2014
PFD Reports
Reports: 557
Areas: 71
55% response rate (below 63% average).
Peter Norman Nott
All Responded
2014-0229
28 Feb 2014
Oxfordshire
Rush Court Nursing Home
Concerns summary (AI summary)
Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks despite prolonged immobility and clear deterioration.
Action Taken
(AI summary)
Rush Court care home has reviewed its policies and procedures when dealing with a resident who has experienced an unwitnessed fall. Neurological observations will commence using the Glasgow Coma Scale and be incorporated into resident care plans; only a registered nurse or person in charge can handover clinical information to paramedics.
Samuel Shaw
All Responded
2014-0076
26 Feb 2014
North Northumberland
Highways Agency
Concerns summary (AI summary)
Pedestrians crossing a 60mph unlit trunk road from a holiday park face extreme danger due to poor visibility, lack of warning signs for drivers, and no central refuge.
Action Planned
(AI summary)
The Highways Agency has arranged for an investigation to consider options for an improved pedestrian crossing facility in the vicinity of Haggerston. The investigation will assess demand, appraise existing routes, and identify suitable locations.
Andre Matei
All Responded
2014-0089
25 Feb 2014
London (North)
Department of Health and Social Care
Concerns summary (AI summary)
The coroner noted the lack of national guidance on the role of interpreters during labour, particularly when an interpreter is required in theatre.
Noted
(AI summary)
The Department of Health acknowledges the coroner's concerns and states that NICE guidance addresses the use of interpreters. The Department will ensure the coroner's concerns are brought to NICE's attention for future consideration.
Arthur Brockett-Deakins
All Responded
2014-0077
25 Feb 2014
London (Inner South)
Department of Health and Social Care
General Midwifery Council
Medicines and Health Regulatory Authori…
+1 more
Concerns summary (AI summary)
Midwives failed to timely escalate abnormal CTG results due to misapplication of guidelines and inadequate training. Concerns also arose about CTG machines potentially misinterpreting maternal heart rate as fetal heart rate.
Noted
(AI summary)
NICE is currently updating its clinical guideline on Intrapartum Care (CG55) and the progress of the update can be monitored via their website. They will consult on the draft recommendations with stakeholders between 13th May - 24th June 2014 and the final guideline will be published in October 2014. The MHRA states that the incident was not reported to them and that the CTG model was placed on the market by Philips Healthcare and sold in the UK between 1992 and 2006. They included a Safety Notice from August 2002, warning of risks associated with the interpretation of CTG traces. The Nursing and Midwifery Council (NMC) will treat the information about one of the midwives as a new referral and investigate. A local supervisory authority (LSA) would be alerted to serious incidents of this nature via their database system and there is a link to the LSA for every maternity service in London who would provide guidance to a supervisor of midwives when a serious incident occurs. The Department of Health acknowledges the coroner's concerns and notes that NICE has responded on CTG interpretation. They explain the role of statutory supervision of midwives and state the NMC is reviewing this.
Kenneth Aldridge
All Responded
2014-0071
24 Feb 2014
Berkshire
West Berkshire Highways Authority
Concerns summary (AI summary)
The design of a service road access on a 70 mph dual carriageway requires dangerous manoeuvres like significant slowing or U-turns, posing a substantial highway safety risk.
Action Planned
(AI summary)
West Berkshire Council will consult with local ward members and parish councils regarding access improvements, including reducing the westbound traffic lanes and potentially blocking one service road entrance.
Benjamin James Carroll
All Responded
2014-0068
20 Feb 2014
Gwent
Welsh Cycling
Concerns summary (AI summary)
The road remained open to traffic during a cycling race sprint towards the finish line, despite accredited marshals with powers to stop traffic being present.
Action Planned
(AI summary)
Welsh Cycling, working with British Cycling, is launching a "racesmart" awareness campaign targeting participants, event organisers, and officials to ensure the safe running of all events. The campaign will focus on safety and responsibility with direct communication, educational digital content, and a managed social media campaign.
