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
Paul Rogerson
Historic (No Identified Response)
2014-0029 22 Jan 2014 York
City of York Council North Yorkshire Fire and Rescue Service North Yorkshire Police
Concerns summary (AI summary) River safety equipment is inadequate, poorly maintained, and lacks proper warning signs. Gaps exist in police river rescue training, inter-agency communication, and hypothermia first aid, compounded by insufficient equipment checks.
William Dowling & Victoria Rose
Historic (No Identified Response)
2014-0027 21 Jan 2014 Wiltshire & Swindon
Association of Chief Police Officers British Medical Association Firearms and Explosive Licensing Workin… +5 more
Concerns summary (AI summary) There's no national system allowing doctors to proactively share concerns about a patient's ongoing suitability for a firearms license, with patient confidentiality potentially overriding public safety.
Mone White
All Responded
2014-0031 21 Jan 2014 London (North)
Department of Health and Social Care London North West University Healthcare…
Concerns summary (AI summary) There is no system to ensure specialist hospital advice for patients with complex clinical requirements is consistently communicated to all treating clinicians.
Noted (AI summary) The Secretary of State acknowledges the concerns, notes that guidance was already provided to relevant organisations, and refers to GMC guidance on information sharing. They consider that systems to ensure clinical advice is brought to the attention of treating clinicians should be addressed locally by the NHS Trust. The North West London Hospitals NHS Trust has developed and implemented a flagging system for patients under the care of specialist hospitals with specialist clinical requirements, in partnership with Consultant Paediatricians and the IT Department. A standard operating procedure supports the process and the system has been discussed widely within the Paediatric Directorate.
Kyle Ashley Smith
Historic (No Identified Response)
2014-0028 21 Jan 2014 Manchester (West)
Longshoot Health Centre
Concerns summary (AI summary) An urgent mental health referral from a GP was significantly delayed in reaching the assessment team, with the reason for this critical communication failure remaining unknown and uninvestigated.
John Malone
Historic (No Identified Response)
2014-0026 21 Jan 2014 Manchester (South)
Tameside Hospital NHS Foundation Trust
Concerns summary (AI summary) A hospital discharge letter was critically deficient, lacking essential patient admission and discharge details, which hindered the GP's ability to provide appropriate ongoing care.
Christine Nutbeam
Historic (No Identified Response)
2014-0025 21 Jan 2014 Berkshire
St Peter’s Hospital Wexham Park Hospital
Concerns summary (AI summary) Critical information about a patient's symptoms was not transferred between hospitals or communicated to surgical teams, and pre-operative checks lacked a standard question about recent vomiting, contributing to surgical risks.
Frederick Pring
All Responded
2014-0024 21 Jan 2014 North Wales (East & Central)
Betsi Cadwaladr University Health Board
Concerns summary (AI summary) Current practices for patient handover at Emergency Departments lead to unacceptable delays, keeping ambulances occupied and unavailable for other critical calls.
Action Planned (AI summary) The Welsh Ambulance Service NHS Trust and Betsi Cadwaladr University Health Board are working towards completing an All Wales Handover Policy for patient handover between clinical teams. The Health Board also proposed acting as a 'Demonstrator Site' to implement recommendations regarding overcrowding in Emergency Departments.
Julie Ann Camm
All Responded
2014-0023 17 Jan 2014 West Yorkshire (East)
Leeds City Council
Concerns summary (AI summary) A vulnerable tenant's property lacked smoke alarms because the housing association's policy only encouraged fire safety checks, failing to ensure installation and increasing the risk of death from fire.
Action Planned (AI summary) Housing Leeds will install hard-wired smoke detection in 40 properties and battery-powered detectors in remaining properties without detection equipment over the next 12 months, in consultation with West Yorkshire Fire & Rescue Service. The Electrical Specification has been updated to include hard-wired detection for major electrical works, and the Annual Tenancy Visit will include smoke detection identification.
