2014

PFD Reports
Reports: 557 Areas: 71

55% response rate (below 63% average).

557 results
Mr Pether
Historic (No Identified Response)
2014-0432 2 Oct 2014 London (East)
Barking, Havering and Redbridge Univers…
Concerns summary (AI summary) Inadequate monitoring and assessment of a patient's wound, delayed identification of infection, and insufficient re-consideration of treatment options despite deteriorating clinical condition.
Lexi Branson
Partially Responded
2014-0428 2 Oct 2014 Rutland & North Leicestershire
Department for Environment Food and Rur… Leicester City Council Leicestershire Local Safeguarding Board +1 more
Concerns summary (AI summary) A complete absence of national or local standards for re-homing stray dogs, assessing dog suitability, applicant suitability, or verifying kennel re-homing policies.
Noted (AI summary) The Department for Environment, Food and Rural Affairs will explore with larger dog rehoming organisations (Dogs Trust, RSPCA etc.) the possibility of sharing their rehoming checks with smaller centres and will write to these organisations to explain the coroner's recommendations. Leicester City Council acknowledges the coroner's concerns regarding stray dogs and rehoming but states they have limited power to prevent future deaths due to the disparate nature of rehoming organisations and the lack of national standards. They will convey learnings from the case to their kennel provider.
Victoria Rhodes
All Responded
2014-0422 30 Sep 2014 Milton Keynes
Milton Keynes Council
Concerns summary (AI summary) High speed limits on grid roads in Milton Keynes where pedestrians have access, necessitating a review of the existing speed limits for safety.
Action Planned (AI summary) Milton Keynes Council is undertaking a comprehensive road safety review, prompted by a rise in serious incidents, and will bear the coroner's points in mind when compiling the report. The report's recommendations are intended to help reduce risk on the road network.
Derek Hawkins
Historic (No Identified Response)
2014-0425 30 Sep 2014 Manchester (North)
Not Listed
Concerns summary (AI summary) The risk assessment tool relies on subjective practitioner judgment, lacks objective rating, and may lead to less experienced staff failing to identify increased risks.
Christopher Davies
Historic (No Identified Response)
2014-0420 29 Sep 2014 North Wales (East & Central)
Betsi Cadwaladr University Health Boar
Concerns summary (AI summary) Insufficient communication to patients and staff regarding the interaction between clozapine, caffeine, and smoking, as well as warning signs of toxicity.
Tiya Chauhan
Partially Responded
2014-0575 29 Sep 2014 London Inner (West)
Department for Education Food Standards Agency Ofsted +1 more
Concerns summary (AI summary) Childcare settings and parents are unaware of the choking risks posed by raw jelly cubes, with packets lacking adequate warnings and supervision during play being insufficient.
Action Planned (AI summary) The Department for Education intends to issue additional guidance to the early years sector in 2015 under the EYFS banner, principally about what constitutes good paediatric first aid provision in settings. This guidance will point out the dangers of using raw jelly in play with young children without sufficient supervision as an example of a choking hazard, and they will review first aid requirements. Ofsted will disseminate the inquest findings to Ofsted and contracted inspectors of EY provisions, ensuring they are aware of the risks of using raw jelly in activities during inspections of EYFS compliance. They are also liaising with the Local Government Association to discuss the report and ensure appropriate warnings are communicated to settings. The Food Standards Agency will forward information about the risks of raw jelly cubes to local authority environmental health services and industry manufacturing/retail trade bodies. They will also forward the coroner's report to the Department of Health for consideration in relation to early years food advice to parents.
Emmanuel Akinmuyiwa
Historic (No Identified Response)
2014-0421 26 Sep 2014 Birmingham & Solihull
Birmingham and Solihull Clinical Commis… Commissioning groups NHS England
Concerns summary (AI summary) The absence of a clear regional protocol for sickle cell disease management led to staff lacking knowledge of crisis symptoms and necessary treatment, compounded by funding issues.
Dorothy Clarkson
Historic (No Identified Response)
2014-0465 26 Sep 2014 Preston & West Lancashire
Care Quality Commission MPS Investments Ltd Nesbit Law Group [Solicitors for the Cl…
Concerns summary (AI summary) Inadequate procedures for providing food to residents needing specific preparations and assistance, alongside a lack of appropriate professional development training for nursing home staff.
Leonard Hudson
Historic (No Identified Response)
2014-0419 24 Sep 2014 Sunderland
City Hospitals Sunderland NHS Foundatio…
Concerns summary (AI summary) Multiple failures in pressure ulcer prevention and management, including policy non-adherence, inadequate documentation, late referrals, inconsistent care, and poor record keeping.
Caroline Carter Crowther
Historic (No Identified Response)
2014-0418 24 Sep 2014 Worcestershire
West Midlands Ambulance Trust
Concerns summary (AI summary) Contradictory policies and training regarding compelling psychiatric patients to hospital, with paramedics uncertain about their authority to physically coerce grievously ill patients.
Jake Johnson
Historic (No Identified Response)
2014-0417 24 Sep 2014 Cheshire
Highways Agency
Concerns summary (AI summary) Unrestricted public access to a motorway due to open steps and damaged boundary fencing, compounded by a lack of warning signs, especially near a children's play area.
Isa Mushtaq
Historic (No Identified Response)
2014-0423 24 Sep 2014 Manchester (City)
Department of Health and Social Care National Institute for Health and Care … Royal College of Gynaecologists and Obs…
Concerns summary (AI summary) A critical lack of detailed national guidance for antepartum CTG assessment, interpretation, and intervention, leading to inconsistent and potentially unsafe management of high-risk pregnancies.