Jack Lynn
All Responded
2014-0066
18 Feb 2014
North Northumberland
Nightingale Home Help Service
Concerns summary (AI summary)
The absence of a continuous medication communication record and a safety/well-being check during a 15-minute care visit exposed the patient to potential risks.
Action Taken
(AI summary)
Nightingales Home Help Service will encourage clients to have medication charts and has advised staff to review their medication policy. They also provided a Safe Handling of Medication course for staff in October 2013 and issued a verbal warning to the employee involved in the incident.
Laura Hill
All Responded
2014-0064
17 Feb 2014
Manchester (South)
Stepping Hill Hospital
Concerns summary (AI summary)
Despite existing training, Falls Risk Assessments were not carried out for the patient during her entire hospital stay, including upon admission and ward transfer.
Action Taken
(AI summary)
Stockport NHS Foundation Trust has instigated an escalation process for locating equipment, to be monitored via the Datix system. The nurses involved were formally counselled, and the case was presented to ward managers at a Surgical Sisters' meeting to disseminate lessons learned.
Refat Hussain
All Responded
2014-0061
12 Feb 2014
London Inner (West)
Harmoni HS
Concerns summary (AI summary)
Out-of-hours GPs working for Harmoni lack access to patients' full medical records, compromising their ability to make accurate diagnoses.
Noted
(AI summary)
Care UK acknowledges the coroner's concerns regarding access to patient information and describes existing systems for receiving information from GPs, including post-event messages, Special Patient Notes, Summary Care Records, and Coordinate My Care in London. They emphasize that the onus is on the registered GP practice to enable access.
John Grooby
All Responded
2014-0054
7 Feb 2014
Warwickshire
Warwickshire County Council
Concerns summary (AI summary)
A lack of signage warning motorists about deer using a specific area as a "game track" creates an avoidable road safety hazard.
Action Planned
(AI summary)
Warwickshire County Council will install two "Wild animals likely to be in the road" warning signs on the A3400, with an order raised on 12 February 2014 and an estimated installation time of 6-8 weeks.
Ryan Clark
All Responded
2014-0057
3 Feb 2014
West Yorkshire (East)
National Offender Management Service
Concerns summary (AI summary)
Prison procedures like the Personal Officer Scheme, ACCT checks, and roll call were not properly implemented. Additionally, prison officers lacked sufficient first aid and CPR training.
Action Planned
(AI summary)
HMP and YOI Wetherby implemented a revised personal officer scheme in October 2013 to ensure greater continuity in the allocation of staff to young people, including a 'relief' arrangement and key points for officers' roles. Leeds City Council has agreed on a procedure between Children's Social Work Service and Youth Offending Service to share all relevant information about a young person going into custody with the Young Offender Institution staff within 24 hours of arrival.
Amanda Vickers
All Responded
2014-0052
3 Feb 2014
Cumbria (North & West)
NHS Cumbria Clinical Commissioning Group
Concerns summary (AI summary)
A severe shortage of specialist crisis home beds, with no clear availability, contributed to a patient's death while awaiting admission, highlighting inadequate commissioning by the CCG.
Action Planned
(AI summary)
Cumbria Clinical Commissioning Group is reviewing the existing framework for wellbeing and mental health and developing a new mental health strategy in partnership with stakeholders. A review of mental health is due to report by the end of May 2014.
Daniel Jones
All Responded
2014-0049
3 Feb 2014
Dorset
Dorset Highways Management
Concerns summary (AI summary)
Insufficient road signage, including warning triangles and white arrows, at a specific junction on the A356 creates a hazard, necessitating improved signage or reduced speed limits.
Action Planned
(AI summary)
Dorset County Council will erect additional 'Side Road Ahead' warning signs on the offside to alert those overtaking to the presence of the junction ahead at Toller Lane. The existing deflection arrows and thickened centre line will have a 'SLOW' road marking laid opposite the new sign for eastbound traffic.
Lee Bonsall
All Responded
2014-0044
31 Jan 2014
Carmarthenshire & Pembrokeshire
Department of Health and Social Care
Concerns summary (AI summary)
Citalopram was inappropriately given on repeat prescription, contravening guidelines. Moreover, long ten-month waiting times for psychotherapy make it an unviable treatment alternative.