Julia Dell
Historic (No Identified Response)
2014-0021 17 Jan 2014 Cornwall
Royal Cornwall Hospitals NHS Trust Medical Centre Stratton, Bude, Cornwall
Concerns summary (AI summary) The medical service received from primary care was exemplary during the period examined, with no concerns identified in the provided text.
Wayne Broad
Partially Responded
2014-0020 17 Jan 2014 London (North)
Association of Chief Police Officers Department of Health and Social Care G4S +1 more
Concerns summary (AI summary) There is a lack of dedicated substance misuse teams in police custody and specialized nursing staff in hospitals. Police handcuffing policies for seriously ill detainees also need alignment with best practice.
Noted (AI summary) The Secretary of State states that specialist substance misuse nurses may not be the most effective use of resources in all hospitals and that a specialist substance misuse nurse would not have changed the outcome for Mr Broad, referring to existing NICE guidance for alcohol use disorders.
Jackie Scott
Historic (No Identified Response)
2014-0022 16 Jan 2014 North Northumberland
Indian Brasserie
Concerns summary (AI summary) Lack of clear allergen information meant the deceased unknowingly consumed peanuts in a take-away meal, resulting in a fatal anaphylactic shock.
James Stokoe
Historic (No Identified Response)
2014-0019 16 Jan 2014 Sunderland
Department of Health and Social Care
Concerns summary (AI summary) Mental Health Services lack formal mechanisms to consult carers/partners, potentially missing vital information that could inform risk assessments and identify domestic abuse, especially in elderly patients.
Russell James Felstead
Historic (No Identified Response)
2014-0016 14 Jan 2014 Manchester (South)
Care Quality Commission Stockport NHS Foundation Trust Choice Support
Concerns summary (AI summary) Doctors failed to access and read vital medical information within nursing notes, resulting in a four-day delay in ordering an urgent CT scan for the patient.
Craig White
Historic (No Identified Response)
2014-0017 14 Jan 2014 South Lincolnshire
British National Formulary British Society of Gastroenterology Intensive Care Society +4 more
Concerns summary (AI summary) Concerns include insufficient TB screening protocols before Infliximab treatment, inadequate prescriber awareness of increased TB risk, and the need for better patient education and prompt treatment for suspected tuberculous meningitis.
Barbara White
Historic (No Identified Response)
2014-0015 13 Jan 2014 Manchester (South)
Tameside General Hospital
Concerns summary (AI summary) Critical lapses included a 12-hour absence of clinical observations, an incorrect PARS score that should have triggered intervention, and severe staff shortages. Poor handover and lack of consultant escalation further compromised care.
Zeeyad Hamadi
Partially Responded
2014-0014 13 Jan 2014 County Durham & Darlington
Department of Health and Social Care HM Prison and Probation Service
Concerns summary (AI summary) Inadequate patient weighing and poor medical record-keeping within the prison were noted. There was limited liaison between prison and hospital staff, confusion over prisoner private healthcare policies, and delays in securing bed watch cover.
Action Planned (AI summary) The Secretary of State acknowledges the concerns and states that the National Offender Management Service (NOMS), NHS England and Public Health England (PHE) are due to meet to discuss governance arrangements for considering prisoner's requests for private treatment.
Jason Nock
All Responded
2014-0013 13 Jan 2014 Black Country
Home Office
Concerns summary (AI summary) An entirely unregulated product is readily available without consumer information on safe dosage or potential consequences, leaving users unaware of the substance they are consuming.
Action Planned (AI summary) The Home Office has asked the Advisory Council on the Misuse of Drugs (ACMD) for advice on AH-7921 and is collecting evidence from health organizations and law enforcement. They are also undertaking a review of the UK's response to new psychoactive substances.
Michael O’Sullivan
All Responded
2014-0012 13 Jan 2014 London Inner (North)
Department for Work and Pensions
Concerns summary (AI summary) The DWP assessment process for fitness to work failed to incorporate vital medical information from the patient's treating GP, psychiatrist, and clinical psychologist, leading to decisions without comprehensive medical input.
