2015

PFD Reports
Reports: 477 Areas: 69

62% response rate (below 63% average).

477 results
Malcolm Burge
Historic (No Identified Response)
2015-0072 27 Feb 2015 Somerset (West)
Newham Council
Concerns summary (AI summary) Council debt recovery procedures failed to accommodate a vulnerable individual's age, mental awareness, and inability to use modern communication methods, contributing significantly to his tragic death.
Simon Costin
All Responded
2015-0071 26 Feb 2015 Leicester (City & South)
NHS England
Concerns summary (AI summary) Inconsistent patient assessment approaches by clinicians and a lack of nationally agreed standard assessment forms hinder effective communication and care continuity for mental health patients across different trusts.
Action Taken (AI summary) NHS England notes the Leicestershire Partnership Trust has addressed standardised mental health assessments and has specific learning points from this incident including the use of translators and liaison with Primary Care. The Trust has also signed up to the Crisis Care Concordat and agreed a Local Action Plan.
Christopher Butler
All Responded
2015-0482 24 Feb 2015 Oxfordshire
Fire and Rescue Oxfordshire
Concerns summary (AI summary) A hidden electrical fault in boiler systems, potentially present in other similar properties, poses an undetected risk that standard electrical testing may miss. The Fire and Rescue Service needs to alert the community.
Action Planned (AI summary) The Fire and Rescue Service has undertaken a review of the circumstances, and plans to review their Near Miss and Fatal Incident Review process with Social Services and will share information with other fire and rescue services. They will also provide home electrical safety booklets and information, and have released a press release to raise awareness of electrical fire safety.
Richard Jones
All Responded
2015-0068 20 Feb 2015 Wiltshire & Swindon
Avon and Wiltshire NHS Mental Health Pa… Department of Health and Social Care Ministry of Defence +3 more
Concerns summary (AI summary) Inadequate recording of patient information, perceived risk levels, and assessment urgency was observed. There was also contradictory evidence and confusion regarding responsibilities and communication between mental health services.
Noted (AI summary) The Ministry of Defence is adding guidance to JSP 950 Leaflet 2-7-2 regarding medical information handling, entitlement of service personnel to NHS services, liaison between DCMHs and local NHS services, and information needs for NHS providers. It also highlights the existing out-of-hours Service Liaison Officer service and the MOD's commitment to the Mental Healthcare Crisis Concordat. The Trust will conduct a root cause analysis investigation jointly with Salisbury District Hospital and the Armed Forces to explore the issues raised in the report and review relevant policies and procedures. The Department of Health is in discussion with the Ministry of Defence and NHS England to address concerns about mental health care for armed forces members, and is working to secure the MoD's commitment to the Mental Health Crisis Care Concordat by the end of April 2015. Following the case review, the SFT Emergency Department implemented a new mental health risk assessment tool, improved information sharing with mental health services, and implemented a system to record and review patients who leave before being seen, also they updated policy to inform GP if patient fails to wait for assessment. Public Health England states its role is to help the public health system achieve 'public health parity' for mental health. They are aware the Department of Health is in discussion with the MoD and will address the concerns raised in the report.
Michael Lyons
All Responded
2015-0067 20 Feb 2015 London (East)
John Stanley Agency
Concerns summary (AI summary) The care agency failed to act on swallowing assessment recommendations, resulting in an inadequate care plan that did not specify choking prevention measures, and staff lacked crucial awareness regarding food preparation.
Disputed (AI summary) The care agency disputes responsibility, stating that they were not informed of Mr. Lyons' swallowing difficulties or risk of choking by social services or family, and therefore could not supervise him adequately during mealtimes.
Lexie Harrison
Partially Responded
2015-0070 20 Feb 2015 West Yorkshire (East)
British Society of Paediatric Gastroent… Leeds Teaching Hospitals NHS Trust NHS Improving Quality +1 more
Concerns summary (AI summary) A critical lack of national and local standardised policies for paediatric oesophageal varix banding procedures leads to inconsistent consultant practices. This impacts patient assessment, post-procedure care, and bleeding management.
Noted (AI summary) The Trust shared the coroner's report with relevant staff and clarified their existing guidelines for managing bleeding oesophageal varices, including resuscitation, antibiotic use, Sengstaken tube placement, and banding procedures. They also highlighted the training provided to paediatric gastroenterology trainees in upper GI endoscopy and oesophageal varices recognition. The UHB acknowledges the coroner's concerns regarding the lack of standardized practices for paediatric endoscopy procedures, but states that they are unable to take the concerns forward themselves and suggest options that may help advance these issues.
Laura Hill
All Responded
2015-0092 20 Feb 2015 Carmarthenshire & Pembrokeshire
Hywel Dda University Health Board
Concerns summary (AI summary) There was a breakdown in information transfer between child and adult mental health teams, coupled with ward understaffing and critical training needs regarding Section 136 procedures, absconding, and powers of detention.
