2014
PFD Reports
Reports: 557
Areas: 71
55% response rate (below 63% average).
Bertram Hamilton
Historic (No Identified Response)
2014-0080
26 Feb 2014
Black Country
Nursing and Midwifery Council
Concerns summary (AI summary)
The coroner was concerned that a nurse appeared not to know that insulin should not be given to a person whose blood sugars were so low.
Hazel Polkinghorn
Historic (No Identified Response)
2014-0078
26 Feb 2014
Central Lincolnshire
Ministry of Justice
Concerns summary (AI summary)
The easy online acquisition of dangerous non-prescribed medication, like Pentobarbital, poses a significant risk of future deaths, necessitating government intervention to regulate such websites.
Samuel Shaw
All Responded
2014-0076
26 Feb 2014
North Northumberland
Highways Agency
Concerns summary (AI summary)
Pedestrians crossing a 60mph unlit trunk road from a holiday park face extreme danger due to poor visibility, lack of warning signs for drivers, and no central refuge.
Action Planned
(AI summary)
The Highways Agency has arranged for an investigation to consider options for an improved pedestrian crossing facility in the vicinity of Haggerston. The investigation will assess demand, appraise existing routes, and identify suitable locations.
Sidney Harvey
Historic (No Identified Response)
2014-0075
26 Feb 2014
South Lincolnshire
South Kesteven District Council
Concerns summary (AI summary)
Non-safety glass doors in rented properties, particularly where vulnerable individuals reside, pose a risk, and there is no clear system for their replacement or safety upgrade.
Andre Matei
All Responded
2014-0089
25 Feb 2014
London (North)
Department of Health and Social Care
Concerns summary (AI summary)
The coroner noted the lack of national guidance on the role of interpreters during labour, particularly when an interpreter is required in theatre.
Noted
(AI summary)
The Department of Health acknowledges the coroner's concerns and states that NICE guidance addresses the use of interpreters. The Department will ensure the coroner's concerns are brought to NICE's attention for future consideration.
Stephen Palmer
Historic (No Identified Response)
2014-0072
25 Feb 2014
Brighton & Hove
Brighton and Sussex University Hospitals
Concerns summary (AI summary)
Multiple failures, including delayed assessments, lack of senior review, inappropriate unit transfer, and a complete CT scanning service failure, led to critical deterioration and suboptimal surgical management.
Lee Curran
Historic (No Identified Response)
2014-0079
25 Feb 2014
Manchester (West)
Department of Health and Social Care
HMP-YOI Forrest Bank
Ministry of Justice
+2 more
Concerns summary (AI summary)
PPO recommendations for high cholesterol and loss of consciousness protocols were not fully implemented, with NICE guidelines ignored by doctors. Additionally, prison staff lacked training in accurate medical note-taking, leading to incorrect entries.
Arthur Brockett-Deakins
All Responded
2014-0077
25 Feb 2014
London (Inner South)
Department of Health and Social Care
General Midwifery Council
Medicines and Health Regulatory Authori…
+1 more
Concerns summary (AI summary)
Midwives failed to timely escalate abnormal CTG results due to misapplication of guidelines and inadequate training. Concerns also arose about CTG machines potentially misinterpreting maternal heart rate as fetal heart rate.
Noted
(AI summary)
NICE is currently updating its clinical guideline on Intrapartum Care (CG55) and the progress of the update can be monitored via their website. They will consult on the draft recommendations with stakeholders between 13th May - 24th June 2014 and the final guideline will be published in October 2014. The MHRA states that the incident was not reported to them and that the CTG model was placed on the market by Philips Healthcare and sold in the UK between 1992 and 2006. They included a Safety Notice from August 2002, warning of risks associated with the interpretation of CTG traces. The Nursing and Midwifery Council (NMC) will treat the information about one of the midwives as a new referral and investigate. A local supervisory authority (LSA) would be alerted to serious incidents of this nature via their database system and there is a link to the LSA for every maternity service in London who would provide guidance to a supervisor of midwives when a serious incident occurs. The Department of Health acknowledges the coroner's concerns and notes that NICE has responded on CTG interpretation. They explain the role of statutory supervision of midwives and state the NMC is reviewing this.
