2015
PFD Reports
Reports: 477
Areas: 69
62% response rate (below 63% average).
Nancy Hughes
All Responded
2015-0221
12 Jun 2015
North Wales (East & Central)
BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, …
Concerns summary (AI summary)
No systematic medication review occurred as per medical practice, and a lack of cohesion between mental health and general medical treatment meant vulnerable patients' mental health information was disregarded in their physical care.
Action Taken
(AI summary)
The Health Board has implemented a system where patients have a named care coordinator responsible for maintaining contact and reviewing medication, including a prescribing guideline for review and discontinuation of medication at 6 or 12 weeks. The Mental Health Improvement Group is working to improve communication between transferring and receiving wards.
Deborah Roberts
Historic (No Identified Response)
11 Jun 2015
Mid Kent & Medway
National Highways
Concerns summary (AI summary)
The Sheppey Road Bridge has a history of rear-end collisions due to its geometry affecting visibility and high speeds. Despite a safety review recommending a 50 mph limit, the speed limit remains 70 mph.
Amanda Harris
Historic (No Identified Response)
2015-0216
10 Jun 2015
London (North)
Mount Vernon Hospital
Concerns summary (AI summary)
Mrs Harris was discharged from the Minor Injuries Unit without a doctor's review, consideration of anticoagulant therapy, or assessment of potential immobility effects from her injury.
Arti Lakhani
All Responded
2015-0217
10 Jun 2015
London (North)
Department of Health and Social Care
Concerns summary (AI summary)
Concerns were raised about the lack of regulation and licensing for the sale of e-cigarette fluid.
Action Planned
(AI summary)
The Department of Health outlines existing controls and upcoming product-specific regulations for e-cigarettes and refills to be introduced in May 2016. These measures are intended to mitigate risks of inadvertent contact and accidental poisoning.
Walter Willows
Historic (No Identified Response)
2015-0218
10 Jun 2015
Manchester (South)
Westwood Homecare Limited
Concerns summary (AI summary)
Care plans, especially feeding regimes, were reviewed insufficiently frequently for clients with changing needs, specifically regarding swallowing ability, leading to inadequate dietary adjustments.
Darren Neville
All Responded
2015-0220
10 Jun 2015
London Inner (North)
Metropolitan Police Service
Concerns summary (AI summary)
Police officers did not adequately consider the significant risk of death associated with prolonged restraint for individuals experiencing acute behavioural disturbance.
Noted
(AI summary)
The Metropolitan Police acknowledge the concerns and detail the challenges of responding to Acute Behavioural Disorder (ABD) incidents, highlighting existing training and the need for officers to act decisively. They assert that measures have been introduced since 2013 and in response to the death to refine training and equip officers.
Lewis Ghessen
Historic (No Identified Response)
2015-0213
9 Jun 2015
London (North)
Rail Safety and Standards Board
Concerns summary (AI summary)
The RSSB Rule Book is flawed as it only permits stopping trains to prevent damage, not to protect individuals in danger from a train.
Alice McMeekin
Historic (No Identified Response)
2015-0211
4 Jun 2015
Cumbria
Cumbria Constabulary
Cumbria Partnership NHS Foundation Trust
Concerns summary (AI summary)
Police failed to act on reported threats and share critical information with mental health services, leading to a flawed psychiatric assessment and early discharge of a high-risk individual with significant mental health issues.
Christopher Tandy
Partially Responded
2015-0234
4 Jun 2015
London (City)
for information)
Transport for London
Concerns summary (AI summary)
Inadequate signage and road layout on London Bridge encourage speeding, with insufficient prominent 20 mph speed limit signs and a lack of separate lanes for cyclists.
Action Planned
(AI summary)
TfL plans to publish proposals for improved traffic arrangements around London Bridge and will investigate the feasibility of a Cycle Superhighway across London Bridge starting in 2016, incorporating public consultation. They will also install an additional pair of speed repeater signs on the north side of the bridge and consider spacing of repeater signs.
