2014
PFD Reports
Reports: 557
Areas: 71
55% response rate (below 63% average).
Essa Shah
All Responded
2014-0250
2 Jun 2014
Bedfordshire & Luton
Luton and Dunstable University Hospital
Concerns summary (AI summary)
Crucial literature on the dangers of co-sleeping is only available in English, preventing non-English speaking mothers from accessing vital safety information.
Action Planned
(AI summary)
Luton and Dunstable University Hospital will ensure Feeding Packs are created containing a UNICEF leaflet in Bengali, Punjabi, and Urdu to advise of the dangers of co-sleeping. Community Midwives will also be equipped with iPads to facilitate communication.
Aimee Varney
All Responded
2014-0249
2 Jun 2014
Bedfordshire & Luton
Luton and Dunstable University Hospital
Concerns summary (AI summary)
NICE Guidelines for referring patients with suspected epilepsy to a Specialist Tertiary Centre were not followed, risking delayed or inappropriate specialized care.
Action Planned
(AI summary)
Luton and Dunstable University Hospital are commissioning a further report from an independent general neurologist to assess whether the individual clinician's practice regarding NICE guidelines on epilepsy referrals fell outside the threshold of reasonable practice.
Jennifer Morrison
All Responded
2014-0265
2 Jun 2014
Wirral
Arrowe Park Hospital
Concerns summary (AI summary)
Missing medical records hampered investigations, and bed shortages combined with inadequate staffing during peak holiday seasons led to prolonged assessment unit stays and treatment delays.
Action Taken
(AI summary)
Wirral University Teaching Hospitals NHS Foundation Trust describes measures to manage medical records, including a Health Records Management Policy and regular audits. The Surgical Division now holds daily management meetings to review staffing levels, and the Surgical Assessment Unit (SAU) underwent a 'Listening into Action' project, increasing junior doctor presence, introducing consultant rounds, and regular staffing reviews.
Denise Prior
All Responded
2014-0262
2 Jun 2014
West Sussex
Western Sussex Hospitals NHS Trust
Concerns summary (AI summary)
Inadequate hospital record-keeping for oxygen levels, prescription, and the application of the NEWS system poses a risk of future deaths.
Action Taken
(AI summary)
Western Sussex Hospitals NHS Trust has undertaken a thorough investigation and review and enclosed an action log setting out the action taken.
Richard Jaeger-Forzard
All Responded
2014-0246
30 May 2014
Buckinghamshire
Terex Global Gmbh
Concerns summary (AI summary)
The inquest identified unresolved professional disagreements regarding the proper steps needed to prevent similar occurrences, which could not be adjudicated.
Action Taken
(AI summary)
Genie issued a mandatory Safety Notice requiring recalibration of Z135/70 machines and updated controller software to prevent instability due to miscalibration.
Stephen Ward
All Responded
2014-0248
29 May 2014
London Inner (North)
Camden & Islington NHS Foundation Trust
Concerns summary (AI summary)
The mental health crisis team lacked a clear protocol for following up with police after requesting a welfare check, leading to delays when police did not respond.
Noted
(AI summary)
Response is blank.
Mark Duggan
All Responded
2014-0182
29 May 2014
London (North)
Association of Chief Police Officers
Coroner's Society
Crown Prosecution Service
+4 more
Concerns summary (AI summary)
Insufficient intelligence gathering and a failure to exhaust all intelligence avenues regarding key individuals prior to the stop, impacting subsequent police actions.