Noted
(AI summary)
The Department of Health acknowledges the coroner's concerns regarding repeat prescriptions of citalopram, referencing NICE guidelines. It states that NICE guidelines are not rules and do not restrict prescribing, including repeat prescribing, and that prescribing remains the clinical responsibility of the doctor concerned. The response indicates it will copy the concerns to NICE for their next guideline review. The Department of Health acknowledges the coroner's concerns regarding citalopram prescriptions and psychotherapy waiting times but states these are the responsibility of the Welsh Government. It includes information about Citalopram's Summary of Product Characteristics and monitoring requirements for potential suicide risks.
Tallulah Wilson
All Responded
2014-0047
30 Jan 2014
London Inner (North)
Department of Health and Social Care
Concerns summary (AI summary)
Healthcare professionals lacked sufficient understanding of young people's evolving internet use and online lives. Digital lives training is not standard for psychiatric or medical inductions.
Action Planned
(AI summary)
The Department of Health highlights a Policy Research Programme investing in projects exploring the internet's role in suicidal behaviour and identifies priorities for prevention. It also mentions that the Royal College of Psychiatrists will recommend making competencies related to media impact compulsory in the next curriculum revision and launching an e-learning tool for children and young people's mental health.
Judith Marshall
All Responded
2014-0039
27 Jan 2014
York
Department of Health and Social Care
General Pharmaceutical Council
NHS England
+1 more
Concerns summary (AI summary)
The pharmacy showed unpoliced drug errors and dispensing mistakes despite checks. Concerns include lack of alert software, mandatory read-back procedures, and a central error database.
Action Planned
(AI summary)
The General Pharmaceutical Council acknowledges the concerns and states they are considering publishing an anonymised summary of the case in their newsletter 'Regulate'. It highlights existing guidance and standards, including the importance of patient safety and a two-person check in dispensing, and also emphasizes its work with the MHRA and NHS England to improve adverse incident reporting. NHS England describes actions underway to improve medication safety, including publishing a new Patient Safety Alert on medication errors in March 2014. It also mentions a review of community pharmacy incident data to prepare a Patient Safety Alert, that would better describe risks arising from dispensing medicines, and safer practices including better use of technology and checking systems. The Royal Pharmaceutical Society acknowledges the concerns and says it could raise awareness and encourage use of 'read-back' as one technique amongst others to reduce errors in the guidance that they produce. They also indicate they can raise awareness of additional checks within guidance that they produce. The Department of Health describes actions taken to address concerns around dispensing errors, including the MHRA working with NHS England to simplify medication error reporting. An integrated reporting route has been introduced to share reports, and a National Medication Safety Network is being established to discuss safety issues and improve the safe use of medicines.
Umul Audu
All Responded
2014-0038
27 Jan 2014
London Inner (North)
University College London Hospitals NHS…
Concerns summary (AI summary)
The lack of transport heater availability during patient transfers risks future patients suffering hypothermia, potentially leading to death.
Disputed
(AI summary)
University College London Hospitals NHS Foundation Trust acknowledges the concerns about the lack of a transport heater, but argues against changing its policy and introducing transport heaters. They believe standard measures are sufficient and their current practice aligns with national standards and that there are contraindications to using such devices for some investigations.
Bertha Cray
All Responded
2014-0037
24 Jan 2014
London Inner (North)
Barts Health NHS Trust
Concerns summary (AI summary)
Inadvertent alteration of 'nil by mouth' signage is possible due to easily turned double-sided signs and an unclear cause of previous alteration, risking recurrence.
Action Taken
(AI summary)
The Trust has stopped using double-sided 'nil-by-mouth' signs with different instructions on each side, and will now issue signs with the same instruction on both sides. The family has been informed of the outcome of the investigation and seemed reassured by the changes made by the Trust.
Alfred Hodges
All Responded
2014-0033
24 Jan 2014
North Central & North East Wales
Conwy County Council
Concerns summary (AI summary)
Conwy's Telecare package lacks standard interlinked smoke alarms, and interim safety provisions are unclear. Additionally, the deceased was not offered a free home fire safety check.
