2015
PFD Reports
Reports: 477
Areas: 69
62% response rate (below 63% average).
Irene Hamilton-Parker
All Responded
2015-0197
20 May 2015
Staffordshire (South)
Department of Business Innovation and S…
Concerns summary (AI summary)
Clothing made of easily flammable man-made fabrics poses a risk, and steps should be considered to reduce the flammability of manufactured or imported clothing.
Noted
(AI summary)
The Department for Business Innovation and Skills acknowledges concerns about clothing flammability but states that most clothing is flammable and reducing it would require flame retardants with their own risks. They don't believe there's sufficient evidence to extend flammability requirements to other types of clothing but will keep the issue under review.
Viola Burke
Partially Responded
2015-0196
20 May 2015
London Inner (North)
City and Hackney GP Confederation
Lawson Practice
Concerns summary (AI summary)
The GP practice failed to inquire about the reason for asthma pump use, and an incomplete care plan system for vulnerable patients meant out-of-hours services lacked full access to critical medical history.
Noted
(AI summary)
The practice explains the background to the Care Plan scheme and the attempts made to contact the deceased. They state that some issues raised are outside their control and rest with the CCG and NHS England, but are willing to cooperate fully in making beneficial changes and are working with their CCG to try and resolve IT problems with the care plans.
Sheila Johnson
All Responded
2015-0238
19 May 2015
Derby and Derbyshire
Tameside Hospital NHS Foundation Trust
Concerns summary (AI summary)
The internal investigation into the death was perfunctory, lacked robust inquiry, missed key interviews, and contained factual inaccuracies, risking future patient harm.
Noted
(AI summary)
The Department of Health states that officials have made enquiries with the Trust and have been assured that it will respond appropriately. The CQC will follow up any actions identified as a result of the Trust's response and will reinforce the duties of the Trust in relation to its duty of candour. Tameside Hospital has made considerable changes to improve internal investigations and patient discharge processes, including a review of senior nursing and medical staffing and revised procedures for incident investigations. A system for the urgent recall of patients discharged with potentially life-threatening conditions has been addressed by the Patient Flow Manager.
Diana Hughes
All Responded
2015-0195
18 May 2015
Gloucestershire
Not Listed
Action Planned
(AI summary)
The Trust is considering amending the WHO surgical checklist and reviewing its documentation policy to improve recording of special instructions for post-operative care. Progress will be monitored through the Safety Experience and Risk Group.
Sara Green
All Responded
2015-0190
15 May 2015
Manchester (South)
Priory Group
Concerns summary (AI summary)
Delays of up to 24 hours in 'writing up' medical consultations risk important information being unavailable or misinterpreted, potentially harming patients.
Action Taken
(AI summary)
The Group Medical Director reminded Hospital Medical Directors of the requirement to ensure service user records were completed during or shortly after consultations. An entry has been made on the Healthcare Division Risk Register to ensure that the required actions are itemised and that a plan is in place.
George Richardson
All Responded
2015-0189
15 May 2015
Sunderland
Department of Health and Social Care
Concerns summary (AI summary)
Lack of a consolidated catheterisation record meant staff were unaware of previous challenges, and national standards may be needed for safe catheterisation skills.
Noted
(AI summary)
The Department of Health acknowledges the concerns, highlights existing national guidance on catheterisation from NICE and RCN, and states that ensuring staff are aware of guidance and how to seek help is for hospital trusts to action locally.
Jacques Lakeman and Torin Lakeman
All Responded
2015-0191
15 May 2015
Manchester (West)
Home Office
Concerns summary (AI summary)
Easy access to anonymous 'Dark Web' sites for unregulated illicit drugs with unknown potency and content poses a significant and ongoing risk of future deaths.
Noted
(AI summary)
The Home Office acknowledges the concerns, describes actions taken by the NCA and Border Force to combat online drug supply, and states that law enforcement agencies have powers to act against suppliers, but does not commit to new actions.
Steven Bottomley
Unknown
2015-0186
14 May 2015
West Yorkshire (West)
Concerns summary (AI summary)
A window lacked a safety device, and remedial action is required to safeguard similar windows in properties to prevent recurrence in line with building regulations.
Hana Elhamid
All Responded
2015-0194
13 May 2015
London (North)
Department of Health and Social Care
Concerns summary (AI summary)
Lack of routine blood tests for sugar in a patient on Clozapine treatment led to an undiagnosed diabetic coma, with resultant trachea injury, directly causing death.
