2015

PFD Reports
Reports: 477 Areas: 69

62% response rate (below 63% average).

Response Status
Responded 295 Historic 181
AI Classification
Action Taken 47%
Action Planned 30%
Noted 21%
Disputed 2%
Based on 385 classified responses
Top Categories
Hospital Death (Clinical Procedure… (224) Other related deaths (54) Community health care and emergenc… (46) Road (Highways Safety) related dea… (38) Child Death (from 2015) (35)
477 results
Gail Prentice
Historic (No Identified Response)
2015-0253 2 Jul 2015 Powys, Bridgend and Glamorgan Valleys
Cwm Taf University Health Board National Assembly for Wales
Concerns summary (AI summary) There is no mandatory requirement for surgeons to acknowledge reading relevant Health Board and national clinical guidelines, potentially leading to inconsistencies in surgical practice and patient care.
David Hallett
Historic (No Identified Response)
2015-0250 2 Jul 2015 Powys, Bridgend and Glamorgan Valleys
HMP Parc HMP Rye Hill National Offender Management Service +1 more
Concerns summary (AI summary) HMP Rye Hill's healthcare was inadequately resourced and unprepared for its re-roll to house sex offenders, resulting in substandard patient care. This raises concerns about similar risks in future national prison re-rolls.
Mary Hyden
All Responded
2015-0251 1 Jul 2015 Staffordshire (South)
University Hospital North Midlands
Concerns summary (AI summary) A consultant neurologist is working excessive hours, including 7-day weeks and 14-hour shifts, which significantly increases the potential for medical errors and risks to patient safety.
Action Taken (AI summary) The University Hospitals of North Midlands NHS Trust has reviewed the consultant's job plan, which will be updated from October 2015 to allow for a better work-life balance. The consultant is also now supported by a second consultant and has been encouraged to use administrative support.
Blaise Farry
Historic (No Identified Response)
2015-0269 30 Jun 2015 London (West)
HMP WORMWOOD SCRUBS
Concerns summary (AI summary) Insufficient staffing levels at HMP Wormwood Scrubs prevent the implementation of a nominated Officer scheme, despite prior recommendations, impacting prisoner welfare and safety.
Colette Hughes
All Responded
2015-0246 30 Jun 2015 London (South)
Hammerson Plc
Concerns summary (AI summary) An easily accessible wall, despite meeting regulations, has been the site of multiple deaths and poses a danger, particularly to impaired individuals. Physical modifications may be necessary to prevent future fatalities.
Action Taken (AI summary) Hammerson PLC is making access to the parapet walls of the car park more difficult with 'hostile planting', installing similar planting on lower level walls and installing vehicle stopping barriers along the floor adjacent to the walls. They are also exploring the feasibility of raising the height of the parapet walls.
Michael Bovell
Historic (No Identified Response)
2015-0248 29 Jun 2015 London (North)
Rail Safety and Standards Board
Concerns summary (AI summary) The RSSB Rule Book's provisions for stopping trains are insufficient, prioritizing potential train damage over human life. Even cautioned trains can strike individuals, highlighting a gap in preventing harm to trespassers on the line.
Davin Short
All Responded
2015-0245 29 Jun 2015 Norfolk
HMP Wayland
Concerns summary (AI summary) The prison's lack of an electronic cell bell recording system and unclear guidance on radio use for healthcare staff create risks of medical emergencies being overlooked or delayed, endangering prisoners.
Action Taken (AI summary) HMP Wayland published a Governor's Order clarifying the recording of medical issues occurring overnight and amended the Local Security Strategy to support this. They also introduced a new radio system with more radios for healthcare staff. HMP Wayland has issued a Governor's Order instructing staff to record medical issues during the night in the wing observation book and amended the Local Security Strategy to reflect this procedure. A new radio system has been introduced at HMP Wayland and all healthcare staff are now routinely issued with radios.