Frederick White
Partially Responded
2015-0212
3 Jun 2015
Black Country
Care Quality Commission
Dudley Group NHS Foundation Trust
West Midlands Ambulance Service NHS Tru…
Concerns summary (AI summary)
There was a significant delay in diagnosing and managing a suspected spinal cord injury, including an initial failure to immobilise the patient and inadequate assessment during the hospital triage process.
Action Taken
(AI summary)
The Dudley Group NHS Foundation Trust, after an internal investigation, strengthened the criterion regarding older adults in Step Four triage. The West Midlands Ambulance Service Foundation Trust (WMASFT) has liaised with the regional trauma network to establish an elderly trauma working group to identify pre-hospital issues and provide advice.
David Price
Historic (No Identified Response)
2015-0210
1 Jun 2015
Manchester (South)
Department of Health and Social Care
University Hospital of South Manchester
Concerns summary (AI summary)
Problems included uncontrolled warfarin prescriptions without clinic attendance, very poor quality handwritten medical notes, failure to act on a radiologist's finding of a foreign body, and an unsatisfactory swab count policy during surgery.
James Savo
Historic (No Identified Response)
2015-0209
1 Jun 2015
South Yorkshire (East)
Rotherham, Doncaster and South Humber N…
Concerns summary (AI summary)
Effective communication systems between families/carers and staff are not routinely followed or audited, and understanding of early discharge plans is inconsistent, hindering seamless patient transitions.
Mark Daniels
All Responded
2015-0208
1 Jun 2015
London Inner (North)
Camden and Islington NHS Foundation Tru…
Concerns summary (AI summary)
The crisis team failed to conduct planned patient visits, adequately record actions, communicate within the team, promptly refer to crisis houses, or consider hospital admission despite the patient's severe suicide risk.
Action Taken
(AI summary)
Camden and Islington NHS Foundation Trust have put in place a comprehensive action plan to address the concerns raised regarding failures by the Crisis team, with measures implemented across all Crisis Teams and Crisis Houses and a plan to monitor their implementation.
Ronald Smith
Historic (No Identified Response)
2015-0207
1 Jun 2015
London (East)
Barking, Havering and Redbridge Univers…
Concerns summary (AI summary)
There was a failure to provide flexible sigmoidoscopy out of hours, and despite a root cause analysis identifying the need for a protocol, one was still not in place 18 months after the death.
Mark Foley
Partially Responded
2015-0204
1 Jun 2015
Cumbria
Minister of Defence
British Army
the suppliers of the software
Concerns summary (AI summary)
Driver inexperience and the commander's failure to wear a safety harness, due to permitted discretion and lax enforcement of standing orders, led to the fatal incident.
1 response
from Department of Health
Melanie Amundsen
Historic (No Identified Response)
2015-0206
29 May 2015
Sunderland
Advisory, Conciliation and Arbitration …
Concerns summary (AI summary)
Not all employers or employees may be aware of mental health issues in the workplace, particularly concerning disciplinary processes, and ACAS resources could be enhanced and better publicised.
Alison Draper
Historic (No Identified Response)
2015-0205
29 May 2015
Avon
Avon and Wiltshire NHS Partnership Trust
Concerns summary (AI summary)
A policy gap exists for managing patients not found within 10-minute observation periods, and guidance is needed for staff balancing hourly checks with more frequent observations.
Elizabeth Lester
All Responded
2015-0204-wp24868
29 May 2015
Manchester (South)
Department of Health and Social Care
Concerns summary (AI summary)
The ambulance service's call-handler script for 'breathing difficulties' critically omits questions about chest pain, potentially delaying appropriate emergency response for cardiac-related issues.
1 response
from Department of Health
Nicholas Stocks
Partially Responded
2015-0200
27 May 2015
West Yorkshire (West)
Kirklees Council
West Yorkshire Police
Concerns summary (AI summary)
Police failed to fully report road traffic collision concerns to the council, and there are inadequate systems for risk assessment and urgent communication of needed repairs to damaged road signs and markings.