Noted
(AI summary)
The Department of Health acknowledges concerns and explains existing NICE guidelines for monitoring patients on antipsychotic medication. NHS England is working with the Royal College of Psychiatrists to investigate patient safety incidents associated with Clozapine.
Fred Hudson
Historic (No Identified Response)
2015-0188
13 May 2015
West Yorkshire (East)
Highways England
Historical Railways Estate
Concerns summary (AI summary)
A disused railway bridge is easily accessible to the public, including children, and no steps have been taken to prevent access despite its location next to a main road.
Paul Littlewood
Partially Responded
2015-0187
13 May 2015
South Yorkshire (West)
Steadplan Ltd
Freight Transport Association Ltd
Road Haulage Association
Concerns summary (AI summary)
Gantry safety barriers were too low, lacked an intermediate crossbar and toe-plate, and fall protection at the access ladder was inadequate, creating significant fall risks.
Noted
(AI summary)
The Freight Transport Association extends condolences and states that it will continue to provide guidance to members in relation to assessing and managing their risk, including their guide 'Preventing Falls from Vehicles'.
Paul Murray
All Responded
2015-0193
13 May 2015
London (North)
Department of Health and Social Care
Concerns summary (AI summary)
Insufficient resources were available for the London Ambulance Service to meet demand on the day of the incident.
Action Taken
(AI summary)
The London Ambulance Service carried out a serious incident investigation, resulting in plans to increase capacity through its modernisation programme, implementation of 'Intelligent Conveyance', consideration of a process for clinical review of repeated calls, and reminders to call takers to free text relevant information.
Paul McGuigan
All Responded
2015-0185
12 May 2015
Manchester (South)
Greater Manchester Police
Home Office
Ministry of Defence
+5 more
Concerns summary (AI summary)
General concerns were raised across relevant agencies about risks that could lead to future deaths, requiring action.
Action Planned
(AI summary)
The Home Office states that the Notifiable Occupations Scheme (NOS) was withdrawn and replaced with a new police-led scheme, the Common Law Police Disclosure (CLPD) scheme, which provides greater consistency across forces in the disclosure of information. The Trust states that following the Bradley Report (2009), the MDO teams transferred into single line management and implemented operational policy and approved documentation for assessment of needs and risks. They are rolling out an electronic clinical record (PARIS) and clinical staff have adequate time to access information from case notes. GMP will train officers in understanding their responsibilities under the pressing social need test, including classroom and NCALT training. They will be entering and holding notifications on the intelligence file of offenders. The SIA offered training and guidance to all UK police forces.
Lydia Corah
All Responded
2015-0181
11 May 2015
Nottinghamshire
Nottingham University Hospitals NHS Tru…
Concerns summary (AI summary)
An error led to a patient undergoing an X-ray intended for another, causing delay in assessment, unnecessary radiation, and adversely affecting the intended patient.
Action Taken
(AI summary)
Enhanced induction training has been implemented to reduce patient identification errors. The RCA generated an action plan that included reflection by the member of staff involved and updating of checking procedures.
Chandni Nigam
Historic (No Identified Response)
2015-0180
11 May 2015
Berkshire
Berkshire Healthcare NHS Foundation Tru…
Concerns summary (AI summary)
No attempt was made to obtain historical input or information from private clinicians when the patient reverted to NHS mental health care, missing potentially helpful treatment guidance.
John Lobo
All Responded
2015-0182
11 May 2015
London (South)
Exora Medical Limited
Concerns summary (AI summary)
Assessing fitness to travel for direct repatriation requires medical expertise beyond a paramedic, and independent medical assessment should be considered in such cases.
Action Planned
(AI summary)
Exora Medical will give consideration to obtaining a second and independent medical assessment in situations where facilities are not being provided by an insurance company for repatriation, especially from distant countries.
Keith Gallimore
All Responded
2015-0184
11 May 2015
London Inner (North)
Camden and Islington NHS Foundation Tru…
Concerns summary (AI summary)
Potentially important patient information documented by one service was not accessible to other services within the same Trust, especially out-of-hours, risking future deaths.
Action Planned
(AI summary)
IAPTUS training will be provided to a small number of front-line staff in the Acute Division to enable routine checks on all new patients against the IAPTUS system, expected to take place at the end of September.
