2015
PFD Reports
Reports: 477
Areas: 69
62% response rate (below 63% average).
Keith Murphy
Partially Responded
2015-0120
25 Mar 2015
Surrey
National Offender Management Service
NHS England
Concerns summary (AI summary)
Prison staff lack basic first aid, CPR, and defibrillator training, and healthcare provision is unavailable outside limited hours, leaving prisoners vulnerable to medical emergencies.
Action Taken
(AI summary)
NOMS states that first aid training is being implemented at HMP Coldingley, with custodial managers trained and monthly closedown sessions used for wider staff training. They also state that a recent Health Needs Assessment confirmed existing healthcare arrangements meet the needs of the prison population.
Harold Ambrose
Historic (No Identified Response)
2015-0118
25 Mar 2015
Essex
Home Office
Concerns summary (AI summary)
There is no requirement for GPs or Mental Health Trusts to notify police about mental health concerns for firearm licence holders, and licence information was not properly flagged in medical records.
Michael Richardson
All Responded
2015-0114
24 Mar 2015
Norfolk
James Paget University Hospital NHS Fou…
Concerns summary (AI summary)
Critical information from ambulance reports, such as a patient's nutritional status, was not adequately reviewed during hospital admission, risking adverse outcomes if not addressed.
Noted
(AI summary)
Response is unintelligible due to formatting issues.
Stuart Baumber
Historic (No Identified Response)
2015-0116
24 Mar 2015
Peterborough
National Offender Management Service
Sodexo Justice Services
Concerns summary (AI summary)
Many prison cell doors lack anti-ligature strips due to an absent retrofit program. Furthermore, the ACCT process lacks a structured national pro forma, leading to inconsistent risk assessments and over-reliance on current prisoner demeanour.
Barbara Mayer
All Responded
2015-0113
23 Mar 2015
Norfolk
Norfolk and Suffolk NHS Foundation Trust
Concerns summary (AI summary)
Carer fatigue was not followed up, inconsistent crisis team contacts prevented establishing trust, and urgent help was delayed due to increased demand. Treatment options were also not adequately discussed with the patient.
Action Planned
(AI summary)
The Trust is implementing the 'Triangle of Care' model and nearing completion of the first stage of this multi-year plan. Localities are reviewing their escalation plans for services such as CRHT and the Dementia Intensive Support Teams.
Elliott Bignall
Historic (No Identified Response)
2015-0111
23 Mar 2015
West Sussex
Network Rail
Concerns summary (AI summary)
The railway foot crossing was poorly lit with inadequate signage, posing a danger to pedestrians who might not see or hear approaching high-speed trains, especially if distracted.
Robert Spring
All Responded
2015-0123
23 Mar 2015
Lincolnshire (Central)
Air Liquide
Lincolnshire County Council
NHS Lincolnshire West Clinical Commissi…
+1 more
Concerns summary (AI summary)
Inadequate communication channels failed to inform the Fire and Rescue Service about high-risk home oxygen users who smoked, preventing assessment for crucial safety equipment like smoke alarms and flame-retardant bedding.
Action Taken
(AI summary)
United Lincolnshire Hospitals NHS Trust has met with Lincolnshire Fire & Rescue and Air Liquide to agree a process for sharing information, formalized the discharge process, and included a documented risk assessment in their standard operating procedure. The operating procedure also outlines a clear and agreed communication process between all parties.
Neil Budziszewski
All Responded
2015-0109
23 Mar 2015
South Yorkshire (West)
South Yorkshire Police
Concerns summary (AI summary)
Multiple failures in police custody included incomplete and unreviewed risk assessments, lack of 30-minute rousing checks for an alcoholic detainee, and inadequate staff training on managing risks associated with alcohol withdrawal.
Action Planned
(AI summary)
South Yorkshire Police will highlight the importance of opening a custody record and completing a risk assessment, even when a detainee is uncooperative, in training and through a briefing document and rotational training. They will also incorporate information about acute alcohol withdrawal syndrome into first aid training for custody staff.
Pamela Pattison
Historic (No Identified Response)
2015-0108
23 Mar 2015
Manchester (South)
Stockport NHS Foundation Trust
Concerns summary (AI summary)
Deficient nurse training on diabetes, doctors omitting critical insulin, and a lack of specialist support, consultant cover, and essential equipment were identified. This was compounded by patient transfer delays and under-resourcing for diabetes care.
Joseph Allison
All Responded
2015-0103
23 Mar 2015
London (East)
British Healthcare Trades Association
Handicare Accessibility Ltd
Concerns summary (AI summary)
Service engineers lack specific training on a known stairlift defect and safety checks. Furthermore, no national safety recall or industry-wide advisory has been issued for the defective Minivator 2000 stairlift.