Action Taken (AI summary) The Health Board has provided transition guidelines between Child and Adolescent and Adult Mental Health teams since January 2013, enhanced training in personality disorder management (including Dialectical Behavioural Therapy), and reinforced awareness of detention powers through ongoing Mental Health Act and Mental Capacity Act training.
Daniel Strickland
Historic (No Identified Response)
2015-0505 20 Feb 2015 Southampton and the New Forest
St Edward’s School
Concerns summary (AI summary) Deficient information management included a lack of written handovers, inaccurate logs, an inaccessible daily log, and no clear method for sharing critical medical information with external parties.
Maria Nekrasova
All Responded
2015-0141 20 Feb 2015 London (Inner South)
Department for Transport London Borough of Lambeth City of Westminster +1 more
Concerns summary (AI summary) The bridge lacked essential pedestrian safety measures, including central barriers and adequate lighting. This created dangerous conditions where oncoming headlights blinded drivers to pedestrians in the carriageway.
Action Planned (AI summary) TfL will conduct a detailed investigation of lighting levels on Westminster Bridge by August 2015 and consider appropriate alterations, also public consultation in summer 2015 on the road layout across the bridge as part of TfL's 'Better Junctions' works programme.
Alexander Ball
All Responded
2015-0069 19 Feb 2015 Cumbria
Cumbria Partnership NHS Foundation Trust
Concerns summary (AI summary) Critical communication breakdowns between the Trust and other agencies, compounded by the absence of a dedicated Care Co-ordinator, resulted in inadequate care coordination for complex patients.
Action Planned (AI summary) Unity is actively involved in the Cumbria wide Crisis Care Concordat working group and members of the Frequent Attenders meetings. They are actively working with partners to provide a joined up approach to managing individuals with the most complex care needs. The Trust is implementing actions by the end of April 2015, including development of a communications protocol and directory, and a review of referral processes. Measures to address waiting times for care coordinators are being rolled out across the Trust during 2015.
Barrie Lewis
All Responded
2015-0065 19 Feb 2015 Powys, Bridgend & Glamorgan Valleys
Cwm Taf Health Board
Concerns summary (AI summary) The provided text is incomplete and does not contain any discernible coroner's concerns.
Action Taken (AI summary) A corrective Action Plan for Improvement was developed, and actions have been taken to improve communication and documentation, including a review of the Care Treatment Plan Policy, a new procedure on the role of the duty officer, and improved monitoring of recording systems.
Elizabeth Leah
All Responded
2015-0064 19 Feb 2015 Manchester (South)
Department of Health and Social Care
Concerns summary (AI summary) Severe ambulance service understaffing and resource shortages led to dangerous delays, resulting in an elderly patient with a broken leg being advised to take a taxi to the hospital. Systemic issues were exacerbated by A&E delays and bed blocking.
Action Taken (AI summary) NWAS has increased staffing levels in control rooms and on the road, and is developing Advanced Community Paramedic roles. They are also increasing the use of volunteer services and have an active frequent caller scheme.
Maria Silkin
Historic (No Identified Response)
2015-0061 19 Feb 2015 Manchester (South)
Appleton Lodge Care Home
Concerns summary (AI summary) The care home's falls risk assessment contained inaccurate information regarding the patient's fall history. This misrepresentation led to a dangerous delay in appropriate medical intervention.
John Dack
All Responded
2015-0151 19 Feb 2015 London Inner (North)
Barts Health
Concerns summary (AI summary) Critical administrative failures, specifically incorrect patient addresses in medical notes despite multiple notifications, led to missed follow-up appointments and have previously resulted in serious consequences.
Noted (AI summary) Barts Health NHS Trust investigated the incident and has reminded staff of the importance of accurately changing patient details and the consequences of not doing so. They note that the patient did know about the follow-up appointment.
Keri Holdsworth
All Responded
2015-0060 18 Feb 2015 Hartlepool
Hartlepool Borough Council Highways Agency
Concerns summary (AI summary) This junction is a recurring danger zone with a history of several serious and fatal incidents, specifically for vehicles making right turns to or from the northbound A19.
Noted (AI summary) The Highways Agency has extended a route safety study to consider whether a bridge at Elwick could facilitate closure of central reserve gaps, including the Dalton Piercy junction. The study is due to report in August 2015. Hartlepool Borough Council clarifies that the relevant stretch of road falls under the jurisdiction of Highways England, but they are in dialogue with Highways England and will assist as required.
Alan Jones
Partially Responded
2015-0059 18 Feb 2015 Swansea & Neath Port Talbot
NHS England NHS Wales Royal College of General Practitioners +1 more
Concerns summary (AI summary) Inadequate GP training on electronic patient systems hindered access to critical clinical information. Software design failures also prevented important patient conditions from being clearly highlighted as alerts.
Noted (AI summary) The Department of Health explains the GP Systems of Choice (GPSoC) scheme, through which the NHS funds the provision of GP clinical IT systems in England.