Margaret Wright
All Responded
2015-0183
11 May 2015
Manchester (West)
Department of Health and Social Care
Concerns summary (AI summary)
Doctors did not routinely telephone patients or families after home visit requests to obtain further information, potentially delaying priority visits and impacting outcomes.
Action Planned
(AI summary)
NHS England's Primary Care Patient Safety Expert Group will consider home visits at their next meeting. NICE is drawing up guidance on Home Care with planned publication in September 2015.
Michael Hacker
Historic (No Identified Response)
2015-0179
8 May 2015
Avon
South Western Ambulance Service
Concerns summary (AI summary)
Concerns were raised regarding the ambulance service policy around the Mental Capacity Act, specifically regarding restraint or force if a patient lacks capacity but does not want to go to the hospital.
Thaker Hafid
Historic (No Identified Response)
2015-0192
8 May 2015
Cardiff & the Vale of Glamorgan
Advisory Council for the Misuse of Drugs
Concerns summary (AI summary)
The free availability and high potency/toxicity of the unlicensed 'designer drug' Acetylfentanyl, sold over the internet, poses a significant risk of future deaths.
Evelyn Kennedy
All Responded
2015-0178
7 May 2015
Brighton & Hove
Brighton and Sussex University Hospital…
Concerns summary (AI summary)
Acute Medical Unit failed significantly in patient care, with issues including incomplete handovers, poor personal hygiene, missing wristbands, unremoved IVs, incomplete care documentation, development of pressure damage, and unescalated NEWS scores indicating clinical deterioration.
Action Taken
(AI summary)
The Trust has been undertaking work, including improved consultant cover, a working group to address practices and documentation, developing specialist areas, improving signage, improving information handover, and increased monitoring of documentation.
Baby Olsberg
All Responded
2015-0177
7 May 2015
Manchester (North)
Department of Health and Social Care
National Institute for Health and Care …
Royal College of Obstetricians
+1 more
Concerns summary (AI summary)
Antenatal screening for Group B Streptococcus (GBS) and prophylactic intrapartum antibiotics for positive cases are not routinely offered by the NHS, potentially putting babies at risk.
Noted
(AI summary)
The RCOG acknowledges the concerns but refers to their guideline which aligns with the National Screening Committee's recommendation against routine screening for GBS. NICE acknowledges the concerns but refers to the UK National Screening Committee's current position that screening for GBS is not supported by the evidence, and that NICE's guideline does not recommend routine screening for GBS. The Department of Health acknowledges concerns about GBS screening but states that the UK National Screening Committee does not currently support universal screening due to insufficient evidence. They note that the NSC will be reviewing the evidence in 2015/16.
Jayne Jowett
Partially Responded
2015-0175
1 May 2015
Nottinghamshire
Annesley Woodhouse
Partnerships In Care
Concerns summary (AI summary)
PIC staff lack adequate training in interpreting and escalating National Early Warning Scores, and struggle to understand critical clinical signs. There's no clear protocol for GP collaboration or for communicating patient physical conditions to GPs.
Action Taken
(AI summary)
All qualified staff at relevant sites have been retrained on NEWS following the inquest, and this will form part of the induction training. Annesley House has a service level agreement with the local GP practice.
Julios Catachanas
All Responded
2015-0174
1 May 2015
Warwickshire
Warwickshire County Council
Concerns summary (AI summary)
The absence of street lighting at a junction, combined with the layout allowing vehicles to drive 'straight through', creates a significant road safety hazard.
Action Taken
(AI summary)
• Following notification of the collision, a Team Leader and a Road Safety Engineer from the Traffic and Road Safety Group attended the site with the traffic Management Assistant from Warwickshire and West Mercia Police's Road Safety Team.
• At the time of the inspection officers attending agreed that there were no immediate actions that needed to be undertaken.
• The County Council undertakes an annual review of all collision cluster sites across the County.
Derrick Stanmore
All Responded
2015-0172
1 May 2015
Leicester (City & South)
Leicester Partnership Trust
Concerns summary (AI summary)
A registered nurse failed to recognise abnormal patient observations requiring escalation, and lacked access to essential healthcare records to contextualise findings. A system like EWS is needed for recognition and escalation.
Action Planned
(AI summary)
An adapted version of the Track and Trigger system will be introduced, with staff trained in its use across the three Prison Healthcare Teams by October 2015. Staff will be reminded to access clinical information before seeing Prisoners.