2015

PFD Reports
Reports: 477 Areas: 69

62% response rate (below 63% average).

477 results
Patrick Sturtivant
Partially Responded
2015-0144 17 Apr 2015 Wiltshire & Swindon
Department for Transport English Heritage National Trust +2 more
Concerns summary (AI summary) Public parking on a Byway adjacent to a main road for Stonehenge viewing creates a significant road safety risk. Concerns were raised that diverting this byway could merely shift the problem elsewhere.
Action Planned (AI summary) The National Trust is supportive of Wiltshire Council's proposal to downgrade a section of Byway 11 to a bridleway. They are also contributing to discussions with the Department for Transport regarding proposals for a tunnel for the A303. Wiltshire Council has commenced the process of exploring potential solutions with multiple agencies, including Highways England and Historic England. The Council has requested an extension to the response deadline to 12 months due to the multi-agency approach required. English Heritage supports the downgrading of Byway 11 to a bridleway and its closure to vehicular access, and offers to work with Wiltshire Council and the police on the matter. They acknowledge concerns about the impact on Byway 12 and that no recent action has been taken to review the use of Byways 11 or 12.
Robert Watt
Historic (No Identified Response)
2015-0145 17 Apr 2015 Mid Kent & Medway
Medway NHS Foundation Trust
Concerns summary (AI summary) Crucial information about clinic attendance and referrals was not communicated or documented. Junior doctors handled specialist consultations, and a urologist failed to review a patient with suspected malignancy and significant symptoms.
Mark Groombridge
All Responded
2015-0142 17 Apr 2015 Staffordshire (South)
HM Prison and Probation Service
Concerns summary (AI summary) There was no direct communication between the local offender manager and the clinician responsible for the patient's care before the recall paperwork was issued, and there was confusion about the recall process among probation staff.
Action Planned (AI summary) While the Director of Probation believes existing guidance on offender recall is clear, Deputy Directors will ensure probation staff are reminded of procedures by 31 August. The Public Protection Casework Section (PPCS) will issue a Senior Leaders Bulletin covering recall actions and will organise Recall Practitioner Forums in each National Probation Service (NPS) division at the end of the year.
Robert Payne
Historic (No Identified Response)
2015-0140 16 Apr 2015 Powys, Bridgend & Glamorgan Valleys
Abertawe Bro Morgannwg University Healt… Health Inspectorate Wales
Concerns summary (AI summary) Repeated falls for a high-risk patient, leading to further surgery, highlighted inadequate fall prevention. An early morning ward transfer lacked documentation, and the fatal fall was unwitnessed.
Jeanne Summers
Historic (No Identified Response)
2015-0139 16 Apr 2015 West Yorkshire (West)
Calderdale and Huddersfield NHS Foundat…
Concerns summary (AI summary) Inadequate discharge assessment, incomplete physiotherapy records, and unsafe patient mobilization practices, including inappropriate footwear and unsupervised transfers, contributed to a fall. The subsequent investigation was also found to be insufficient.
Maurice Camfield
Historic (No Identified Response)
2015-0176 16 Apr 2015 West Yorkshire (East)
Mid Yorkshire Hospitals NHS Trust
Concerns summary (AI summary) Crucial one-to-one nursing care, stipulated in the agreed care plan, was not consistently provided to the patient.
Kesia Leatherbarrow
Partially Responded
2015-0143 16 Apr 2015 Manchester (South)
Crown Prosecution Service Department of Health and Social Care Greater Manchester Police +8 more
Concerns summary (AI summary) Critical communication failures and incomplete information sharing between Children's Services and CAMHS across different regions, along with a failure to transfer the Youth Offending Team case, led to a lack of support for a high-risk young person.