Martin Dean
Historic (No Identified Response)
2014-0416 22 Sep 2014 Manchester West
Salford Royal Foundation Trust
Concerns summary (AI summary) Inadequate adherence to hand hygiene by visitors on a Critical Care Ward, directly increasing the risk of infection to vulnerable patients.
Jerome Gonnet
Partially Responded
2014-0415 22 Sep 2014 Teesside
A-One+ Cleveland Police Roads Policing Unit
Concerns summary (AI summary) Unclear and insufficient signage for a 'no entry' slip road, with temporary warnings frequently being ineffective, leading to repeated instances of drivers entering incorrectly.
Action Planned (AI summary) A-one+ has investigated options for improvement at the A66 Elton Interchange, including installing demountable bollards/marker posts and additional road markings. A proposal for these works will be submitted for funding during the next round for improvement schemes.
Linda Rignall
Historic (No Identified Response)
2014-0414 19 Sep 2014 Brighton & Hove
Royal Sussex County Hospital
Concerns summary (AI summary) A patient's significant clinical deterioration, recorded on a NEWS chart, was not reported to a doctor or assessed promptly, risking future deaths.
Satheeskumar Mahatheaven
All Responded
2014-0412 19 Sep 2014 London Inner (North)
HMP Pentonville
Concerns summary (AI summary) Failures in information sharing, multi-agency communication procedures, and inadequate training contributed to an accident within prison services.
Action Taken (AI summary) HMP Pentonville and HMP Thameside have implemented local policies to ensure appropriate information sharing and effective communication between prison staff and healthcare providers. Community GP records are now routinely requested in all cases with health concerns, and all new healthcare staff are shown how to use the SystmOne electronic record system correctly.
Aaron Plowman
Historic (No Identified Response)
2014-0411 19 Sep 2014 London (Inner South)
Network Rail
Concerns summary (AI summary) Unblocked access points to commercial unit roofs under railway arches allow unauthorized persons to climb from the street, posing a safety risk.
Beatrice Gatt
Historic (No Identified Response)
2014-0566 18 Sep 2014 Northampton
Shire Lodge Nursing Home
Concerns summary (AI summary) A critical antipsychotic medication was not administered due to a transfer error between medication sheets, highlighting a lack of formal training for nursing staff on medication management.
Marjorie Phillips
Partially Responded
2014-0413 18 Sep 2014 Manchester (South)
Sunrise Medical Limited Faversham Nursing Home
Concerns summary (AI summary) The patient's fall from a hoist was attributed to the sling's tendency to "bagging" at the sides, creating a fall risk if the patient shifted their weight.
Noted (AI summary) Sunrise Medical Limited states that their instruction manual is a comprehensive document which deals with the issues of purchase; maintenance and operation of equipment supplied by them, therefore no action is proposed at this stage.
Brian Dalrymple
Partially Responded
2014-0410 18 Sep 2014 West London
GEOAmey Nestor Primecare Serco +2 more
Concerns summary (AI summary) The report identifies a lack of awareness among detention staff regarding indicators of mental health issues, a failure to act on recorded observations, inadequate medical visits to segregated detainees, and the absence of a comprehensive clinical record system.
Noted (AI summary) GEO Group states that as the contract for Harmondsworth IRC passed to Mitie, they cannot take action regarding working practices there. However, they will consider lessons learned from the inquest for their other operations.
William France
Historic (No Identified Response)
2014-0409 18 Sep 2014 Somerset (West)
Network Rail
Concerns summary (AI summary) Railway crossing barriers malfunctioned due to a single-arm treddle, causing long delays. Drivers also faced obstructed visibility and a poorly located emergency telephone.
Janet Goodacre
All Responded
2014-0408 18 Sep 2014 Leicester City & South Leicestershire
University Hospitals of Leicester NHS T…
Concerns summary (AI summary) The Trust submitted an inaccurate and flawed investigation report with incorrect root causes, failing to identify actual service difficulties and delaying communication of these issues.
Action Taken (AI summary) University Hospitals of Leicester NHS Trust has established a process where each RCA investigation has a named 'Chair', introduced RCA Oversight training for RCA Chairs, and established a new 'Adverse Events Committee' to review all serious untoward events (SUIs).
George Palmer
All Responded
2014-0407 15 Sep 2014 Surrey
Community Mental Health Recovery Servic…
Concerns summary (AI summary) Discharge follow-up mechanisms were inadequate for patients transferring areas, leading to a lack of continuity of support, and follow-up letters for non-contact were inappropriate.
Action Taken (AI summary) The Trust reviewed and reinforced procedures for sharing information with new service providers when patients relocate, including requesting GP details and sending discharge notifications. They have also logged the issues in their corporate action plan and will share learning through quarterly events.
Evelyn Smith
Historic (No Identified Response)
2014-0406 12 Sep 2014 Warwickshire
Health Education England NHS England Royal College of Emergency Medicine +1 more
Concerns summary (AI summary) Inaccurate vital sign recording and lack of clinician knowledge regarding pediatric early warning and croup severity scoring systems hindered early recognition of illness and effective data entry in GP records.
Barbara Cooke
Historic (No Identified Response)
2014-0405 12 Sep 2014 Isle of Wight
Care Quality Commission Isle of Wight Adult Safeguarding Team St Mary’s Hospital +1 more
Concerns summary (AI summary) Severe understaffing at a care home caused patient neglect, poor infection control, and lacking external nurse communication protocols. The hospital also had no system to record safeguarding alerts or notify authorities of deaths for vulnerable patients.