Action Taken
(AI summary)
The council has installed 105 linked smoke detectors, funded a full-time installation post, and received refresher training from NWFRS on smoke detector placement. They also prepared a briefing note for Social Services staff to identify and test smoke alarms during home visits.
Mone White
All Responded
2014-0031
21 Jan 2014
London (North)
Department of Health and Social Care
Northwick Park Hospital
Concerns summary (AI summary)
There is no system to ensure specialist hospital advice for patients with complex clinical requirements is consistently communicated to all treating clinicians.
Noted
(AI summary)
The Secretary of State acknowledges the concerns, notes that guidance was already provided to relevant organisations, and refers to GMC guidance on information sharing. They consider that systems to ensure clinical advice is brought to the attention of treating clinicians should be addressed locally by the NHS Trust. The North West London Hospitals NHS Trust has developed and implemented a flagging system for patients under the care of specialist hospitals with specialist clinical requirements, in partnership with Consultant Paediatricians and the IT Department. A standard operating procedure supports the process and the system has been discussed widely within the Paediatric Directorate.
Frederick Pring
All Responded
2014-0024
21 Jan 2014
North Wales (East & Central)
Betsi Cadwaladr University Health Board
Concerns summary (AI summary)
Current practices for patient handover at Emergency Departments lead to unacceptable delays, keeping ambulances occupied and unavailable for other critical calls.
Action Planned
(AI summary)
The Welsh Ambulance Service NHS Trust and Betsi Cadwaladr University Health Board are working towards completing an All Wales Handover Policy for patient handover between clinical teams. The Health Board also proposed acting as a 'Demonstrator Site' to implement recommendations regarding overcrowding in Emergency Departments.
Julie Ann Camm
All Responded
2014-0023
17 Jan 2014
West Yorkshire (East)
Leeds City Council
Concerns summary (AI summary)
A vulnerable tenant's property lacked smoke alarms because the housing association's policy only encouraged fire safety checks, failing to ensure installation and increasing the risk of death from fire.
Action Planned
(AI summary)
Housing Leeds will install hard-wired smoke detection in 40 properties and battery-powered detectors in remaining properties without detection equipment over the next 12 months, in consultation with West Yorkshire Fire & Rescue Service. The Electrical Specification has been updated to include hard-wired detection for major electrical works, and the Annual Tenancy Visit will include smoke detection identification.
Jason Nock
All Responded
2014-0013
13 Jan 2014
Black Country
Home Office
Concerns summary (AI summary)
An entirely unregulated product is readily available without consumer information on safe dosage or potential consequences, leaving users unaware of the substance they are consuming.
Action Planned
(AI summary)
The Home Office has asked the Advisory Council on the Misuse of Drugs (ACMD) for advice on AH-7921 and is collecting evidence from health organizations and law enforcement. They are also undertaking a review of the UK's response to new psychoactive substances.
Michael O’Sullivan
All Responded
2014-0012
13 Jan 2014
London Inner (North)
Department for Work and Pensions
Concerns summary (AI summary)
The DWP assessment process for fitness to work failed to incorporate vital medical information from the patient's treating GP, psychiatrist, and clinical psychologist, leading to decisions without comprehensive medical input.
Action Planned
(AI summary)
DWP acknowledges concerns and will issue a reminder to staff about guidance related to suicidal ideation. They also state that they will continue to monitor their policies around assessment of people with mental health problems.
Albert James Hand
All Responded
2014-0010
9 Jan 2014
Bedfordshire & Luton
East of England Ambulance Service
Concerns summary (AI summary)
The coroner reported concerns about a patient with a head injury waiting over an hour and a half for transport to hospital, insufficient ambulance crews in the Luton and Bedfordshire area, and protocols for dealing with emergency calls potentially putting patients at risk.
Action Taken
(AI summary)
The East of England Ambulance Service NHS Trust has reviewed its Demand Management Plan, commenced issuing a clinical manual to staff, and is commissioning an upgrade to the Computer Aided Dispatch (CAD) system. They are also continuing to augment their clinical coordination function within the Health and Emergency Operations Centres (HEOCs).