Action Planned (AI summary) The Department of Health has shared the report with NHS England, who are working to develop Liaison and Diversion services in Greater Manchester. NHS England is also reshaping mental health services commissioning and delivery and will prioritize investment in areas with Local Transformation Plans. The government has already made a partial change to PACE via the Criminal Justice and Courts Act to require 17 year olds to be treated as 10-16 year olds for detention after charge. Planning is underway to amend the remaining PACE provisions, and the Secretary of State for Education wrote to local authorities reminding them of their duty to provide accommodation for children denied bail. A multi-agency working group has been commissioned to understand issues and develop solutions. The CPS has modified CPS training so advocates conducting youth court cases are reminded that a youth can always be remanded for their "own welfare". The Chief Crown Prosecutor for Greater Manchester is discussing wider issues and lessons learned with the Assistant Chief Constable for GMP. Pennine Care NHS Foundation Trust has completed an investigation, requesting written clinical summaries and risk assessments when young people transfer from other mental health services. The health diversion pathway has been re-published and re-promoted, and a multi-agency panel now has the capacity to deal with children and young people.
Nicholas Rowley
Partially Responded
2015-0138 15 Apr 2015 Stoke-on-Trent & North Staffordshire
Department of Health and Social Care G4S National Police Chiefs’ Council +2 more
Concerns summary (AI summary) Insufficient verbal consultation between medical practitioners and custody staff, coupled with inadequate joint training, led to unclear observation levels and poor management of drug/alcohol risks in detainees.
Noted (AI summary) The College of Policing will incorporate guidance on verbal consultation between medical practitioners and custody sergeants and will make additions to the Detention and Custody Authorised Professional Practice providing advice on observation levels; updated guidance will be published circa summer 2015. Guidance has been issued to custody staff and the medical services provider to ensure verbal updates are given by medical practitioners to the Custody Sergeant. A Custody Training sub-group has been created and further guidance issued regarding levels of observation, and training secured regarding drug and alcohol abuse. G4S no longer provides Detention Officer Services to Staffordshire Police as of June 2015. They state they always have and continue to provide mandatory training regarding setting levels of observation and first aid, and will write to contracting police forces to recommend joint ventures as best practice.
Stephen Myers
Partially Responded
2015-0150 15 Apr 2015 County Durham & Darlington
Department of Business, Innovations and… General Product Safety Department
Concerns summary (AI summary) A product containing isopropyl nitrite, misused by inhalation, has inadequate labelling that fails to comply with current safety regulations (CLP) regarding hazards and warnings.
Noted (AI summary) The Department for Business, Innovation and Skills clarifies that responsibility for labelling of "poppers" rests with the Health and Safety Executive and enforcement with local Trading Standards. It states that General Product Safety Regulations would not have been breached in this case as instructions for use were not followed and the Home Office tackles new psychoactive substances.
Austen Harrison
All Responded
2015-0481 13 Apr 2015 Oxfordshire
Hugo Boss UK
Concerns summary (AI summary) Basic health and safety training for managers, coupled with a lack of understanding of responsibilities and infrequent professional audits, led to undetected hazards like an unsafe mirror.
Action Taken (AI summary) Hugo Boss appointed a new Health and Safety Manager who undertook a detailed review of health and safety training, relaunched enhanced training for store and general managers via a workshop, and introduced a Health and Safety Management Workbook. Senior management also discuss health and safety trends and issues at quarterly review meetings.
Hayden Norton
Partially Responded
2015-0137 13 Apr 2015 Exeter & Greater Devon
Dorset Healthcare University NHS Founda… NHS England
Concerns summary (AI summary) After the deceased arrived at HMP Dartmoor, there was no record that his blood pressure was monitored, or that he had been informed of a screening test for aortic aneurysm; furthermore, there was a delay in calling an emergency ambulance because HMP Dartmoor lacked an emergency code protocol.
Action Taken (AI summary) The Trust has implemented new policies and procedures to improve service provision and provides a AAA screening programme. HMP Dartmoor now has an emergency code protocol in place.
Aleysha McLoughlin
All Responded
2015-0136 8 Apr 2015 Manchester (West)
Department for Education Department of Health and Social Care Ministry of Housing, Communities & Loca…
Concerns summary (AI summary) The training system for professionals working with young people regarding self-harm requires a comprehensive review, as self-harm is a growing public health crisis.
