2014
PFD Reports
Reports: 557
Areas: 71
55% response rate (below 63% average).
Leslie Harding
All Responded
2014-0169
8 Apr 2014
Plymouth, Torbay & South Devon
Oak Side Surgery
Concerns summary (AI summary)
There was a failure to take prompt action and ensure robust treatment for a patient with a suspected life-threatening pulmonary embolus over a critical period.
Action Planned
(AI summary)
The doctor has decided to adopt a system of writing notes using the computer appointment system and a ring-bound notebook. The practice is composing a letter informing people of the risks of non-concordance with medication and has extended this review to patients receiving low molecular rate heparin and novel oral anti-coagulants; they have scheduled a further discussion of the case at the next significant event analysis meeting.
Andrew Horgan
All Responded
2014-0163
8 Apr 2014
Wiltshire & Swindon
Great Western Hospital
Concerns summary (AI summary)
Doctors lacked clear understanding and training on mental health referral procedures, leading to inadequate patient assessment processes.
Action Taken
(AI summary)
The Trust increased the number of Mental Health Liaison nurses from 2.6 to 6.8 and appointed a dedicated Consultant Psychiatrist. They also state that 82% of clinical staff had undertaken Mental Health Act training and 94% MCA and DoLS during 2013/14.
Roger Duggan
All Responded
2014-0157
7 Apr 2014
Exeter & Greater Devon
Royal Devon and Exeter Hospital NHS Tru…
Concerns summary (AI summary)
An agitated patient was left unsupervised in the Emergency Department, and staff failed to take responsibility for monitoring him, leading to his unnoticed departure.
Action Taken
(AI summary)
The staff nurse involved in the incident was reminded of the importance of contemporaneous record keeping. The Trust is using its Care Quality Assessment Tool (CQAT) to ensure that documentation is given a higher priority in scoring, and case notes are audited through various review processes. The incident reporting policy will be more explicit in relation to retaining equipment and devices. Following an investigation, the Trust upgraded its version of 'NHS Pathways' to version 6.5.1, including a dedicated Mental Health Pathway, and trained staff on its use; a Mental Health Group has also been established to monitor responses to patients with mental health concerns.
Eric Matthews
All Responded
2014-0151
4 Apr 2014
London Inner (North)
University College London Hospitals NHS…
Concerns summary (AI summary)
There is limited public awareness and insufficient research regarding the risk of positional asphyxia associated with baby slings.
Noted
(AI summary)
The Trust investigated a survey of 'cot deaths' in unusual scenarios but it did not prove feasible due to data protection and consent issues. They suggest coroners liaise with clinicians working on sudden infant death and release data from existing child death reviews.
Danuta Corbett
All Responded
2014-0150
3 Apr 2014
Brighton & Hove
Sussex Partnership NHS Foundation Trust
Concerns summary (AI summary)
The hospital's leave policy for informal patients was not followed, and inadequate risk assessment for escorted leave, using an untrained agency worker, resulted in critical safety failures.
Action Taken
(AI summary)
The consultant psychiatrist now carefully reviews notes taken during ward review. The Trust has reinforced with staff that should extraordinary circumstances arise again, a retrospective note must be completed, and the nurse responsible will ensure proper handovers take place in the future.
Graham Watts
All Responded
2014-0149
3 Apr 2014
Brighton & Hove
Brighton and Sussex University Hospital…
Royal Sussex County Hospital
Princess Royal Hospital
Concerns summary (AI summary)
The hospital's discharge procedure was severely flawed, involving blank paperwork, lack of communication with family or care home, and discharging a medically unfit patient.
Action Taken
(AI summary)
A social worker has started attending daily "Board Round" meetings to assist in patient discharge planning. The Trust acknowledges shortcomings in the discharge planning process and is aiming to start a one year pilot scheme to focus on consistent multi-disciplinary management of frail elderly patients, in preparation for their discharge.