Action Planned
(AI summary)
Handicare has adjusted internal processes and training for in-house engineers. It will also raise the issue of sharing safety information with all manufacturers at the next BHTA stairlift section meeting and via letter during the week commencing 15th June 2015. BHTA will remind manufacturer members to continue training to address field safety issues until all products have been traced and necessary action taken. BHTA will recommend that the Health & Safety Executive talk to the MHRA and see if they might tap into the alerting system for alerts regarding products sold into the care sector.
James Bateley
All Responded
2015-0115
23 Mar 2015
West Sussex
NHS Coastal West Sussex Clinical Commis…
Sussex Community NHS Trust
Concerns summary (AI summary)
Nursing homes and community nurses face significant delays in accessing essential wound dressings, as orders through GPs can take weeks, impacting patient care.
Action Taken
(AI summary)
The CCG contacted the Deputy Chief Nurse, Sussex Community NHS Trust to investigate the delay in ordering dressings, and assurance was obtained from the Pharmacy that there was no delay in processing the order. The Residential Care Home has completed a review of their Management of Prescriptions policy. Immediate actions taken include meeting with the CCG, implementing a 'Stock box/First Dressing' system, and implementing an escalation process for delays in dressings supply. Longer-term actions are being discussed with the CCG to implement an ONPOS (On-line Non Prescription Ordering Service) in shadow from July, with full rollout planned from January 2016.
Kingsley Burrell
All Responded
2015-0472
20 Mar 2015
Birmingham and Solihull
National mental health working group
Association of Ambulance Chief Executiv…
Association of Chief Police Officers
+1 more
Concerns summary (AI summary)
There is a national lack of understanding and training regarding acute behavioural disturbance and the risks of prolonged restraint. Additionally, specialized mental health crisis teams and updated patient conveying policies are not nationally implemented.
Action Planned
(AI summary)
AACE has been working with the NPCC, Home Office and the Department of Health to drive further improvements in both the speed of ambulance response and the proportion of patients conveyed by ambulance rather than police vehicles. The College of Policing, Health and Ambulance Service representatives are currently working together to devise a national protocol for the management of ABD in the pre-hospital setting. The Metropolitan Police national instruction is to monitor and review all service requests to mental health environments and for escalation and supervisory involvement on every occasion where police are requested to, or effect, restraint in health environment whatever the circumstances. Multi-agency membership includes NHS England, the Royal College of Psychiatrists, the Royal College of Nursing, and NICE. The Department published the Crisis Care Concordat in 2014 to ensure that anyone experiencing a mental health crisis receives the right support in the right place. The Department has also funded a number of street triage pilot schemes where mental health professionals provide on the spot advice to police when dealing with people with possible mental health problems.
Brenda Leyland
All Responded
2015-0112
20 Mar 2015
Leicester (City & South)
Department of Health and Social Care
Concerns summary (AI summary)
Helium gas canisters are freely available in large volumes without purchase controls or modified valves to restrict gas release, posing an uncontrolled risk.
Noted
(AI summary)
The Department of Health acknowledges the concerns raised about helium gas and suicide, noting ongoing discussions with partners but without specific outcomes to report. They highlight the need to balance helium availability with safety and reference Samaritans' media guidelines.
Elsie Hayward
All Responded
2015-0224
19 Mar 2015
Cardiff & Vale of Glamorgan
Cardiff and Vale NHS Trust
Concerns summary (AI summary)
Overstretched medical staff due to excessive patient ratios led to care deficiencies, including neglected neuro observations and poor note-taking. This resulted in significant confusion and communication breakdowns between nursing and medical teams.
Action Taken
(AI summary)
Cardiff Vale University Health Board has already undertaken actions including ward-level board rounds, safety briefings, MDT meetings, disciplinary investigation of a nurse, and staff retraining, following an internal investigation and continuous improvement plan.
Valerie Walton
All Responded
2015-0107
19 Mar 2015
Coventry
Coventry City Council
Concerns summary (AI summary)
The positioning of a pedestrian crossing on the apex of a sharp bend was a factor in the death, and the coroner suggested the crossing should be on a straight section of the road or controlled by traffic lights.
Action Planned
(AI summary)
Coventry City Council proposes to enhance the zebra crossing's conspicuity by installing more intensely illuminated Belisha beacon heads and illuminated poles, with work anticipated in the next three to six months.
Anne Fowler
Historic (No Identified Response)
2015-0104
19 Mar 2015
Black Country
Home Office
Concerns summary (AI summary)
Smoke alarm covers were left in place after installation, making them inaccessible and ineffective. Legislation should require their removal by builders or landlords prior to occupation.
Anais Thouvenot
All Responded
2015-0110
18 Mar 2015
Leicester (City & South)
Leicester Campaign Cycling Group
Leicester City Council
Concerns summary (AI summary)
The road junction at Upper Kings Street and Regent Road has significant safety concerns due to poor visibility, inadequate filter lanes, heavy traffic, and road contour, posing risks to cyclists.
Action Planned
(AI summary)
Leicester City Council will investigate potential improvements to the junction, including advanced cycle stop lines, road markings, parking restrictions, and signal timing changes to reduce conflict between cyclists and vehicles, with a view to including improvements in future works programmes.