Alec Mathias
Historic (No Identified Response)
2015-0247 26 Jun 2015 Exeter and Greater Devon
Royal Devon and Exeter Hospital
Concerns summary (AI summary) Critical drug sensitivity information was not included in discharge letters sent to the patient's GP, nor was it highlighted in hospital records, posing a significant risk.
Brian Gillard
Historic (No Identified Response)
2015-0244 26 Jun 2015 Manchester (West)
Royal Bolton Hospital
Concerns summary (AI summary) A critical breakdown in patient handover between hospital departments led to ward staff being unaware of a patient's need for ambulatory oxygen, resulting in the patient being left unsupervised without oxygen and suffering a cardiac arrest.
Summer Robertson and Alice Barnett
Historic (No Identified Response)
2015-0243 26 Jun 2015 Shropshire, Telford and Wrekin
Lattitude Global Volunteering
Concerns summary (AI summary) There was a critical lack of awareness and specific risk assessment for rip currents, inadequate warnings for those entering the water, and no clear guidance on how to escape them.
Richard Turner
Historic (No Identified Response)
2015-0242 26 Jun 2015 Derby and Derbyshire
Department for Transport
Concerns summary (AI summary) Light goods vehicles with significant rear blind spots are widely used without mandatory reversing aids like cameras or audible warnings, increasing the risk of fatal collisions with pedestrians.
Lottie Reid
All Responded
2015-0241 25 Jun 2015 Birmingham and Solihull
Good Hope Hospital
Concerns summary (AI summary) There were critical medication discrepancies between the discharge letter and the administration chart, with no clear protocol for checking these errors, especially problematic on weekends.
Action Planned (AI summary) Birmingham Heartlands Hospital is piloting new documentation within palliative care for clarity of prescribing. Dissemination of information about the Intermediate Care Procedure to all wards at Good Hope Hospital and staff at the intermediate care facility can check the patient's prescribed medication by telephoning the discharging ward directly.
Anthony Geerts
Partially Responded
2015-0240 24 Jun 2015 Brighton and Hove
Brighton and Sussex University Hospital… Princess Royal Hospital
Concerns summary (AI summary) The provided text is incomplete and does not contain any discernible coroner's concerns.
Action Taken (AI summary) Brighton and Sussex University Hospitals NHS Trust has integrated the neck of femur service at the Princess Royal Hospital. They also recruited a new Clinical Nurse Practice Educator and implemented a structured teaching program for junior doctors and nurses.
Alice Mead
All Responded
2015-0239 24 Jun 2015 Brighton and Hove
Sussex Partnership NHS Foundation Trust
Concerns summary (AI summary) Significant failings in mental health care involved the absence of a care coordinator, ignored patient requests for medication review, and an unacceptably delayed, "hands off" response to urgent concerns for a vulnerable patient.
Action Taken (AI summary) Sussex Partnership NHS Trust implemented an improved system for reviewing care coordinator caseloads, especially when a care coordinator leaves. Staff in East ATS and MHRRS have undergone Applied Suicide Intervention Skills Training (ASIST), and a new approach to calls is underway in East ATS.
Steven Curtis
Historic (No Identified Response)
23 Jun 2015 Oxfordshire
Derbyshire Trading Standards Division
Concerns summary (AI summary) There are safety concerns regarding Maplin N19KJ telescopic ladders, with 43,000 sold, warranting investigation into a potential catastrophic failure and the origin of the accident ladder.
Jan McLean
Historic (No Identified Response)
2015-0237 22 Jun 2015 Surrey
Surrey Police
Concerns summary (AI summary) Police officers require full and adequate training to thoroughly interrogate all details relating to warning markers held on the PNC to prevent future deaths.
Kathleen Eaton
Historic (No Identified Response)
2015-0236 22 Jun 2015 Manchester (South)
Peaks and Plains Housing Trust
Concerns summary (AI summary) An emergency trust link officer lacked formal medical assessment training and head injury policies, with no written guidance for ambulance summoning, raising doubts about the adequacy of emergency response from a distant base.