Melvin Bandtock
All Responded
2014-0147
3 Apr 2014
County Durham & Darlington
Durham Constabulary
Durham County Council
Concerns summary (AI summary)
A duty manager's decision not to grit roads based on inaccurate weather assessment led to dangerous conditions; improved information sharing and review of council procedures are needed.
Disputed
(AI summary)
The Council intends to meet with weather forecasters prior to the next winter season to determine whether notifications relating to changes in weather can be improved. Duty Managers have been reminded to ensure that appropriate action is taken and the safety of the highway network is the paramount consideration. The Constabulary disputes the coroner's concern, stating that their procedures for dealing with road incidents are not managed on an ad-hoc basis and that they have robust, well-managed procedures and good communication with Durham County Council.
John Dodd
All Responded
2014-0145
2 Apr 2014
Black Country
Dudley Group NHS Foundation Trust
Concerns summary (AI summary)
Inadequate patient monitoring, including missed INR checks and unreported temperature rise, coupled with significant delays in A&E medical assessment, compromised patient safety.
Action Planned
(AI summary)
The Trust will develop a written guideline to include routine checking of INR for all patients presenting after a fall who are receiving vitamin-K antagonist anticoagulants. The Emergency Department will develop an audit process to review the appropriate referral of patients for senior review, and the electronic clinical information system will be reconfigured to create a visible alert to the consultant in charge when a patient's vital signs fall outside normal parameters.
Lee Hollman
All Responded
2014-0135
26 Mar 2014
West Sussex
Horsham and Mid Sussex Clinical Commiss…
Royal College of General Practitioners
Concerns summary (AI summary)
The practice had inadequate systems for maintaining accurate medical records, removing outdated repeat prescriptions, and reviewing patients' medication within guidelines.
Action Planned
(AI summary)
The RCGP and Royal Pharmaceutical Society will convene a multi-stakeholder group and establish a joint working group, including patients, to explore recommendations and develop a work program focused on shared standards, education and training. Riverside Surgery met with the Horsham Community Mental Health Team to improve communication, discussed prescribing with the CCG, and has ongoing reviews for mental health patients, including specialist consultations, case review meetings, and face-to-face reviews, leading to modified policies and processes.
Margaret Walker
All Responded
2014-0134
25 Mar 2014
Manchester (West)
5 Boroughs Partnership
Concerns summary (AI summary)
Incomplete medication history, poor record-keeping, and failure to apply a defibrillator promptly by ward staff contributed to critical care delays.
Action Taken
(AI summary)
The Trust has reviewed its medicines policy, will issue further guidance on medicines reconciliation, has implemented Trust-wide initiatives for managing physical health and diabetes, developed diabetes guidelines, introduced Diabetes Link Nurses/Associates and provided the Hospital at Home service.
Caroline Pilkington
All Responded
2014-0269
25 Mar 2014
Manchester (West)
Department of Health and Social Care
North West Ambulance Service
Concerns summary (AI summary)
North West Ambulance Service staff lack control and restraint training, forcing reliance on police who are not clinically trained, leading to delayed patient care and inappropriate diversion of police resources.
Noted
(AI summary)
Greater Manchester Police expresses concern about the increasing demand on police due to gaps in health services, emphasises that officers are trained in restraint but that medical emergencies require different approaches, and offers support to NWAS in training initiatives. NWAS acknowledges the coroner's concerns but maintains that ambulance staff are not trained nor expected to restrain patients who are acting in a threatening or violent manner, as advanced control and restraint is a specialised skill best left to the police. The Department of Health acknowledges the coroner's concerns but supports the NWAS's collaborative approach with the police in handling patients requiring advanced control and restraint. The Department of Health acknowledges the coroner's concerns about NWAS training, but supports the NWAS position that ambulance staff are sufficiently trained and that more advanced restraint training is not needed or beneficial.
