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
William Anderson
Historic (No Identified Response)
2014-0452 17 Oct 2014 West Yorkshire (East)
Solicitors Leeds Community Healthcare NHS Trust Solicitors +1 more
Concerns summary (AI summary) Prison staff lacked effective vigilance over inmate gatherings involving drugs/alcohol, were insufficiently trained in breathalyser use, and failed to adequately record inmate behaviour or promptly call emergency services.
Stephen Atherton
Historic (No Identified Response)
2014-0451 17 Oct 2014 London Inner (North)
Barts Health NHS Trust NHS Tower Hamlets Clinical Commissionin… NHS England +1 more
Concerns summary (AI summary) The deceased required multiple, increasingly complex investigations, suggesting potential issues in initial diagnostic pathways or management of his condition.
John Bird
Historic (No Identified Response)
2014-0450 16 Oct 2014 London Inner (North)
Hawthorn Green Care Home Sanctuary Care Limited
Concerns summary (AI summary) The care home manager failed to ensure staff were familiar with residents' falls risk assessments and care plans, leading to an untrained carer inaccurately assessing a high-risk patient's mobility.
Roger de Klerk
All Responded
2014-0448 16 Oct 2014 London (South)
London Borough of Croydon
Concerns summary (AI summary) Poorly designed bicycle lanes and confusing signage at a junction create significant dangers for cyclists due to tramlines, forcing unsafe crossing angles and conflicts with pedestrians.
Action Planned (AI summary) The council will conduct a detailed review of the Addiscombe Road / Cherry Orchard Road junction, engaging TfL's design team to find improvements for cyclists and road safety, including short-term and extensive options, and will discuss Quietway funding with TfL. The council will also review signing and markings at all other sites in Croydon where cyclists cross tram tracks and is researching potential products to fill the gap in tram tracks.
David Thomson
Historic (No Identified Response)
2014-0447 16 Oct 2014 Liverpool
Department for Business, Innovation and…
Concerns summary (AI summary) E-cigarette batteries charged via universal micro USB ports are at risk of explosion if an incompatible charger supplies the wrong current.
Seweryn Glowinski
Historic (No Identified Response)
2014-0446 15 Oct 2014 Worcestershire
HMP Long Larkin
Concerns summary (AI summary) Serious communication breakdown between prison units, incorrect documentation due to "cutting and pasting" prisoner information, and senior staff unawareness of segregation policies for at-risk prisoners.
Lucasz Lewandowski
Partially Responded
2014-0445 15 Oct 2014 Manchester (North)
Greater Manchester Police Green Surgery MEDACS Healthcare
Concerns summary (AI summary) The report identifies concerns regarding the timeliness of the police response, communication gaps between agencies, use of the Mental Health Act due to resource constraints, and a lack of correspondence from a psychiatric practice with the patient's GP.
Action Taken (AI summary) A protocol is being implemented for psychiatric practice, including risk assessment and communication with healthcare professionals, to be reviewed regularly. The referral system is being improved to flag occurrences like missed appointments, and the surgery will encourage a more inclusive approach from clinicians in patient care. The Operational Communications Branch (OCB) has reviewed its Escalation Policy, issued individual management advice to staff involved in the incident, and recirculated the policy with emphasis on accurate recording. The Custody Branch has circulated the MEDACs Escalation Policy to all staff and included it in its October 2014 Custody Branch Orders.
Alan Peck
Historic (No Identified Response)
2014-0444 14 Oct 2014 Manchester (South)
Tameside Hospital NHS Foundation Trust
Concerns summary (AI summary) Critical medication was not delivered due to an unconnected syringe driver and its subsequent failure to be transferred with the patient, depriving him of essential drugs during transport.
Mary Fenton
All Responded
2014-0443 13 Oct 2014 Manchester (South)
Department of Health and Social Care Tameside Hospital NHS Foundation Trust
Concerns summary (AI summary) The coroner notes that there was no cardiology consultant on call after 5pm or at weekends, a lack of facilities for echocardiograms after hours, shortages of Isoprenaline, and failures in assessing the patient's mental capacity and obtaining consent to treatment.
Noted (AI summary) The Department of Health acknowledges the concerns about shortages of Isoprenaline and outlines the complexity of pharmaceutical supply chains. They note that Isoprenaline injection is unlicensed in the UK, but that the NHS UK Medicines Information service (UKMI) produced a memo summarising the situation and advising on alternative sources of supply. The trust has updated its DNACPR policy, stressed the importance of communication, reminded clinicians of relevant policies, and advised them to seek refresher training; cardiology staff have been instructed by the Lead Consultant Cardiologist that no usage of Isoprenaline should be permitted in the CCU Ward 31 without the consent of a Consultant Cardiologist or the on-call Cardiologist for pacing out of hours. The Trust has also issued a warning to all medical staff as to their duties to report matters to Her Majesty's Coroner.
Arsema Dawit
All Responded
2014-0442 13 Oct 2014 London (Inner South)
Metropolitan Police Service
Concerns summary (AI summary) Police investigation suffered from premature offence classification, misleading record entries, and inadequate supervision of action plans. There was also a gap in domestic violence reporting for non-adults and a reluctance to use interpreting services.
Action Taken (AI summary) The Metropolitan Police Service has made improvements in training and reference materials for staff, investigator accreditation & quality assurance, supervision, and provision of support resources; it has broadened the function of the civilian Station Reception Officer to 'PAO' -Public Access Officer, developed a supervisor training package, updated the MPS 'Supervision Toolkit', increased the number of accredited PIP level 2 investigators, and invested heavily in providing translation services.