Kian Gill
All Responded
2015-0235 22 Jun 2015 Leicester City and South Leicestershire
Leicestershire County Council
Concerns summary (AI summary) Highway safety is compromised by overgrown hedgerows obscuring junction visibility, a lack of warning signage, and an uncurtailed national speed limit, creating collision risks.
Action Planned (AI summary) Leicestershire County Council proposes to place give way road markings on Bonehams lane and "Slow" markings on Ullesthorpe Road to advise drivers of the presence of a junction with a view to encouraging them to reduce their speed.
Elizabeth Godwin
All Responded
2015-0233 19 Jun 2015 Wiltshire and Swindon
Avon and Wiltshire NHS Mental Health Pa… Royal United Hospitals Bath NHS Foundat… Wiltshire Council
Concerns summary (AI summary) Critical issues exist in mental health care regarding incomplete information gathering for assessments, poor urgency monitoring, inadequate inter-agency communication, unclear care responsibilities, and a lack of audit trails for patient transfers.
Action Planned (AI summary) Royal United Hospitals Bath NHS Foundation Trust (RUH) has implemented additional resource for Mental Health Services and amended the Mental Health Assessment Matrix. All junior doctors, Emergency Nurse Practitioners and Nursing staff receive training in the use and application of the mental health matrix at induction. Wiltshire Council describes planned discussions between Wiltshire Council (WC) and AWP to be held to clarify roles and responsibilities and ensure that a process is followed. Avon and Wiltshire NHS Trust highlights that the Trust Care Programme Approach, (CPA), and Risk Policy outlines that staff will involve families and carers in the CPA process including assessment of risk. The Trust CPA and Risk Training highlights the need for staff to include the views of service users and carers in undertaking any assessment.
John Bartle
Historic (No Identified Response)
2015-0232 18 Jun 2015 Stoke-on-Trent and North Staffordshire
am Margaret CORONER Jones, Assistant Coroner, for Stoke-on-…
Concerns summary (AI summary) Concerns were raised about a perceived lack of staff over a bank holiday leading to delayed interventions, alongside poor nutritional support, inadequate pain control, and poor communication from nursing staff.
Andre Mickley
Historic (No Identified Response)
2015-0231 17 Jun 2015 Lincolnshire (Central)
Medicines and Healthcare products Regul…
Concerns summary (AI summary) Product information for SSRI drugs fails to adequately inform prescribers about potential adverse pharmacokinetic interactions with cocaine and other illicit substances, or to advise patients to seek caution.
Andrew Nickolls
Historic (No Identified Response)
2015-0230 17 Jun 2015 Plymouth, Torbay and South Devon
Devon County Council Northern Eastern and Western Devon Clin… Plymouth City Council +2 more
Concerns summary (AI summary) The provided text is incomplete and does not contain any discernible coroner's concerns.
Isaac Bahar
All Responded
2015-0229 15 Jun 2015 Brighton and Hove
Brighton and Sussex University Hospital…
Concerns summary (AI summary) A patient with advanced kidney disease was fatally prescribed Codeine, directly breaching hospital policy and national guidance on medication for vulnerable patients.
Action Taken (AI summary) Brighton and Sussex University Hospitals Trust has discussed the incident with general surgeons and the nursing and pharmacy teams, leading the general surgeons to decide that codeine should no longer be routinely available for them to prescribe.
Marie Harding
Historic (No Identified Response)
2015-0214 12 Jun 2015 West Yorkshire (West)
NHS England
Concerns summary (AI summary) The trust lacked clear guidelines and up-to-date staff training for chest drain insertion, compounded by an unawareness of interventional radiologist availability, indicating systemic procedural deficiencies.
Sidney Barnett
Partially Responded
2015-0222 12 Jun 2015 Manchester (South)
Berrycroft Manor Care Home Stockport Metropolitan Borough Council
Concerns summary (AI summary) The care home provided inadequate observation and general welfare for the client, and the subsequent safeguarding investigation was flawed, relying too heavily on unverified staff statements.
Action Taken (AI summary) The care home has implemented room visit charts, enhanced personal care documentation, dignity training delivered by the manager, and window checks as part of the room visit checks.