Rachel Burke
Partially Responded
2014-0074
25 Feb 2014
London (Inner South)
ABTA - The Travel Association
Himalayan Encounters
Ministry of Culture, Tourism and Civil …
+3 more
Concerns summary (AI summary)
An adventure company misrepresented ascent altitudes, leading to unsafe rates for altitude sickness prevention. The trek leader prioritized cost over urgent medical care and failed to appreciate illness severity due to inadequate training.
Action Taken
(AI summary)
The Adventure Company has reviewed its Nepal high altitude treks against Wilderness Medical Society guidelines and implemented changes to reduce some altitude increases, to be fully implemented by the start of the new trekking season in September. They have also removed a manual that referred to finding cost effective solutions.
Kenneth Aldridge
All Responded
2014-0071
24 Feb 2014
Berkshire
West Berkshire Highways Authority
Concerns summary (AI summary)
The design of a service road access on a 70 mph dual carriageway requires dangerous manoeuvres like significant slowing or U-turns, posing a substantial highway safety risk.
Action Planned
(AI summary)
West Berkshire Council will consult with local ward members and parish councils regarding access improvements, including reducing the westbound traffic lanes and potentially blocking one service road entrance.
Mark Burgess
Historic (No Identified Response)
2014-0069
24 Feb 2014
Blackburn, Hyndburn & Ribble Valley
Highways Agency
Concerns summary (AI summary)
The M65 motorway's decommissioned lighting system meant drivers could not see debris in the unlit carriageway, directly causing multiple subsequent collisions and injuries.
James Sutton
Historic (No Identified Response)
2014-0090
24 Feb 2014
London (North)
Department of Health and Social Care
Concerns summary (AI summary)
The London Ambulance Service failed to automatically link multiple risk factors—a 5-foot fall, patient age over 50, and anti-clotting medication—to trigger an 8-minute emergency response.
Benjamin James Carroll
All Responded
2014-0068
20 Feb 2014
Gwent
Welsh Cycling
Concerns summary (AI summary)
The road remained open to traffic during a cycling race sprint towards the finish line, despite accredited marshals with powers to stop traffic being present.
Action Planned
(AI summary)
Welsh Cycling, working with British Cycling, is launching a "racesmart" awareness campaign targeting participants, event organisers, and officials to ensure the safe running of all events. The campaign will focus on safety and responsibility with direct communication, educational digital content, and a managed social media campaign.
Simon McAndrew
Historic (No Identified Response)
2014-0067
19 Feb 2014
London (North)
Central and North West London NHS Found…
Concerns summary (AI summary)
Poor communication between different NHS Trusts, particularly regarding mental health and drug misuse information, resulted in important details being missed, inappropriate referrals, and a lack of effective care coordination.
Jack Lynn
All Responded
2014-0066
18 Feb 2014
North Northumberland
Nightingale Home Help Service
Concerns summary (AI summary)
The absence of a continuous medication communication record and a safety/well-being check during a 15-minute care visit exposed the patient to potential risks.
Action Taken
(AI summary)
Nightingales Home Help Service will encourage clients to have medication charts and has advised staff to review their medication policy. They also provided a Safe Handling of Medication course for staff in October 2013 and issued a verbal warning to the employee involved in the incident.
Selina Broadhurst
Historic (No Identified Response)
2014-0065
17 Feb 2014
Manchester (South)
National Institute for Health and Care …
Concerns summary (AI summary)
Strict adherence to NICE Guidelines regarding CT head scans, which don't recommend scans without obvious neurological signs, is causing delayed or missed severe brain injury diagnoses in frail elderly patients.