Action Planned (AI summary) The Department for Education is developing an assessment and accreditation system for child and family social workers. DCLG is focussed on supporting local services to provide early, integrated support for people who need the most help and supports local authorities on the delivery of the expanded troubled families programme.
Daniel Foss
All Responded
2015-0062 8 Apr 2015 Swansea Neath & Port Talbot
Swansea Council
Concerns summary (AI summary) A serious design flaw on the Kingsway/Metro system has led to over 100 road traffic incidents, including injuries and two fatalities, involving pedestrians and coaches.
Action Planned (AI summary) An advisory 20 mph speed limit was introduced and temporary pedestrian barriers were installed. First Cymru is decommissioning the Metro bus and the Authority is revising the road layout, removing the eastbound bus movements along the Kingsway with an anticipated layout change in October 2015.
Julie McCabe
Historic (No Identified Response)
2023-0508 4 Apr 2015 North Yorkshire and York
CPTA
Concerns summary (AI summary) The hair colourant industry's reliance on "spontaneous reports" significantly underestimates allergic reactions to PPD, creating a massive disconnect with independent research on consumer safety.
Christopher Watson
All Responded
2015-0133 1 Apr 2015 Norfolk
Norfolk County Council
Concerns summary (AI summary) Social care failed to ensure a vulnerable individual received, understood, or could read a letter offering help, and did not make direct contact to assess their capacity or needs.
Action Taken (AI summary) Norfolk County Council has stopped sending letters to individuals about whom concerns have been raised, and staff have been instructed to make face-to-face contact when telephone contact is not possible. Staff have also been reminded to record all steps taken to make contact, assess risk, and escalate cases to senior staff if contact is not made within two days.
John Lowe
Historic (No Identified Response)
2015-0132 1 Apr 2015 Nottinghamshire
Nottinghamshire Healthcare NHS Trust
Concerns summary (AI summary) Nursing staff incorrectly believed 1:1 care could not be provided for falls risk alone, only for mental health needs, regardless of a patient's physical care requirements.
Olive Nugent
Historic (No Identified Response)
2015-0134 31 Mar 2015 Newcastle Upon Tyne
South Tyneside Council
Concerns summary (AI summary) Falls activator device responses were delayed due to subjective prioritisation and insufficient staffing, particularly for non-verbal users, leaving vulnerable individuals without timely assistance.
Thomas Beaty
Partially Responded
2015-0130 31 Mar 2015 Manchester (North)
Department of Health and Social Care Pennine Acute Hospitals NHS Trust Royal College of Obstetricians and Gyna…
Concerns summary (AI summary) Guidance on instrumental delivery was ambiguous and potentially open to misinterpretation, lacked operational definitions for terms like 'imminent', and the term 'gentle' traction was misleading; furthermore, it's difficult for Trusts to change guidance until the RCOG issues changes/improvements.
Noted (AI summary) The Department of Health acknowledges the concerns raised about RCOG guidance and has forwarded the coroner's report to the RCOG. The Pennine Acute Hospitals Trust reviewed and revised the Guideline for Assisted Vaginal Delivery to provide staff with greater clarity and guidance regarding consultant presence for trial in theatre. The guideline was amended to state to abandon the procedure when there is no descent even after the 1st pull.
Sharon Butcher
Partially Responded
2015-0129 31 Mar 2015 County Durham & Darlington
HMP Frankland National Offender Management Service
Concerns summary (AI summary) There was a delay in calling for an ambulance after an emergency medical code was broadcast, and a recurring issue of lack of clarity in response to medical emergencies at HMP Frankland and HMP Durham.
Action Taken (AI summary) HMP Frankland revised local contingency plans and re-issued instructions to staff following Sharon Butcher's death to ensure that staff do not delay in calling an ambulance in all cases where there are serious concerns about an offender's health. The local protocols provide clear guidance to all staff to ensure timely, appropriate and effective response to medical emergencies.