Kerry Jacobs
All Responded
2014-0133
21 Mar 2014
West Sussex
Surrey and Sussex NHS Trust
Concerns summary (AI summary)
The hospital lacked a policy requiring doctors to document reasons for prescribing medication outside BNF guidelines. There was also no protocol for pharmacists and clinicians to discuss queried medication dosages.
Action Taken
(AI summary)
The Chief Medical Officer issued a directive for staff to record the rationale for prescribing medication outside of BNF guidance, and the Chief Pharmacist has reiterated the medication screening procedure to pharmacy staff, instructing direct discussion between prescribing doctor and dispensing pharmacist.
Derrick Plater
All Responded
2014-0130
21 Mar 2014
Norfolk
Cambridgeshire County Council
Concerns summary (AI summary)
There was no protocol for visiting care homes before placing patients with complex needs, relying solely on assurances. A lack of clear guidelines for when visits should be undertaken during assessment poses a risk.
Disputed
(AI summary)
The council believes that a pre-placement visit by a social worker would not have provided any added assurance and is not and will not be part of the assessment and placement process.
Robert Jones
All Responded
2014-0190
20 Mar 2014
Carmarthenshire and Pembrokeshire
West Wales General Hospital Glangwili C…
Concerns summary (AI summary)
CT scan results were not made available promptly to relevant departments, nor were they acted upon without delay and within a reasonable timeframe.
Action Planned
(AI summary)
The Radiology department will sample emergency CT scan report times. All staff will be reminded to document review of test results, and verbal results. A report on these actions will be presented to the Health Board's Putting Things Right Committee in September.
David Oldfield
All Responded
2014-0117
14 Mar 2014
West Yorkshire (East)
West Yorkshire Police Force
Concerns summary (AI summary)
Concerns were raised about the appropriateness and justification of tasering the deceased, given discrepancies in officer accounts. Unjustified tasering unnecessarily increases the risk of serious injury or death.
Noted
(AI summary)
West Yorkshire Police acknowledge the concerns raised, particularly regarding officer accounts, and state that the IPCC was informed. They also offer a visit to their training facilities to demonstrate Taser training and usage.
Michael Tarratt
All Responded
2014-0115
14 Mar 2014
Leicester City & South Leicestershire
Leicestershire Partnership NHS Trust
Concerns summary (AI summary)
There was an unacceptable 18-month lapse in communication between the drug and alcohol team and the GP. Services failed to exchange information on inappropriate prescriptions for an opiate-dependent patient.
Action Taken
(AI summary)
An urgent memo was sent to the Drug & Alcohol team regarding GP communication standards (minimum every 3 months). Standard GP letter templates have been reviewed to ensure detailed updates are sent and are due to be uploaded within 14 days, with prompts and reminders by June 30th. A case note audit is due within 14 days, with follow-ups every 6 months.
Janette Sutherland
All Responded
2014-0114
13 Mar 2014
Gwent
Caerphilly County Borough Council
Concerns summary (AI summary)
A drainage channel and concrete headwall present a significant hazard to road users. A safety barrier is needed to prevent vehicles from impacting the headwall.
Action Planned
(AI summary)
The council will investigate the site of the incident to provide recommendations for measures to alleviate future incidents. A Road Restraint Risk Assessment Process (RRRAP) survey was carried out on March 27th, and the council will complete the RRRAP in a timely manner and provide details of any findings/outcomes. Following a Road Restraint Risk Assessment Process (RRRAP), the council will demolish a headwall and re-profile the surrounding ditch, with works programmed for commencement in July.
Jean James
All Responded
2014-0112
13 Mar 2014
Sunderland
City Hospitals Sunderland NHS Foundatio…
Concerns summary (AI summary)
Initial documentation delays and the unreviewed omission of prophylactic medication occurred. Pharmacy queries were poorly communicated, indicating that existing systems and protocols may be insufficiently robust to prevent human factor failures.