Grant Benson and Gordon Davidson
All Responded
2015-0102
18 Mar 2015
County Durham & Darlington
Yorkshire Ambulance Service
Concerns summary (AI summary)
Ambulance control failed to accurately locate a severe incident due to inaccurate GPS and a call handler's lack of local knowledge. Inadequate cross-boundary systems prevented effective call transfer or dispatch of a nearby ambulance, causing critical delays.
Action Taken
(AI summary)
County Durham and Darlington Fire and Rescue Service introduced a new mobilising and communications system in December 2014 and reviewed call handling procedures for adjoining emergency services, updating contact information and communication protocols. North East Ambulance Service has reviewed processes and systems for cross-border incidents, passed information to the training department to review call handling procedures and clarified the circumstances under which mutual aid agreements would be used.
Alasdair Penny
All Responded
2015-0106
17 Mar 2015
West Sussex
Sussex Police
West Sussex County Council
Concerns summary (AI summary)
Bridge railings are easily mounted, facilitating suicides. Despite existing support notices, physical barriers should be reconsidered to prevent spontaneous jumps from the bridge.
Action Planned
(AI summary)
Sussex Police highlights that the East Grinstead Neighbourhood Joint Action Group implemented 6 Samaritans signs on the bridge, and the Street Pastors and police continue to patrol the bridge. West Sussex County Council will investigate the technical feasibility of increasing the height of the parapet on College Lane Bridge and intends to undertake alterations within this financial year if an appropriate solution can be determined.
Kevin Hoey
All Responded
2015-0101
17 Mar 2015
Cambridgeshire (North & East)
East of England Ambulance Service NHS T…
Concerns summary (AI summary)
The East of England Ambulance Service needs to review training from another trust to improve paramedic decisions on whether to treat patients in the community or transfer them to hospital.
Action Planned
(AI summary)
East of England Ambulance Service is reviewing the East Midlands Ambulance Service's Paramedic Pathfinder Programme to determine its potential implementation within the Trust and implications for current training.
Joshua Booth
All Responded
2015-0125
16 Mar 2015
Lincolnshire (Central)
Lincolnshire County Council
Concerns summary (AI summary)
A seriously substandard, subsided road section poses an immediate danger to motorists, requiring urgent repair, warning signage, and an advisory speed limit. Dangerous posts at the bank's foot also necessitate an Armco barrier.
Action Taken
(AI summary)
Lincolnshire County Council reports that the section of road identified as having subsidence has now been levelled. Temporary signage advising of the uneven road surface has been left in place to supplement the existing permanent signs.
Tom Sawyer and Danny Winters
All Responded
2015-0100
16 Mar 2015
Wiltshire & Swindon
Minister of State for the Armed Forces
Concerns summary (AI summary)
Reliance on insecure handwritten radio logs, absence of critical communication records, and ineffective communication between soldiers hindered investigation. There is a lack of secure digital recording for encrypted radio signals in combat scenarios.
Action Planned
(AI summary)
The MOD will investigate the inclusion of automated secure voice logs in the next generation tactical command system, with a decision expected by 2018. The Army Chief Information Officer will determine how such a capability will be used.
Philip Robinson
All Responded
2015-0225
13 Mar 2015
Nottinghamshire
Doncaster and Bassetlaw Hospitals NHS F…
Concerns summary (AI summary)
Unclear ECG guidelines for breathlessness, unsatisfactory safe discharge audits, and inadequate communication of Early Warning Scores (EWS) are significant concerns. Delays in digital system implementation and the extreme risk of absent senior medical review compound these issues.
Action Taken
(AI summary)
The Trust completed an "observations project" including documentation of EWS on discharge and implemented a safety brief at shift changes. They are also planning to implement the i-Hospital whiteboard system and broaden advanced nurse practitioner roles.
James McManus
All Responded
2015-0097
13 Mar 2015
Manchester (North)
Pennine Acute Hospitals NHS Trust
Concerns summary (AI summary)
Trust staff demonstrated a lack of knowledge and failure to implement key protocols for managing bleeding related to thrombolytic therapy and massive blood loss.
Action Taken
(AI summary)
The Trust drafted a new Thrombolysis Policy, circulated it on the Trust Intranet, and provided training sessions to Critical Care staff. They are also developing a training presentation and reviewing the Adult Critical Care Operational Policy.
Maurice Cowling
All Responded
2015-0096
13 Mar 2015
North Lincolnshire & Grimsby
North Lincolnshire and Goole Hospitals …
Concerns summary (AI summary)
Despite the rarity of deaths from certain medical procedures, three fatalities occurred within a short period, two within the Trust, indicating a potential systemic issue.
Noted
(AI summary)
The Trust conducted a patient safety review of three cases and concluded that the complications were managed appropriately and existing arrangements are adequate. They state no further specific actions have been identified, but will be kept under review.