Kenneth Williams
All Responded
2015-0135 30 Mar 2015 Surrey
Epsom and St Helier University Hospital…
Concerns summary (AI summary) Inadequate review of patient history and imaging before invasive procedures, insufficient respiratory consultant input, and poor communication between medical teams increased risks. Staff also lacked training to access historical imaging.
Action Taken (AI summary) Epsom and St Helier University Hospitals NHS Trust has introduced a medical proforma to support clerking of patients and requires patients' medical history and medication to be taken. Mr Williams' case is the focus of some of the trust's current training in the use and insertion of chest drains.
Jason Houghton
All Responded
2015-0127 30 Mar 2015 Manchester (West)
Home Office
Concerns summary (AI summary) The unregulated online supply and international importation of Class A drugs, specifically Diacetyl Morphine/Heroin in pill form via postal systems, poses a significant risk of future deaths.
Action Taken (AI summary) The Home Office acknowledges concerns about online drug supply, notes ongoing efforts by law enforcement to close UK-based websites and work with international partners. Since the death, the MHRA closed down the website Wmedipk com.
Sabrina Stevenson
All Responded
2015-0126 30 Mar 2015 London North (Inner)
College of Paramedics London Ambulance Service NHS Trust NHS England
Concerns summary (AI summary) Worsening ambulance response times, staffing shortages, unaddressed training issues (e.g., pregnancy testing, extraction), and a lack of system improvements like automated re-categorisation pose ongoing risks.
Action Planned (AI summary) The College of Paramedics commits to writing to NHS ambulance services and HEIs to offer assistance in recruiting paramedics, advising them of revised Paramedic Curriculum Guidance. It will also advise the JRCALC on the recommendation made by the Consultant Gynaecologist and the issue of triage tools. London Ambulance Service secured additional investment of £27.2m to improve response times, increase staffing, and improve productivity and are on track to recruit 850 staff in 2015/16. The LAS has also updated its Serious Incident Policy to ensure staff receive feedback from investigations. NHS England details actions taken with the LAS, including weekly performance reviews, additional funding of £27.2m for 2015/16 to increase staffing and capacity, and improve ambulance response times, with a goal to meet national standards by September 2015. They also cite initiatives to reduce unnecessary vehicle dispatches.
Andrea Thirkell
Historic (No Identified Response)
2015-0124 30 Mar 2015 County Durham & Darlington
Darlington Memorial Hospital
Concerns summary (AI summary) Lack of formal monitoring for patients awaiting discharge and an absence of clear policy for safe late-night discharges risk inconsistent, potentially erroneous decisions by medical staff.
Kelly Willis
All Responded
2015-0122 30 Mar 2015 Kent (Central & South East)
East Kent Hospitals University NHS Trust
Concerns summary (AI summary) Failure to timely liaise with a tertiary care center regarding a patient's complex medical history and specific requests delayed critical investigations, missing opportunities to prevent deterioration.
Action Planned (AI summary) East Kent Hospitals will include an article in the "Risk Wise" publication reminding staff of the importance of reassessing and completing outstanding actions, and considering contacting tertiary treatment centers for guidance. They also highlight existing handover and review processes.
Bryan Whitby
All Responded
2015-0121 25 Mar 2015 Manchester (South)
Central Manchester University Hospitals… Davyhulme Medical Centre
Concerns summary (AI summary) The provided text is incomplete and does not contain any discernible coroner's concerns.
Action Taken (AI summary) Central Manchester reviewed the case and presented it at a directorate meeting. The trust implemented an AKI e-alert system trust-wide and conducted teaching sessions for junior doctors on AKI recognition and management and now have two Critical Care Nurses on site at Trafford at all times. Davyhulme Medical Centre clarified Mr. Whitby's renal function and stated that the NICE guidance on acute kidney injury has been read by all GPs to improve management and awareness of the condition. An electronic alert system to tackle acute kidney injury was introduced locally on 9 March 2015.