2015

PFD Reports
Reports: 477 Areas: 69

62% response rate (below 63% average).

477 results
Margaret Pegnall
Historic (No Identified Response)
31 Dec 2015 Norfolk
Old Catton Medical Practice
Concerns summary (AI summary) A GP practice had a vague domestic abuse flowchart focused on depression, lacked a specific domestic abuse questionnaire, and had no system for escalating urgent patient calls.
Mollie Bentham
Historic (No Identified Response)
30 Dec 2015 Manchester (West)
Royal Bolton Hospital NHS Foundation Tr…
Concerns summary (AI summary) Repeated family concerns about abdominal pain and rising infection markers were not documented, escalated to medical teams, or examined, leading to a significant delay in diagnosing a critical condition.
Imran Douglas
Partially Responded
2015-0446 29 Dec 2015 London Inner (South)
General Medical Council London Borough of Tower Hamlets National Offender Management Service
Concerns summary (AI summary) A more flexible, person-based system may be safer than the current rule-based system regarding the transition of duties from YOT/YJB to PMU at age 18. Also, there appeared to be a disconnection between Looked After Child pathway planning and Transition Planning.
Action Planned (AI summary) • Leeds City Council has been working to design a scheme which provides safe pedestrian assisted facilities across the Ring Road at this location and the neighbouring Coal Road junction. • Design considerations have been concluded and a final layout has been confirmed, which will be compatible with proposed future improvements planned at the Coal Road/ Ring Road junction and also longer term aspirations along this strategic corridor. • A Highways Board report is to be presented to the Chief Officer (Highways and Transportation) early in the New Year to seek formal funding approval to progress the junction improvement measures at the Ramshead Approach/ Ring Road junction.
Angela Brealey
Partially Responded
2015-0473 24 Dec 2015 Staffordshire (South)
South Staffordshire and Shropshire NHS … St George’s Hospital
Concerns summary (AI summary) The trust lacked clear procedures for handling third-party information, showed minimal multidisciplinary team involvement in patient care, and its serious incident review process failed to identify several treatment concerns.
Action Taken (AI summary) The Trust has reviewed and amended its Serious Incident Review process and now employs a full-time Serious Incident Review Co-ordinator and Administrator. Reports now go through an additional governance process, with commissioners carrying out a challenge review.
Christopher Higgins
All Responded
2015-0480 24 Dec 2015 Norfolk
James Paget University Hospital Norfolk and Norwich University Hospital Norfolk and Suffolk NHS Foundation Trust +1 more
Concerns summary (AI summary) Inconsistent mental health observation practices, inadequate patient escort protocols during police transfers, unassessed safety risks in the environment, and poor inter-agency agreements for A&E assessment of detained patients led to unsafe conditions.
Action Taken (AI summary) The Trust updated its Observation and Engagement of Service Users policy and communicated changes to staff. Additional height bars were added to a railing on the disabled access ramp and the Trust has decided to enclose the ramp, with work scheduled for completion by the end of March 2016. The Trusts have worked together to develop a process for ensuring that patients under the care of mental health services who require acute care have a clear pathway which includes agreed communication channels between clinicians. A flow-diagram has been developed and is being used. The hospital has worked with Norfolk and Suffolk NHS Foundation Trust to develop a referral pathway to ensure inpatients from the local mental health facility can access care and treatment in the Emergency Department in a timely manner. A written pathway and flow diagram has been developed for staff.
Shalini Ganesh-Ram
Historic (No Identified Response)
2016-0117 22 Dec 2015 London Inner (North)
Royal London Hospital
Concerns summary (AI summary) The report identifies that a raised pulse, abdominal pain and lack of urine output did not prompt a CT scan and a surgical consult was not sought until four days post operation, suggesting suboptimal care due to issues within the system.
Kay Sheard
Historic (No Identified Response)
21 Dec 2015 North Wales (East and Central)
BCUHB, Ysbyty Gwynedd
Concerns summary (AI summary) Pulse oximeter alarm settings are fixed at a routine level rather than being adjusted to individual patient baselines, risking unnoticed significant oxygen desaturation.
Mary Hollands
Historic (No Identified Response)
21 Dec 2015 North Wales (East and Central)
BCUHB, Ysbyty Gwynedd
Concerns summary (AI summary) The system for providing radiologist reports to the Emergency Department is unreliable, creating a risk that subtle injuries may be missed and patient safety netting is ineffective.
James Graham
Historic (No Identified Response)
17 Dec 2015 County Durham
G4S Medical Services Premier Physical Healthcare Spectrum Community Health CIC
Concerns summary (AI summary) Critical communication failures between primary care and podiatry, coupled with a lack of ownership in referral processes and administrative errors, caused significant delays in secondary care access.
Edna Cleaton
Historic (No Identified Response)
17 Dec 2015 Birmingham and Solihull
Jockey Road Medical Centre
Concerns summary (AI summary) The practice lacked systems for regular medical reviews of patients on citalopram, resulting in a three-year delay in review and a missed opportunity to identify deterioration.
William Driscoll
Historic (No Identified Response)
16 Dec 2015 Birmingham and Solihull
The Driver and Vehicle Licensing Author…
Concerns summary (AI summary) There are serious deficiencies in the medical assessment process for drivers, including insufficient investigation of health conditions, leading to inadequately assessed individuals being permitted to drive.
Derek Thomas
Partially Responded
2015-0502 15 Dec 2015 County Durham and Darlington
CARE UK G4S GEOAmey +2 more