Noted
(AI summary)
The IPCC acknowledges the coroner's concerns, particularly regarding access to intelligence materials, and states it is best placed to determine who within the IPCC investigation should have access. The IPCC considers that there should be a clear legal right of access by IPCC investigations to all relevant intelligence material. The Home Office acknowledges the concerns raised, particularly regarding the IPCC's resources at the scene and access to intelligence. The response explains the existing legal framework for investigations and information disclosure, highlighting the need to balance transparency with national security. The National Armed Policing Portfolio has commenced work to determine whether the introduction of body worn video (BWV), might be included in armed policing operations. The National Policing portfolios will ensure liaison with the College of Policing to incorporate, reiterate and reflect issues relating to cordon management and evidence preservation in its post incident management and operational training. The National Crime Agency notes the concerns raised and states it has undertaken a thorough internal review of its operating procedures regarding intelligence gathering, development, and dissemination. Following this review, the Agency believes that no more could have realistically been done to avoid the incident. The MPS will adopt a procedure for all future police shootings whereby a Garage Sergeant or Collision Investigator is called by the DPS to download the IDR at the scene, which will then be available to police; the IPCC and any subsequent legal proceedings
Magdalen Dwerryhouse
All Responded
2014-0244
29 May 2014
Manchester (West)
5 Boroughs Partnership NHS Foundation T…
Concerns summary (AI summary)
Poor communication led to a missed patient appointment. A health trust also failed to engage with the fire service, preventing vulnerable individuals from receiving crucial home safety checks due to a lack of information sharing.
Action Taken
(AI summary)
The Trust has reviewed and amended operational guidance for community teams, specifically regarding actions when service users miss appointments. They have also established an information-sharing agreement and reciprocal training arrangements with the Greater Manchester Fire and Rescue Service.
Dana Baker
All Responded
2014-0242
29 May 2014
Worcestershire
Worcestershire Safeguarding Children’s …
Concerns summary (AI summary)
Inadequate inter-agency communication and a lack of shared knowledge, exacerbated by confidential Individual Management Reviews, prevented a comprehensive understanding of mutual concerns.
Noted
(AI summary)
The WSCB acknowledges the concerns but states that national practice is followed and questions if the report should have been directed to the Department for Education. The guidance in place at the time of the EW Serious Case Review (SCR) was undertaken is outlined, that which is now in place and WSCB's response to this is set out.
Arnold Soulsby
All Responded
2014-0241
28 May 2014
Black Country
Department for Transport
Concerns summary (AI summary)
Current regulations do not mandate retrospective fitting of forward mirrors on lorries, leaving many vehicles without a crucial safety feature and increasing the risk of similar road deaths.
Action Planned
(AI summary)
The Department for Transport has asked officials to prepare a consultation about retro-fitting forward-facing mirrors on heavy goods vehicles first registered before 26 January 2007. The consultation will explore the potential benefits and costs associated with requiring retro-fit of these mirrors.
Laura Page
All Responded
2014-0254
28 May 2014
Leicester City & South Leicestershire
Leicester Partnership NHS Trust
Concerns summary (AI summary)
Inadequate clinician response to failed home visits included lack of client contact and failure to escalate issues. Policies for escalation, welfare checks, and auditing failed visits require urgent review.
Action Taken
(AI summary)
The Trust has notified teams of the outcome of the investigation, developed a clear process for handling failed visits, and updated the Crisis Resolution Team's Operational Procedure. They have also clarified time targets for action and the threshold for requesting a welfare check, and the Crisis Service Manager is undertaking weekly audit checks on failed visits.
Michaela Christoforou
All Responded
2014-0285
25 May 2014
London (North)
Care UK
Concerns summary (AI summary)
All staff at the unit did not carry ligature cutters, posing a significant risk in preventing self-harm incidents.
Action Planned
(AI summary)
Care UK has now located nine sets of ligature cutters throughout Rhodes Farm. Clinical staff will carry ligature cutters for a six month trial period commencing in September 2014 and a protocol/procedure is being developed that covers all aspects concerned with the carrying and management of ligature cutters.
Josephine Foday
All Responded
2014-0301-wp24614
23 May 2014
Essex
Chartered Institute of Environmental He…
Concerns summary (AI summary)
The pool's inherently dangerous profile was not properly risk-assessed. A lack of lifeguards, unmonitored CCTV, unclear signage, and untrained staff in aquatic rescue created significant drowning risks, especially for non-swimmers.
