2014
PFD Reports
Reports: 557
Areas: 71
55% response rate (below 63% average).
Barry Horrocks
Historic (No Identified Response)
2014-0492
7 Nov 2014
West Yorkshire (East)
Department of Health
National Offender Management Service
NHS England
Concerns summary (AI summary)
A disabled prisoner's essential daily living needs were unmet as the prison environment lacked adaptations and no care provider took responsibility for vital 'social services' support.
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)
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. 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. 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.
Rebecca Curtis-Small
Partially Responded
2014-0483
4 Nov 2014
Exeter & Greater Devon
Maritime and Coastguard Agency
North Devon District Council
Parkdeane Holidays
+1 more
Concerns summary (AI summary)
Beach signage is insufficient, lacking prominent display and specific warnings about variable riptide hazards, increasing public risk.
Noted
(AI summary)
North Devon District Council will undertake an audit of signs at the beaches under their control and ownership. They also intend to bring the issue to the attention of their partner organisations. Parkdean states that the signage at Croyde Beach has been designed and erected in agreement with the RNLI and they consider the signage in place is appropriate and sufficient. However, the company is willing to discuss the matter further with the RNLI and act upon any recommendations suggested. The MCA states that the placement, content and maintenance of signage at Croyde Beach is not their responsibility, nor the RNLI's. The MCA will proactively engage with the RNLI on this issue and offer support where necessary.
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
Alan Evans
Historic (No Identified Response)
2014-0472
29 Oct 2014
Powys, Bridgend & Glamorgan Valleys
Powys Highways Department
Concerns summary (AI summary)
The road layout with obscured views and permitted overtaking, combined with protruding "old style cats eyes," creates a significant highway safety risk requiring double white lines and slim-line catseye replacement.
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.
Cherylin Norrell-Goldsmith
Partially Responded
2014-0470
27 Oct 2014
Surrey
HMP Downview
Lord Chancellor
Surrey and Borders Partnership NHS Foun…
+1 more
Concerns summary (AI summary)
Concerns include accessible ligature points in cells, insufficient multi-disciplinary input in ACCT reviews, and critical medical information not being readily available to prison staff on non-medical records. Data retention issues also exist.
Action Taken
(AI summary)
The Ministry of Justice Estate Directorate is providing 'safer cells' in new construction and refurbishment projects. HMP Downview's local policies and procedures have been reviewed and strengthened, and the NHS England Area Team has produced data-sharing agreements. All staff will be reminded of ACCT procedures and the requirement to record significant information on both CNOMIS and SystmOne.
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.
Jackson Mitchell
Partially Responded
2014-0468
27 Oct 2014
Norfolk
NHS England
Norfolk and Norwich University Hospital…
Queen Elizabeth Hospital King’s Lynn NH…
Concerns summary (AI summary)
The death was caused by liver damage from parenteral nutrition extravasation, likely due to a low-lying umbilical venous catheter, highlighting risks associated with currently acceptable UVC placement practices.
Action Taken
(AI summary)
The Trust conducted an internal review, shared findings at paediatric governance meetings, and introduced a new X-ray review checklist. Regionally, guidelines are being developed (King's Lynn is already following them), and nationally, NHS England and BAPM are working on new guidance for central venous lines, with publication expected in autumn 2015.
Betty Smith
Historic (No Identified Response)
2014-0467
27 Oct 2014
Kent (South East & Central)
East Kent Hospitals University NHS Foun…
Concerns summary (AI summary)
Inadequate pre-operative assessment and failure to secure an HDU bed for a high-risk patient were major concerns. Insufficient ITU bed capacity due to nursing shortages further compromises patient care.
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.
Eliza Bashir
Partially Responded
2014-0461
24 Oct 2014
Manchester (North)
Central Manchester University Hospitals…
Department of Health and Social Care
Oldham Metropolitan Borough Council
Concerns summary (AI summary)
Concerns focus on easily accessible button batteries in products not classified as toys, lack of national awareness regarding ingestion risks, and medical professionals needing better guidance for such incidents.
Action Planned
(AI summary)
The Department of Health will share information on button battery risks with health visitors, school nurses, and child health leads at Public Health England's regional centers and will contact the National Social Partnership Forum to raise awareness of the issues.
Hilda Cole
Historic (No Identified Response)
2014-0460
24 Oct 2014
Staffordshire (South)
Care Quality Commission
Welbeing
Concerns summary (AI summary)
The pendant alarm provider failed to adequately inform customers about additional safety features, specifically the option to link to fire alarms, creating an unaddressed fire risk for vulnerable users.
Maria Stubbings
Historic (No Identified Response)
2014-0458
23 Oct 2014
Essex
Ministry of Justice
Select Committee, Home Affairs
Home Office
+1 more
Concerns summary (AI summary)
Gaps in the system allow individuals convicted of murder abroad to enter the UK without conditions or local police notification, lacking retrospective data sharing, passport warnings, or local police alerts.
Sonielia Holmes
Historic (No Identified Response)
2014-0459
23 Oct 2014
Bedfordshire & Luton
Bedford Hospital NHS Trust
Concerns summary (AI summary)
The report identifies that doctors had difficulty contacting the Haematology Department at the Hospital and haematologists failed to respond to messages requesting advice and review of the patient.
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.
Elsie Plumb
Historic (No Identified Response)
2014-0455
21 Oct 2014
Avon
Royal College of Obstetricians and Gyna…
Concerns summary (AI summary)
The Royal College of Obstetricians and Gynaecologists' guideline on preventing neonatal Group B Strep disease is ambiguously worded regarding the timing and necessity of antibiotic prophylaxis during labour induction.
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.
Yaser Saleh
Historic (No Identified Response)
2014-0453
17 Oct 2014
London (Inner South)
Department of Health and Social Care
EMIS Health
Iveagh Surgery
Concerns summary (AI summary)
The GP's computer system only prompts reviews for patients on regular prescriptions, failing to identify those with chronic diseases like asthma who are not currently prescribed medication but still require monitoring, posing a risk of preventable deaths.