Laura Hill
All Responded
2014-0064
17 Feb 2014
Manchester (South)
Stepping Hill Hospital
Concerns summary (AI summary)
Despite existing training, Falls Risk Assessments were not carried out for the patient during her entire hospital stay, including upon admission and ward transfer.
Action Taken
(AI summary)
Stockport NHS Foundation Trust has instigated an escalation process for locating equipment, to be monitored via the Datix system. The nurses involved were formally counselled, and the case was presented to ward managers at a Surgical Sisters' meeting to disseminate lessons learned.
John Davies
Historic (No Identified Response)
2014-0063
13 Feb 2014
London Inner (West)
General Medical Council
Medical Protection Society
Royal College of Physicians
Concerns summary (AI summary)
GMC investigations are causing unrecognised psychological distress in clinicians, underscoring the need for improved communication, support resources, and proactive assessment for suicidal or self-harming behaviours.
Lisa Inkin
Historic (No Identified Response)
2014-0062
13 Feb 2014
London Inner (West)
Cygnet Health Care
Kent and Medway Mental Health Directora…
NHS England
Concerns summary (AI summary)
A severe shortage of local specialist psychiatric beds, critical communication failures between services, and inadequate staff training led to delayed escalation of suicidal intent and insufficient supervision for eating disorder patients.
Refat Hussain
All Responded
2014-0061
12 Feb 2014
London Inner (West)
Harmoni HS
Concerns summary (AI summary)
Out-of-hours GPs working for Harmoni lack access to patients' full medical records, compromising their ability to make accurate diagnoses.
Noted
(AI summary)
Care UK acknowledges the coroner's concerns regarding access to patient information and describes existing systems for receiving information from GPs, including post-event messages, Special Patient Notes, Summary Care Records, and Coordinate My Care in London. They emphasize that the onus is on the registered GP practice to enable access.
Georgina Swindells
Historic (No Identified Response)
2014-0060
12 Feb 2014
London Inner (North)
Radiology Reporting Online LLP
University College London Hospitals NHS…
Concerns summary (AI summary)
The coroner identified concerns regarding delays in image transfer, a lack of available data to investigate the issue, the absence of an image transfer backup process, and the apparently erroneous scan report, raising the possibility of misreporting in the future.
John Grooby
All Responded
2014-0054
7 Feb 2014
Warwickshire
Warwickshire County Council
Concerns summary (AI summary)
A lack of signage warning motorists about deer using a specific area as a "game track" creates an avoidable road safety hazard.
Action Planned
(AI summary)
Warwickshire County Council will install two "Wild animals likely to be in the road" warning signs on the A3400, with an order raised on 12 February 2014 and an estimated installation time of 6-8 weeks.
Adrian Cowan
Partially Responded
2014-0111
7 Feb 2014
London (North)
Barnet Enfield and Haringey Mental Heal…
North London Forensic Service
Concerns summary (AI summary)
The trust's emergency policy lacked clear guidance and a requirement to call a duty doctor, and nursing staff were unable to calmly apply basic life support training during a patient collapse.
Action Taken
(AI summary)
Barnet, Enfield and Haringey Mental Health Trust has reviewed and updated the Trust’s resuscitation policy to include additional action to be taken in response to the “deteriorating patient”. They have also implemented regular assessments and practical sessions using a lifelike manikin, and conduct unannounced resuscitation scenarios across the Forensic wards.
Brian Kent
Historic (No Identified Response)
2014-0053
6 Feb 2014
London (South)
Italian Embassy
Concerns summary (AI summary)
No specific concerns are detailed in the provided text.
Keith Martin
Historic (No Identified Response)
2014-0055
5 Feb 2014
Surrey
St Peter’s and Ashford Hospitals
Concerns summary (AI summary)
Systemic delays in A&E assessment, diagnostics, senior review, and treatment for chest pain, combined with unclear protocols and poor documentation, resulted in critical care failures.