)
South London and Maudsley trust
Concerns summary (AI summary)
A vulnerable patient with complex mental and physical health needs was discharged into unsupported accommodation without a care package or necessary medical oversight, highlighting severe failures in discharge planning and care coordination.
1 response
from South London and Maudsley NHS Trust
Polly Carpenter
All Responded
2014-0469
28 Oct 2014
Exeter & Great Devon
Devon Partnership NHS Trust
Concerns summary (AI summary)
The hospital lacked clear, auditable records for patient risk assessments and observation levels on RIO, leading to staff being unaware of risks and hindering accountability. The "Named Nurse system" was also unclear.
Action Taken
(AI summary)
Level 2 observation forms are stored for two years, and uploaded if an incident occurs. Level 3 observation levels are entered straight on to the RiO progress notes. Revised documentation including space for comments has been developed and implemented, with guidance issued on expected content. Local training and supervision is in place to support the implementation of these changes.
Agnes Hannan
All Responded
2014-0573
27 Oct 2014
Manchester (South)
Tameside Hospital NHS Foundation Trust
Concerns summary (AI summary)
Critical issues included unavailable hospital records, poor staff communication and handover, inadequate nursing observations, and a lack of consultant oversight. Delays in CT scanning and end-of-life discussions were also noted.
Action Taken
(AI summary)
The hospital replaced its computer system for medical records, is purchasing a scanner for the A&E department to improve record accessibility, and has reviewed and updated its DNACPR policy, emphasizing discussions with patients and families; this includes a DVD available on the intranet and promoted via screensavers.
Philip Allen
All Responded
2014-0466
27 Oct 2014
London (Inner South)
Eltham Palace Surgery
Concerns summary (AI summary)
The GP surgery's repeat prescription system failed to prevent the continued prescribing of a medication after a specialist advised stopping it, indicating a risk of medication errors.
Action Taken
(AI summary)
The practice conducts twice-weekly ward rounds and medication reviews every 3 months by a prescribing advisor and twice a year by the attending clinician, using electronic prescriptions. They have repeatedly requested an N3 line for direct access to patient records and have purchased laptops for some record access.
Phyllis Kerry
All Responded
2014-0457
23 Oct 2014
Nottinghamshire
Nottingham University Hospitals NHS Tru…
Concerns summary (AI summary)
There is a lack of clear, communicated guidelines for managing patients with intra-cerebral bleeds while on Warfarin, leading to uncertainty about clinical responsibility and treatment protocols.
Action Planned
(AI summary)
A new guideline has been prepared to improve the management of anticoagulation in patients with intracerebral hemorrhage, clarifying specialty responsibilities. The specialties involved are currently consulting with colleagues to finalize the guideline, and it will be added to the NUH guideline app. A new guideline for treating warfarin patients with intracranial hemorrhage has been agreed and will be communicated to medical staff and included in specialty inductions. The guideline group will also consider including it in the NUH guideline app.
Mary Stroman
All Responded
2014-0454
21 Oct 2014
Wiltshire & Swindon
Haringey Council
Concerns summary (AI summary)
A child's recommended long-term therapeutic placement was delayed and ultimately overturned by Children's Services, despite multi-agency support, due to a perceived failure to meet statutory accommodation thresholds.
Action Taken
(AI summary)
Haringey Council reports strengthened management oversight of decision-making, improved joint working with partner agencies, and revised processes for funding long-term therapeutic placements. Placements are now only made in establishments graded 'good' or 'outstanding' by Ofsted, with risk assessments conducted if the grade changes.
Samuel Duckworth
All Responded
2014-0456
20 Oct 2014
London (Inner South)
Department of Health and Social Care
Concerns summary (AI summary)
The ease of purchasing prescription-only drugs like Diazepam via the internet without medical supervision creates an ongoing risk for vulnerable individuals.
Noted
(AI summary)
The Home Office acknowledges concerns about the supply of prescription-only medicines online, noting ongoing work with law enforcement and internet providers to close illegal websites. They highlight international collaboration and monitoring efforts but describe no new actions.
Kirsty Pritchard
All Responded
2014-0565
17 Oct 2014
Black Country
Black Country NHS Partnership Trust
Concerns summary (AI summary)
There were communication failures between community and inpatient teams regarding the patient's post-discharge contacts, delaying self-harm risk assessment. Deficiencies also existed in systems for locating the patient during crises.
Action Planned
(AI summary)
A protocol has been developed to ensure that if telephone contact cannot be established with a service user assessed to be in immediate risk of harm or death within 30 minutes, the CHTT are to carry out a cold call of the service user’s home address/ last known location within 1 hour, and if they still cannot gain access or locate the service user they are to contact the police to conduct a ‘safe and well’ check.