2015

PFD Reports
Reports: 477 Areas: 69

62% response rate (below 63% average).

Response Status
Responded 295 Historic 181
AI Classification
Action Taken 47%
Action Planned 30%
Noted 21%
Disputed 2%
Based on 385 classified responses
Top Categories
Hospital Death (Clinical Procedure… (224) Other related deaths (54) Community health care and emergenc… (46) Road (Highways Safety) related dea… (38) Child Death (from 2015) (35)
477 results
Katherine Bonaventura
Historic (No Identified Response)
2015-0031 28 Jan 2015 Surrey
Surrey and Borders Partnership NHS Foun…
Concerns summary (AI summary) The system for assessing detained patients returning from leave is flawed, lacking thorough family/carer consultation and adequate mental state assessment documentation.
Lana-Liza Chervonenko
Historic (No Identified Response)
2015-0022 28 Jan 2015 London (East)
Queen’s Hospital
Concerns summary (AI summary) High activity on the labour ward led to delayed medical reviews, incorrect emergency grading, incomplete patient assessments, and a flawed prioritisation decision, resulting in significant delays to emergency delivery.
Susanna Geraty
All Responded
2015-0026 27 Jan 2015 Surrey
East Surrey Hospital
Concerns summary (AI summary) Post-operative care failures included inadequate fluid balance monitoring and recording, poor nursing records, failure to recognise an acutely unwell patient, and unaddressed family concerns.
Action Taken (AI summary) SASH has introduced mandatory training for newly qualified nurses on fluid balance and has issued a reminder to staff regarding the importance of accurately completing fluid balance charts. A Serious Incident Review Group has been formed to review SI investigations and reports.
Rafel Delezuch
All Responded
2015-0024 27 Jan 2015 Leicester City & South Leicestershire
Leicester University Hospitals NHS Trust
Concerns summary (AI summary) Emergency department staff lacked awareness and training on restraint policies, the dangers of prone restraint, and suitable medications for rapid tranquilisation, leading to unsafe practices.
Action Taken (AI summary) All clinical staff in the Emergency Department are now aware of the Trust's Restraint Policy and the dangers of prolonged restraint in the prone position. The Chief Pharmacist has met with the Leicestershire Partnership Trust to develop a shared rapid tranquilisation guideline, expected to be in place by the end of May 2015.
Hilary Moock and Janice Taylor
All Responded
2015-0020 23 Jan 2015 West Sussex
West Sussex County Council
Concerns summary (AI summary) An ancient, high-risk rural road with poor design, unlit conditions, and a difficult, low-visibility entrance creates a dangerous situation for turning vehicles.
Noted (AI summary) West Sussex Council argues that the specific location of the incident does not express a high collision rate. Lighting for the route would be disproportionate to benefit and would be contrary to light pollution minimisation within such a rural setting.
Sian Armstrong
Historic (No Identified Response)
2015-0019 21 Jan 2015 Avon
North Bristol NHS Trust
Concerns summary (AI summary) A significant delay occurred in providing Cognitive Behavioural Therapy (CBT) for a child, Sian Armstrong, who was assessed as needing it, highlighting a lack of timely access to critical mental health support.
Robert Jones
Partially Responded
2015-0018 21 Jan 2015 Exeter & Greater Devon
North Devon Healthcare NHS Trust South Molton Community Hospital South Molton Health Care Centre
Concerns summary (AI summary) Communication failures meant staff were unaware of a patient's total falls, an outdated post-falls checklist was used, and neurological observations were not correctly recorded per NICE guidelines.
Action Taken (AI summary) The GP practice shared the hospital's action plan with their GPs and will have ongoing discussions with the hospital. The hospital updated its falls policy, implemented falls assessments on admission, monitors blood pressure, introduced falls stickers, conducts regular safety briefings, ensures bedside handovers, and delivers targeted training on neurological observations to nursing staff and healthcare assistants. The Trust's falls policy has been revised to include information relating to the frequency and duration of neurological observations, and published on the Trust's policy website. Targeted training on performing neurological observations for nursing staff is in place and all registered nurses completed this training by the end of February 2015.
Philip Smith
Historic (No Identified Response)
2015-0017 21 Jan 2015 West Yorkshire (West)
Huddersfield Royal Infirmary
Concerns summary (AI summary) Extensive failures in nursing and doctors' record-keeping, including missed observations and medications. A junior doctor also declined a senior medical review despite a nurse's concerns about the patient's deterioration.
James Colton
Partially Responded
2015-0021 20 Jan 2015 Worcestershire
HMP Long Lartin Healthcare Worcestershire Health and Care Trust
Concerns summary (AI summary) Prison healthcare staff failed to correctly diagnose and treat Mr Colton, missing his developing cancer due to not revisiting the initial diagnosis. There was also inadequate pain management, poor continuity of care, and communication failures.