Action Planned
(AI summary)
• IOSH will raise awareness among its 44,000 members by highlighting the facts of this case, the concerns raised, and the Health and Safety Executive guidance on this topic.
• A summary of the key findings will be included in the next available issue (September 2014) of the Institution's official member magazine the Safety and Health Practitioner.
• A news item will be included in the e-bulletin, Connect, on Monday 21 July, which is distributed to all members.
Christian Devereux
All Responded
2014-0240
23 May 2014
Rutland & North Leicestershire
RAC Motorsports Association
Concerns summary (AI summary)
A HANS type device likely would have prevented or reduced fatal head and neck injuries in a collision. Many drivers in the race were not using these affordable and beneficial safety devices.
Noted
(AI summary)
The Motor Sports Association details its history of considering frontal head restraints and insurance policies, and provides statistics on affiliated clubs, license holders, officials and authorised events.
Rainer Wickens
All Responded
2014-0234
20 May 2014
Surrey
St George’s Healthcare NHS Trust
Concerns summary (AI summary)
Significant delays in clot treatment and CTPA scans were caused by poor communication during handovers and between medical staff. Additionally, medical notes had gaps and vulnerable patients had unsupervised access to stairs.
Action Taken
(AI summary)
St George's Healthcare NHS Trust apologized for sub-optimal care and delays in a Serious Incident investigation. They have shared the investigation's learning outcomes, now investigate all cases of hospital-acquired thrombosis, and have completed some actions from the SI panel's report, with the rest due by 31 July 2014.
Peter Franklin
All Responded
2014-0230
19 May 2014
Mid Kent & Medway
Kent and Medway NHS and Social Care Par…
Maidstone and Tunbridge Wells NHS Trust
Concerns summary (AI summary)
Confusion in terminology and lack of information sharing between health teams and the CRISIS team hindered effective care. Significant delays in documentation meant the GP was unaware of crucial hospital admissions and mental health involvement.
Action Planned
(AI summary)
Kent and Medway NHS Trust has developed a joint action plan with Maidstone and Tunbridge Wells NHS Trust, extending Liaison Psychiatry service hours, introducing a recovery card for patients on discharge, and holding monthly meetings to review frequent presenters. Tunbridge Wells Hospital is implementing a SMART tool, working towards electronic discharge summaries by October 2014, holding frequent attenders' meetings, and adding a 3-hour Mental Capacity Act session to the junior doctor teaching program.
Gregg O’Reilly
All Responded
2014-0221
19 May 2014
London Inner (North)
Barts Health
Concerns summary (AI summary)
The coroner noted a missed opportunity to refer the deceased to critical care, and the lack of observation records during a critical period before the deceased suffered a second bleed and cardiac arrest.
Action Planned
(AI summary)
Barts Health NHS Trust has concluded an investigation and outlined recommendations including recruiting a Band 7 Sister, shortening the transition to an electronic patient record, establishing a Critical Care Board (meeting August 2014), and launching an education strategy to identify deteriorating patients.
Gary Bradshaw
All Responded
2014-0232
15 May 2014
Manchester (South)
Department of Health and Social Care
Stockport NHS Foundation Trust
Concerns summary (AI summary)
The hospital experienced significant delays in diagnosis, inappropriate medication prescribing before test results, inadequate patient monitoring, and poor communication/IT systems, leading to suboptimal care.
Noted
(AI summary)
Stockport NHS Foundation Trust has purchased the Patientrack electronic tracking system which is being piloted and evaluated, with phased rollout planned across the Trust, starting with vital sign input in January 2015. The Department of Health acknowledges the concerns and highlights existing national guidance (NICE, Royal College of Physicians) on early warning scores and the care of acutely ill patients, noting that clinical interpretation is still essential.
Mitchell Clifton
All Responded
2014-0227
13 May 2014
Staffordshire South
Casualty Reduction Team
Concerns summary (AI summary)
The wide access way to a car park, shared by pedestrians and vehicles, has a potentially unsafe layout that could be improved with better markings or physical dividers.