Action Planned (AI summary) DWP acknowledges concerns and will issue a reminder to staff about guidance related to suicidal ideation. They also state that they will continue to monitor their policies around assessment of people with mental health problems.
Mustafa Cicek
Partially Responded
2014-0116 13 Jan 2014 East Sussex
Department for Transport National Highways The Chief Coroner
Concerns summary (AI summary) Highway safety issues include a collision black spot with inadequate warning signage and a potentially hazardous eucalyptus sapling. "SLOW" warnings are also needed on the carriageway approach.
Action Taken (AI summary) The Highways Agency has installed 'SLOW' road markings and removed a eucalyptus tree. It is also increasing the number of chevrons on the bend and ensuring they are on yellow backgrounds.
Dr Edward Slaney
Historic (No Identified Response)
2014-0030 10 Jan 2014 West Yorkshire (East)
Ministry of Housing, Communities & Loca…
Concerns summary (AI summary) There is a lack of established criteria and guidance for planning authorities to assess the wind effects of tall buildings on the safety of all highway users.
Pauline Meredith
Partially Responded
2014-0011 10 Jan 2014 Staffordshire South
Browning Street Surgery General Medical Council
Concerns summary (AI summary) Concerns include prolonged prescribing of excessive medication without review, adding morphine to a high-dose regimen for an alcohol-dependent patient, and a GP's perceived reluctance to address family concerns. Delayed involvement of mental health services was also noted.
Action Planned (AI summary) The practice will endeavor to identify patients with additional complex needs for specific discussion at practice meetings to improve service to patients. They will also aim to maximise the health and wellbeing of their vulnerable patients with complex mental health needs.
Mary Waldron
Historic (No Identified Response)
2014-0127 10 Jan 2014 Coventry
Care Quality Commission Nursing and Midwifery Council St Mary’s Nursing Home +1 more
Concerns summary (AI summary) Nursing home staff failed to recognise and act on an acutely unwell resident due to inadequate ongoing training and poor internal investigation. Communication issues during ambulance transfer also posed a risk.
Albert James Hand
All Responded
2014-0010 9 Jan 2014 Bedfordshire & Luton
East of England Ambulance Service
Concerns summary (AI summary) The coroner reported concerns about a patient with a head injury waiting over an hour and a half for transport to hospital, insufficient ambulance crews in the Luton and Bedfordshire area, and protocols for dealing with emergency calls potentially putting patients at risk.
Action Taken (AI summary) The East of England Ambulance Service NHS Trust has reviewed its Demand Management Plan, commenced issuing a clinical manual to staff, and is commissioning an upgrade to the Computer Aided Dispatch (CAD) system. They are also continuing to augment their clinical coordination function within the Health and Emergency Operations Centres (HEOCs).
Jonathan Thorpe
Historic (No Identified Response)
2014-0006 8 Jan 2014 Manchester (South)
King Street Medical Centre
Concerns summary (AI summary) A GP failed to consult or refer a known self-harmer to Mental Health Services, prescribing medication without adequate assessment of his ongoing mental health needs.
Grace Mary Bates
All Responded
2014-0007 7 Jan 2014 London (North)
Barnet and Chase Farm Hospitals NHS Tru… Department of Health and Social Care
Concerns summary (AI summary) The hospital lacked a specialist diabetic nurse available over the weekend, posing a risk to patients requiring specific care.
Noted (AI summary) A business case for the appointment of a minimum of one WTE IPDSN to complement the current diabetes team, to provide improved cover for the Hospital across the calendar week has been approved and an appointment is awaited. The Secretary of State for Health acknowledges the coroner's concerns regarding diabetes management at Barnet Hospital and refers to existing NICE quality standards and NHS England initiatives for improving patient outcomes and weekend services. The response emphasizes local organizations' responsibility for delivering high-quality care.