Henry Powell
All Responded
2015-0058 18 Feb 2015 Leicester (City & South)
Leicester Partnership Trust University Hospitals of Leicester
Concerns summary (AI summary) Discharge planning was inappropriate due to insufficient staff training on bed rails. There were also policy conflicts between hospital and community services, and inadequate coordination for equipment provision and follow-up.
Action Taken (AI summary) An alert on the NRS Healthcare ordering system has been put in place. The alert requires the healthcare professional ordering the equipment to confirm that a full assessment and risk assessment has been completed that supports the bed rails are a safe and appropriate for the individual patient. The Lead Discharge Nurse has met with staff to reinforce bed rail ordering procedures and risk assessment, and training will be provided to relevant staff. An alert system is now in place on the electronic ordering system to prompt staff to consider a bed rails risk assessment.
Huseyin Erdogan
Historic (No Identified Response)
2015-0066 17 Feb 2015 London (North)
Barnet Enfield and Haringey Mental Heal…
Concerns summary (AI summary) Key action plans developed following a death, with a November 2014 completion date, remained largely unimplemented by the time of the inquest, raising concerns about preventing future deaths.
George Marks
All Responded
2015-0057 17 Feb 2015 Mid Kent & Medway
Mayday Health Care Plc
Concerns summary (AI summary) Agency staff demonstrated a fundamental lack of understanding regarding medication administration policies, prescription chart recording, patient nursing notes documentation, and correct handover procedures.
Action Taken (AI summary) Mayday Healthcare has implemented measures including monthly SMS reminders to staff, consultant training, client feedback forms, quarterly letters to staff, and updated yearly training program in regards to documentation, escalation, administration of medication and compassion.
Mohammed Yousaf
Historic (No Identified Response)
2015-0056 16 Feb 2015 Manchester (North)
Department of Health and Social Care Pennine Acute Hospitals NHS Trust Royal College of Obstetricians and Gyna…
Concerns summary (AI summary) There are no national guidelines on how to interpret and/or classify antenatal CTG tracings, and there were concerns about the dissemination, application, and applicability of the Trust’s Interpreting Policy, specifically regarding obtaining informed consent.
Richard Westgate
All Responded
2015-0050 16 Feb 2015 Dorset
British Airways Civil Aviation Authority
Concerns summary (AI summary) Aircraft cabin air contains organo-phosphate compounds harming occupant health and impairing flight control. There is no real-time monitoring of these compounds or consideration for individual genetic susceptibility.
Noted (AI summary) The CAA acknowledges the coroner's concerns but states that expert studies have not found a definitive link between cabin air quality and health issues. They will cooperate with EASA's ongoing investigations into cabin air quality and review their position in due course. British Airways notes the concerns but states that they have been fully dealt with by government and regulatory bodies. BA follows existing guidance and legislation and monitors research in this area.
Christopher Taylor
Partially Responded
2015-0055 13 Feb 2015 Avon
Avon and Salisbury Constabulary Bath and North East Somerset Local Auth… Sainsburys Plc
Concerns summary (AI summary) The dispatch team lacked immediate visibility of incoming incidents, hindering timely action. Also, the landowner of a high-risk river stretch should consider providing vandal-proof life buoy stations.
Action Planned (AI summary) Sainsbury's met with local council and fire services, cleared vegetation to improve visibility and access, and maintains service level agreements. They also endorsed RoSPA's recommendation for user education and prioritize preventing falls into the river. Avon and Somerset Constabulary outlines changes to their communication services, including a new call scripting system with dynamic assessment capabilities to be adopted in April 2015. They have also established a consolidated Learning Board to drive forward lessons from events such as this.
Francoise Snape
Historic (No Identified Response)
2015-0054 13 Feb 2015 Worcestershire
Worcestershire Acute Hospitals NHS Trust
Concerns summary (AI summary) No VTE assessment was performed due to staff misconceptions and perceived busyness. Staff also lacked knowledge of NICE guidelines regarding DVT prevention and mechanical anti-DVT devices, representing a lost opportunity for care.
Robert Yarnell
Historic (No Identified Response)
2015-0052 13 Feb 2015 Manchester (West)
Lancashire Care NHS Foundation Trust
Concerns summary (AI summary) After the patient's discharge from a mental health unit, the Burnley and Pendle Complex Care and Treatment Team did not make sufficient attempts to contact him or his family, and care was not effectively transferred to the Trafford Crisis Resolution Home Treatment Team.
Isobel Griffin and Jane Clark
Historic (No Identified Response)
2015-0049 12 Feb 2015 Northamptonshire
Northamptonshire NHS Partnership Trust …
Concerns summary (AI summary) For Jane Clark, challenging events were not handed over, the nurse in charge did not read the notes before granting leave, risk assessment was ill-informed, not discussed, and poorly documented; for Isobel Griffin, there were issues with key worker allocation, updating risk assessments, clinician reviews, medication management, and ligature points.