Noted
(AI summary)
Staffordshire County Council reports that the Co-operative introduced road humps, lane markings, and a pedestrian route after the accident. The Co-operative has agreed to renew worn road markings, and the council will add further markings on the highway. The Department for Transport acknowledges the concerns but states that changes to vehicle requirements are not proposed, as they are not convinced that changes to existing requirements would necessarily prevent similar incidents.
Amanda Richards
All Responded
2014-0228
12 May 2014
Coventry
Whitefriars Housing
Concerns summary (AI summary)
The absence of domestic sprinkler systems in special accommodation, like Ms Richards', significantly increased the risk of death from fire.
Action Planned
(AI summary)
Whitefriars Housing states that they will participate in a serious incident review led by the West Midlands Fire Service, and will commission and pay for the installation of domestic sprinkler system to an individual dwelling if it is agreed as the appropriate action.
Courtney Mills
All Responded
2014-0224
12 May 2014
Portsmouth & South East Hampshire
Portsmouth Hospitals NHS Trust
Waterside Medical Centre
Concerns summary (AI summary)
Repeated prescription errors and severe communication breakdowns between the GP surgery and hospital led to dangerous delays in obtaining critical medication, putting the patient at risk of withdrawal.
Noted
(AI summary)
Waterside Medical Centre acknowledges the concerns and details their prior communications with the hospital and pharmacy regarding the patient's medication, suggesting the delay was due to the medication's limited availability in the community. Portsmouth Hospitals NHS Trust states that the Clonidine medication was not prescribed by them and that the hospital would have supplied it if approached. They suggest that the Royal Pharmaceutical Society should consider the issue on a national level.
Ernest Harper
All Responded
2014-0223
9 May 2014
Bedfordshire & Luton
Bedford Borough Council
Concerns summary (AI summary)
Design flaws allowed falling between the safety barrier and vehicle, compounded by the lack of formal assessment for passenger health and mobility for safe access.
Action Taken
(AI summary)
Bedford Borough Council has retro-fitted devices to block gaps on Ford Transit vehicles. A new assessment form designed with Occupational Therapists will be introduced by July 14, 2014, and a client-specific risk assessment will be conducted for non-ambulant clients. A written form has been produced to ensure information regarding the client is also provided in a written format.
Gary Richards
All Responded
2014-0212
9 May 2014
London (Inner South)
South London and Maudsley Trust
Concerns summary (AI summary)
Psychiatric services failed to properly assess self-harm risk, communicate patient vulnerabilities, ensure follow-up due to unrecorded contact details, and implement crucial recommendations from a previous incident report.
Action Planned
(AI summary)
The Trust has secured funding for a mental health specific homeless project, linked to an existing scheme across hospitals. There is now an expectation that discharge summaries will be sent to GPs for all discharges.
Akua Anokye-Boateng
All Responded
2014-0211
9 May 2014
London (Inner South)
Medicines and Healthcare Products Regul…
Concerns summary (AI summary)
The report raises concerns about the use of NSAIDs in children with sickle cell disease, specifically regarding the potential for a single dose to cause GI damage and the lack of clear guidance on gastro-intestinal protection measures.
Action Planned
(AI summary)
The MHRA will publish an article in the September 2014 Drug Safety Update to remind healthcare professionals of existing SPC information regarding GI side-effects of NSAIDs. They will also strengthen the patient information for all NSAIDs regarding GI risk, with changes implemented within 12 months.
Linda Fisher
All Responded
2014-0226
9 May 2014
Blackpool & Fylde
Blackpool Teaching Hospitals NHS Founda…
Concerns summary (AI summary)
Inaccurate medication dosages resulted from doctors relying on patient-reported weight, and critical family medical history was not obtained or effectively communicated among staff.
Action Taken
(AI summary)
Blackpool Teaching Hospitals states that staff now perform a Mid Upper Arm Circumference calculation in line with the Malnutrition Universal Screening Tool (MUST) to assist is establishing an accurate weight, if it is not possible to weigh the patient.