Action Taken (AI summary) The trust held study sessions reviewing the case notes of Mr. Colton, increased the consultant psychiatrist's sessions at HMP Long Lartin, appointed a clinical director for offender healthcare, and formalised a new process for clinical supervision through the South Worcestershire Federation.
Awa Jeng
All Responded
2015-0015 20 Jan 2015 London (East)
Barts Health
Concerns summary (AI summary) A high-risk patient for renal failure was not closely monitored, and critical blood tests and checks directed by a consultant were not performed, indicating failures in monitoring, task handover, and medical review.
Action Taken (AI summary) The trust is implementing a revised early warning score system (NEWS and CREWS), has been awarded funding to implement a vital signs monitoring process (Vitalslink), has a full complement of middle grade doctors, holds regular mortality and morbidity meetings, sent instructions to junior doctors regarding trauma sheet completion, and discusses all renal dialysis patients with the renal team.
Simon Alliston
All Responded
2015-0023 19 Jan 2015 Bedfordshire & Luton
South Essex Partnership University NHS …
Concerns summary (AI summary) A patient with a long mental health history was discharged without a formal handover or recorded reason, despite the community team believing ongoing support was needed. No serious incident investigation followed his death.
Action Taken (AI summary) The trust has made changes to its Serious Incident reporting process, ensuring clinical information is made available, decisions are taken by Executive Directors, and the process no longer requires confirmation of the Cause of Death before reporting. Weekly and monthly meetings are held to monitor investigations and reported deaths.
Robert Anstice
Historic (No Identified Response)
2015-0014 16 Jan 2015 Norfolk
Norfolk and Suffolk NHS Foundation Trust
Concerns summary (AI summary) Critical recommendations for support and care coordination were not actioned, and communication breakdowns meant team members were unaware of appointments. The patient was discharged despite difficulties in engagement and unmet practical needs.
Louise Henry
All Responded
2015-0013 16 Jan 2015 Derby & Derbyshire
Derbyshire County Council Derbyshire Healthcare NHS Foundation Tr… NHS England
Concerns summary (AI summary) A critical misunderstanding existed between mental health teams regarding care coordination and adherence to the Care Programme Approach (CPA), leading to confusion about who was responsible for the patient's ongoing care.
Action Planned (AI summary) Derbyshire County Council will rebrand its recovery team as "Fieldwork (Mental Health)" and launch this at the next Social Care Forum. Derbyshire Healthcare NHS Foundation Trust is undergoing a transformation and will use new terminology in place of 'Recovery Team' by November 2015. NHS England recommends practices review their Serious Mental Illness registers to ensure appropriate patients have information shared with Out of Hours providers. The Medical Interoperability Gateway has been introduced in parts of Nottinghamshire and will be rolled out to the rest of the county and also across Derbyshire, allowing access to coded information in the patient's medical record with consent.
Judith Saville
All Responded
2015-0011 15 Jan 2015 Exeter & Greater Devon
Axminster Medical Practice Devon Partnership NHS Trust
Concerns summary (AI summary) Over-prescription of medication to a patient with a history of overdoses was identified. There was a lack of a robust computer system to warn practitioners about overdose history, and an action plan's implementation needed auditing.
Disputed (AI summary) The practice disagrees that too many Zopiclone pills were prescribed and argues that a special flag highlighting past overdoses would be problematic and potentially offensive. They believe their current assessment process and referral to the Crisis Response Team are adequate. The Trust undertook a Root Cause Analysis Investigation following the death, accepted the recommendations, and completed the identified actions. Assurance that changes have been embedded into clinical practice is monitored through routine audit.
Max Carlton-Smith
All Responded
2015-0007 14 Jan 2015 London (Inner South)
Department of Health and Social Care
Concerns summary (AI summary) Organizers of an unlicensed rave failed to provide medical assistance, delayed calling emergency services, and operated in an unsafe venue with poor ventilation. Police lacked sufficient powers to intervene effectively in squatted commercial premises.
Noted (AI summary) The Home Office believes the police have sufficient powers under existing legislation (Criminal Justice and Public Order Act 1994) to prevent and stop illegal raves. The use of these powers is an operational matter for the police.
Annette Charlton
Partially Responded
2015-0009 9 Jan 2015 Birmingham & Solihull
Crescent Pharma Ltd Department of Health and Social Care General Pharmaceutical Council +3 more
Concerns summary (AI summary) Pharmaceutical manufacturers are producing medications in almost identical packaging, which significantly increases the risk of dispensing errors and poses a serious threat to patient safety.
Action Planned (AI summary) Crescent Pharma has scheduled a meeting with the MHRA to discuss packaging redesign and the use of colour to differentiate products and strengths, after their request to do so in May 2014. Agreement of design and product range colour chart will lead to the creation of new artwork for all Crescent products, submission for MHRA approval and co-ordination of new artwork introduction after MHRA approval.