Action Planned
(AI summary)
The hospital information system is being updated to require completion of VTE prescriptions for at-risk patients, with alerts on medication administration records. A new format for clinical handover from the Acute Medical Unit to base ward has been introduced. The Trust will hold a clinical symposium in the autumn regarding VTE management.
Wendy Brown
All Responded
2014-0113
12 Mar 2014
Wiltshire & Swindon
Swindon Borough Council
Concerns summary (AI summary)
Significant delays in implementing care packages and providing respite support for vulnerable carers, compounded by inadequate signposting of adult care services, complicated funding routes, and lengthy application processing times, put carers under severe strain.
Action Taken
(AI summary)
Swindon Borough Council recognises complexity and potential delays in decision making are real issues. An immediate action taken is that; were services over and above the indicative budget are requested, the indicative budget can be agreed pending any additional information required to ensure that some services are in place in a timely manner.
Craig Marren
All Responded
2014-0106
10 Mar 2014
West Yorkshire (East)
Tyersal Farm
Concerns summary (AI summary)
Trees and foliage at a blind left-hand bend significantly impede driver visibility, creating a dangerous road hazard that requires cutting back.
Action Taken
(AI summary)
City of Bradford Council confirms that an order has been raised for a hedge to be flailed back to clear the highway obstruction.
Neil Carter
All Responded
2014-0103
5 Mar 2014
London (West)
Care Quality Commission
Priory Group
Concerns summary (AI summary)
There were repeated failures in basic nursing observations, chronic inadequate staffing and skill mix, and deliberate falsification of nursing records, compounded by management's failure to address reported issues.
Action Planned
(AI summary)
The CQC will include information held on deaths in psychiatric detention in all future annual reports. They will also work with partners in developing the Mental Health Crisis Care Concordat and deliver a thematic programme around the experiences and outcomes of people experiencing a mental health crisis, with a national report expected in the autumn of 2014. The organisation disciplined and dismissed a nurse for falsifying records and referred them to the NMC. They have also implemented changes to the staff induction programme and introduced daily monitoring visits, 'flash' meetings and monthly staff meetings to improve communication and patient care.
Kathleen Border
All Responded
2014-0095
4 Mar 2014
Portsmouth & South East Hampshire
Northwood Square
Concerns summary (AI summary)
Inadequate and unclear signage for parking areas led to a delivery vehicle reversing outside a designated zone, causing a fatal collision.
Action Taken
(AI summary)
Hanover has installed an extra sign to alert drivers to pedestrians and will remind residents and visitors to take care when walking behind parked vehicles via the estate newsletter.
Marco Lima De Araujo
All Responded
2014-0093
3 Mar 2014
Portsmouth & South East Hampshire
Queen’s Harbour Master Portsmouth
Concerns summary (AI summary)
There is no formal protocol for reporting and coordinating rescue efforts during life-threatening incidents in Portsmouth Harbour.
Noted
(AI summary)
The Maritime Coastguard Agency outlines its existing protocols for maritime search and rescue, including communication and cooperation with the Queen's Harbour Master Portsmouth and participation in the SOLFIRE multi-agency response group.
Carl Morris
All Responded
2014-0092
3 Mar 2014
Cumbria (North & West)
Professional Association of Diving Inst…
Action Planned
(AI summary)
PADI will include an additional statement in the 'Learning Agreement' to further enforce the issue of medical illness to both the Instructor and student diver with regards to doctor's approval and medical fitness. This will be notified to instructors via quarterly training bulletins.
Richard White
All Responded
2014-0085
28 Feb 2014
County Durham & Darlington
700 Club
Concerns summary (AI summary)
Hope House lacked a formal, documented policy or protocol for medication administration, which was unknown to prescribers and not made available to staff.
Noted
(AI summary)
The 700 Club clarifies that it does not store or administer medication to clients, emphasizing that responsibility for safeguarding clients regarding medication lies with GPs. They will receive medication if handed to them, but will not return it without GP authorisation.