Action Taken
(AI summary)
West Yorkshire Police reviewed reporting processes for damage to street furniture, ensuring updated contact details for local authorities and using generic mailboxes. They have updated the Force Communications system with current contact numbers for Kirklees Council.
Matthew Hoare
All Responded
2015-0203
27 May 2015
London (Inner South)
National Rail
Concerns summary (AI summary)
Ineffective security equipment allowed easy access to the station and tracks after operational hours, with individuals able to climb through widely spaced yellow tape.
Action Taken
(AI summary)
Network Rail reports that following the incident, the roller shutters at the station entrance have been reinstated and are now locked during non-operational hours, and anti-trespass grids have been installed at the Denmark Hill end of the platforms. LOROL are working on a system allowing their stations to be opened remotely from the central control centre.
Oliver Asante-Yeboah
All Responded
2015-0201
27 May 2015
London Inner (North)
Care Quality Commission
Concerns summary (AI summary)
Concerns were raised about the lack of formal regulation for non-medical providers of circumcision, a procedure considered surgical with increased infection risk in non-medical settings.
Noted
(AI summary)
The CQC states it has no regulatory remit over non-therapeutic circumcisions performed for religious purposes by non-healthcare professionals, as the regulations would require amendment by the Secretary of State. The Department of Health acknowledges concerns about non-medical settings for male circumcision and notes that a change in legislation would require consultation. They will copy the letter to clinical leads of CCGs in England to highlight the case and reiterate the advice that circumcision should be carried out by a regulated healthcare professional.
Yusuf Abdismad
Historic (No Identified Response)
2015-0202
27 May 2015
London Inner (North)
London Ambulance Service NHS Trust
Concerns summary (AI summary)
Emergency medical dispatchers use confusing questioning to ascertain consciousness, leading to misinterpretation of patient status and missing critical symptoms like a rash or obscured pupils.
Olive Darbyshire
Historic (No Identified Response)
22 May 2015
Blackpool and The Fylde
Blackpool Teaching Hospital NHS Foundat…
Concerns summary (AI summary)
An urgent CTPA procedure was delayed and miscategorised, exacerbated by a lack of follow-up from the clinical team, radiology department errors, and potential impact of reduced Christmas staffing levels.
Barbara Patterson
All Responded
2015-0198
21 May 2015
Northumberland (North)
Care Quality Commission
Department of Health and Social Care
North East Ambulance Service NHS Founda…
Concerns summary (AI summary)
The Pathways system has a fault preventing timely CPR advice for agonal breathing, and ambulance dispatch was delayed due to paramedic shortages and handover issues at hospitals.
Noted
(AI summary)
NHS Pathways has provided a response to concerns and will be meeting to discuss these issues. NHS England plans to publish guidance to help ambulance services develop new ways of working, and will work to increase the number of Physician Associate training programmes. HEE will also ensure that paramedic training provides an additional 16% growth. The CQC will include concerns about ambulance dispatch procedures as part of their planned comprehensive inspection, and will discuss ambulance dispatch management and handover processes with the North East Ambulance Service in September 2015. They will also meet to monitor NEAS staffing levels and recruitment. The North East Ambulance Service refers to their attached response which repeats the evidence given at the inquest and highlights the national operational standard for ambulance trusts.
Wanda Stachurska
All Responded
2015-0199
20 May 2015
West Sussex
Surrey and Borders Partnership NHS Foun…
Surrey and Sussex Healthcare NHS Trust
Concerns summary (AI summary)
Mental health risk assessments were diminished by untrained interpreters and staff unaware of policies. Furthermore, a serious incident review was not undertaken, delaying learning opportunities.
Action Taken
(AI summary)
The Trust has worked with East Surrey Hospital to ensure a shortcut to SASH policies is loaded onto Psychiatric Liaison staff computers, and has mandated that two staff members undertake assessments when a translator is required. An audit tool to review compliance with the translation policy will be embedded in supervision sessions.