Pauline Taylor
All Responded
2015-0008 9 Jan 2015 West Yorkshire (East)
Department of Health and Social Care Leeds Teaching Hospitals NHS Trust
Concerns summary (AI summary) Ambiguity in the surgical term "nephroureterectomy" caused critical misunderstandings between clinicians regarding procedure extent. There was also an absence of a case manager to oversee complex patient care and communication.
Noted (AI summary) The Department of Health acknowledges the concerns, notes BAUS's definition of nephroureterectomy, and states that decisions on clinical team operations are for the local Trust to address, also suggesting the GMC as the appropriate body for fitness to practice concerns. The hospital clarified that "nephroureterectomy" means removal of the kidney with the whole ureter, emphasized this guidance to staff and included it in induction information. They filled Clinical Nurse Specialist posts to coordinate care for patients with possible cancer diagnoses.
Jason Lawson
Historic (No Identified Response)
2015-0006 9 Jan 2015 Rutland & North Leicestershire
HM Prison and Probation Service NHS England
Concerns summary (AI summary) Welfare checks failed to identify a deceased prisoner. Prison healthcare lacked a computer-driven system to track missed and lapsed prescriptions, and there was no policy for constant medical supervision for high-risk prisoners.
Mark Burdett
Historic (No Identified Response)
2015-0005 9 Jan 2015 Warwickshire
Warwickshire City Council
Concerns summary (AI summary) A lack of signage warning motorists about a concealed entrance posed a significant safety risk, especially for traffic approaching from a particular direction.
Thomas Hunt
Partially Responded
2015-0004 9 Jan 2015 South Lincolnshire
North LCC Highways North Lincolnshire Council
Concerns summary (AI summary) A number of unrecorded non-injury collisions indicate a hazardous road section. The existing 60mph speed limit on a village road bordered by residential properties is deemed inappropriate and should be reduced.
Action Planned (AI summary) Lincolnshire County Council will assess reducing the speed limit on the B1192 at Brothertoft, following the adoption of a revised Speed Limit Policy expected in Autumn 2015. The council is currently reviewing its Speed Limit Policy, and the revised policy is due to be considered by the Council's Highways and Transport Scrutiny Committee on 9 March 2015.
George Hulme
Historic (No Identified Response)
2015-0016 8 Jan 2015 Manchester (South)
Bamford Grange Nursing Home
Concerns summary (AI summary) Care home agency staff lacked resident identification information and adequate induction. Rooms were not clearly marked, leading to confusion during emergencies and incorrect patient file retrieval for treatment.
Eve Cullen
All Responded
2015-0002 8 Jan 2015 Worcestershire
Worcestershire Health and Care NHS Trust
Concerns summary (AI summary) Referrals from hospital were not actioned or treated as urgent due to a lack of service-wide definition for "urgent" and no agreed timeframes. The process led to lost opportunities for timely intervention in mental health care.
Action Taken (AI summary) Worcestershire Health Care NHS Trust conducted a serious review and acknowledges differences in urgent referral processes across the county. As a result, it is working with North CCGs to introduce a standardised system county-wide and towards performance measures for all referral categories with defined timescales.
John Ioannou
All Responded
2015-0012 6 Jan 2015 London (North)
Department of Health and Social Care
Concerns summary (AI summary) There is a lack of clear guidance for General Practitioners when patients fail to collect essential mental health medication, potentially compromising treatment continuity and patient well-being.
Noted (AI summary) The Department of Health acknowledges the concerns about GPs monitoring medication collection for mental health patients, but cites practical and ethical challenges to implementing such a system. NHS England advises that it has sought the advice of its Primary Care Patient Safety Expert Group and Mental Health Patient Safety Expert Group on what action might feasibly be taken in this area. NHS England will be able to provide an update on these discussions by the end of April 2015.
Dale Proverbs
All Responded
2015-0010 6 Jan 2015 London (North)
Department of Health and Social Care
Concerns summary (AI summary) Observation policies for secluded mental health patients were found to be inadequate under the current Code of Practice, which could lead to future fatalities. Higher observation standards previously in place would likely have prevented the death.
Action Taken (AI summary) The Department of Health notes that Partnerships in Care (PIC) redrafted their policies to conform exactly to the 2008 Mental Health Act 1983 Code of Practice. Staff failure in this case to comply with the Mental Health Act Code of Practice is unacceptable.
Carla London
All Responded
2015-0003 6 Jan 2015 London (North)
Department of Health and Social Care
Concerns summary (AI summary) Concerns were raised about the need to consider NICE guidance on late-onset sepsis in premature babies and to research infection monitoring systems to improve early detection and treatment.
Action Planned (AI summary) The Department of Health has shared the coroner's report with NICE, so NICE can take the concerns into account in the development of its guideline on sepsis. NICE expects to publish its final guidance on this topic in July 2016.