Concerns summary (AI summary) Prison reception procedures failed under extreme pressure, leading to suicide risk information being overlooked due to staffing issues. Additionally, there was poor communication and conflicting understanding between prison and escort staff regarding critical safety form procedures.
Noted (AI summary) Nursing staff have been instructed to review all documents when completing reception screening, and staff have been reminded of the importance of ensuring all paperwork accompanies an individual. All initial healthcare assessments are undertaken by qualified mental health nurses, unless circumstances prevent this. The prison has implemented mandatory verbal handover of SASH form information from reception staff to healthcare staff. All staff working in reception must complete an online training course, managed by their line manager and monitored through the staff appraisal system. Care UK is no longer the healthcare provider at HMP Durham. It will forward the concerns to heads of healthcare at other facilities where it interacts with GEO Amey and the prison service. GEOAmey provided refresher training to over 90% of their officers regarding the completion of Prisoner Escort Records (PER) and Self Harm and Suicide Warning Forms (SASH Forms), following concerns raised about procedures and training.
Joyce Tozer
Historic (No Identified Response)
15 Dec 2015 Birmingham and Solihull
University Hospitals Birmingham NHS Fou…
Concerns summary (AI summary) Omnipaque is frequently administered at doses exceeding manufacturer's guidelines, sometimes via central lines, which exposes interventional radiology patients to potential toxicity risks.
Ruth Smith
Historic (No Identified Response)
15 Dec 2015 West Yorkshire (West)
Calderdale and Huddersfield NHS Foundat…
Concerns summary (AI summary) There were significant delays in doctor review, inadequate nursing observations, and poor record-keeping by both nursing and medical staff. Crucial follow-up for medical interventions was also absent.
Kamrul Rubel
Historic (No Identified Response)
15 Dec 2015 Birmingham and Solihull
Birmingham City Council
Concerns summary (AI summary) The gym did not enforce the use of the emergency stop cord despite providing advice, raising concerns about adherence to safety protocols for gym equipment.
Julie Rose
Historic (No Identified Response)
14 Dec 2015 Kent (Central and South East)
Kent and Medway NHS and Social Care Par…
Concerns summary (AI summary) The "Unable to Make Contact Protocol" lacks clarity on mandatory police welfare checks for high-risk patients, and staff demonstrated inadequate understanding of its procedures.
Kevin Gilbert
Historic (No Identified Response)
14 Dec 2015 Kent (Central and South East)
St Thomas' Hospital
Concerns summary (AI summary) There was confusion and unreasonable delay in transferring an acute aortic dissection patient to a tertiary center, including a failure to escalate the transfer decision to a consultant.
Alan Walker
Historic (No Identified Response)
14 Dec 2015 North Wales (East and Central)
BCUHB, Ysbyty Gwynedd
Concerns summary (AI summary) Critical information was not consistently recorded in nursing notes, and handovers did not reference these records, risking significant patient details being missed by incoming staff.
Daniel Byrne
Historic (No Identified Response)
14 Dec 2015 Milton Keynes
Ms Claire Murdoch, Chief Executive, Cen… Northwest London NHS Trust
Concerns summary (AI summary) There were repeated failures to identify and assess suicide risk in newly arrived prisoners, with nursing staff notably absent from initial health screenings and reviews.
Paul Whitehead
Historic (No Identified Response)
14 Dec 2015 West Yorkshire (East)
WE Rawson Ltd, Castle Bank Mills, Porto…
Concerns summary (AI summary) Emergency response procedures were inefficient, with delays in contacting emergency services, inadequate first aid provision, and difficulties for paramedics locating the casualty on-site.
William Maskell
Historic (No Identified Response)
14 Dec 2015 Exeter and Greater Devon
Devon Partnership NHS Trust Students Union, University of Exeter University of Exeter
Concerns summary (AI summary) The absence of clear protocols and an overemphasis on student autonomy led to delayed intervention and reluctance to force entry for a student in distress, risking future deaths.
Margaret O’Brien
Historic (No Identified Response)
11 Dec 2015 London (West)
CARE UK
Concerns summary (AI summary) Staff lacked specific, prescribed training on how to properly conduct and record observations of residents.
Ololade Olaobaju
Historic (No Identified Response)
10 Dec 2015 London Inner (South)
ENT UK Royal College Anaesthetists
Concerns summary (AI summary) There is no joint guidance for "Can't Intubate Can't Oxygenate" situations when both anaesthetists and ENT surgeons are present, leading to inconsistent clinical judgments and limited practitioner experience.
Jake Robinson
All Responded
2015-0474 9 Dec 2015 Manchester (South)
Bodmin Road Health Centre Greater Manchester NHS Area Team Greater Manchester West Health NHS Trust
Concerns summary (AI summary) The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.
Noted (AI summary) Bodmin Road Health Centre provided context and clarified their actions regarding the patient's care, and noted a past apology to the patient's mother. They reflected on whether further information sharing would have made a difference. Trafford Aim has implemented a more streamlined process for receiving letters and faxes. CMHT staff have been reminded to consider alternative ways to carry out assessments and engage service users, and a dedicated duty worker role has been established. GMCA stated that Greater Manchester West Mental Health Foundation Trust implemented systems to capture and act upon letters or faxes received. They also set up a Dual Diagnosis Steering Group.
Madhumita Mandal
Historic (No Identified Response)
8 Dec 2015 London (South)
Croydon Clinical Commissioning Group Croydon Health Services Virgin Care Wandle LLP
Concerns summary (AI summary) An emergency department streaming model that relied on untrained receptionists without medical observations led to critical delays in patient assessment by qualified healthcare professionals.