George Vickery
Historic (No Identified Response)
2014-0441 13 Oct 2014 Portsmouth & South East Hampshire
Southern Health NHS Trust
Concerns summary (AI summary) The decision to change a patient's treatment location without formally consulting or adequately considering the GP's request for home treatment jeopardised continuity of care.
Vincent Oliver
All Responded
2014-0438 9 Oct 2014 Northumberland (North)
HMP Northumberland
Concerns summary (AI summary) A prison officer's failure to check a prisoner's well-being during unlocking, combined with a lack of recorded compliance with physical response requirements during roll checks, risks missed deaths.
Action Taken (AI summary) HMPS Northumberland has introduced a written system for recording wellbeing checks of prisoners throughout the day, with wing diaries amended to reflect the change.
Stephen Simpson
Historic (No Identified Response)
2014-0437 9 Oct 2014 Northumberland (North)
Home Group
Concerns summary (AI summary) The building's design, featuring smooth concrete stairs without non-slip surfaces and no lobby to cushion falls, creates a serious risk of injury or death from impact with the external door.
Sapper Dylan Gibson
All Responded
2014-0436 9 Oct 2014 Wiltshire & Swindon
Ministry of Defence
Concerns summary (AI summary) The absence of master keys in the guard room for all camp buildings prevents prompt access in emergencies, potentially delaying critical interventions.
Action Taken (AI summary) Sapper Gibson's unit now holds keys to all buildings and rooms in the guardroom. The MOD is updating its Health and Safety risk assessment guidance to ensure site risk assessments consider rapid access to locked rooms, and procedures are tested regularly; the Royal Navy, Army, Royal Air Force, Defence Equipment and Support and Joint Forces Command have all directed that master or spare keys to all rooms will be held centrally in the guardroom (or similar where there is no guardroom).
Tracey Rooke
Historic (No Identified Response)
2014-0435 9 Oct 2014 Wiltshire & Swindon
Wiltshire Council
Concerns summary (AI summary) Identified road signage issues, including location and condition, were not addressed by the Highways Authority, which delayed action until a Coroner's report was issued, despite earlier recommendations.
Wade Patel
All Responded
2014-0434 9 Oct 2014 Leicester City & South Leicestershire
Department for Communities and Local Go…
Concerns summary (AI summary) Outdated glass in older rented properties poses a significant safety risk as there is no legal requirement for landlords to proactively check or replace it unless it breaks or during refurbishment.
Noted (AI summary) The Department for Communities and Local Government acknowledges the concerns regarding glazing safety but notes that Building Regulations only apply to new building work and extensions. It outlines the duties of landlords and the powers of local authorities to tackle poor-quality accommodation.
Chloe Siokos
Historic (No Identified Response)
2014-0439 8 Oct 2014 London (North)
Department of Health and Social Care
Concerns summary (AI summary) Primary care lacks a clear framework and ready access to interpreters, and there is no system to flag relevant patient connections, impacting continuity of care.
Ella Block
Historic (No Identified Response)
2014-0433 7 Oct 2014 Plymouth, Torbay & South Devon
Plymouth Hospitals NHS Trust
Concerns summary (AI summary) Opportunities for timely sepsis treatment in children may be missed because newly qualified clinicians struggle to identify this rare but fatal condition.
Elouise Winship
Historic (No Identified Response)
2014-0431 7 Oct 2014 North Wales (East & Central)
Betsi Cadwaladr University Health Board
Concerns summary (AI summary) There is no documented standard practice for regular fetal heart auscultation after opiate administration or for further maternal examinations following a change in condition during labour.
Timothy Cowen
Historic (No Identified Response)
2014-0430 7 Oct 2014 North Wales (East & Central)
Betsi Cadwaladr University Health Board
Concerns summary (AI summary) New training on procedures is not mandatory for all staff, and the Acute Liaison Nurse role, crucial for patient support, lacks adequate cover during absences.
Zakariyya Clark
Historic (No Identified Response)
2014-0440 7 Oct 2014 South Yorkshire (East)
Doncaster and Bassetlaw NHS Foundation …
Concerns summary (AI summary) Significant deficiencies in A&E patient assessment and documentation, including vital signs and injury details, posed a risk to future patients if not addressed by system enhancements.
Kai Lambe
Historic (No Identified Response)
2014-0557 6 Oct 2014 Staffordshire South
Environment Agency Headquarters
Concerns summary (AI summary) Inadequate safety measures and insufficient warning signage at a dangerous weir and salmon chute put children playing in the area at significant risk.
Matthew Flatman
Historic (No Identified Response)
2014-0429 6 Oct 2014 Portsmouth & South East Hampshire
Home Office
Concerns summary (AI summary) The slow process of proscribing the "legal high" MDAI/Gogaine poses a fatal risk, particularly to users with cardiac problems, requiring accelerated action.
John Andrews
Historic (No Identified Response)
2014-0426 3 Oct 2014 Milton Keynes
Milton Keynes Hospital
Concerns summary (AI summary) Inadequate discharge planning and communication for a vulnerable patient, leading to them returning home without necessary care arrangements, heating, or groceries.
Gavin Bradley, Mark Thorpe and Darren Thorpe
Historic (No Identified Response)
2014-0424 2 Oct 2014 Northumberland (South)
Northumbria Water
Concerns summary (AI summary) Unsafe weir design lacks specific channels for kayaks and suitable upstream landing areas, coupled with insufficient warnings, risking water users' safety.