2015
PFD Reports
Reports: 477
Areas: 69
62% response rate (below 63% average).
Elsie Brown
Historic (No Identified Response)
4 Dec 2015
Nottinghamshire
Your Health Ltd
Concerns summary (AI summary)
Absent falls/bed rails assessments, incomplete care plans, poor record-keeping, inadequate night staffing, and informal handovers created significant safety risks due to unclear staff responsibilities.
Codrut Iederan
Historic (No Identified Response)
3 Dec 2015
London Inner (North)
Zelltec Limited
Concerns summary (AI summary)
The construction site had inadequate first aid provision, with the designated first aider off-site and non-English speaking workers untrained and unaware of how to summon emergency help.
Barbara Rawlinson
Historic (No Identified Response)
2023-0413Deceased
1 Dec 2015
Inner North London
Royal Free London NHS Foundation Trust
Concerns summary (AI summary)
Pre-hysterectomy CT scans are not routinely performed, relying solely on ultrasound. This raises concern that uterine sarcoma diagnoses could be missed due to inadequate diagnostic imaging protocols.
Ricky Hudson
Historic (No Identified Response)
1 Dec 2015
Birmingham and Solihull
Department for Transport
Driver and Vehicle Licensing Agency
Driver and Vehicle Standards Agency
Concerns summary (AI summary)
Quad bike riders on public roads are not required to wear crash helmets or possess additional driving qualifications, posing significant safety risks due to insufficient regulations.
Bryan Catanach
Historic (No Identified Response)
1 Dec 2015
Worcestershire
Royal Orthopaedic Hospital
Concerns summary (AI summary)
Significant communication failures between clinicians and staff led to delays in patient transfer, senior review, and confusion over care instructions. Additionally, inadequate patient supervision resulted in a fall, and essential traction equipment was unavailable.
Stephen Adams
Historic (No Identified Response)
30 Nov 2015
Worcestershire
Worcestershire Health and Care NHS Trust
Concerns summary (AI summary)
Mental Health Liaison Team risk assessment forms are inadequately completed, with the suicide risk box frequently left blank. This leads to crucial risk information not being properly recorded or easily identifiable.
Thelma Clarkson
Historic (No Identified Response)
27 Nov 2015
Portsmouth and South East Hampshire
National Institute for Health and Care …
Concerns summary (AI summary)
The NICE Head Injury Pathway fails to include Clopidogrel as a trigger for CT scans, unlike Warfarin, despite its known bleeding risk. This omission can lead to missed diagnoses and delayed treatment.
Darren Jones
Historic (No Identified Response)
27 Nov 2015
Nottinghamshire
Burton Hospitals NHS Foundation Trust
Concerns summary (AI summary)
The report identifies a need for review of protocols regarding when renal advice should be sought, especially for transplant patients, along with the education of staff and availability of immunosuppressant drugs.
Robert Mansfield
Historic (No Identified Response)
26 Nov 2015
Carmarthenshire and Pembrokeshire
Pembrokeshire County Council
Concerns summary (AI summary)
Three deaths at the Millpond indicate significant safety concerns, highlighting the need for fencing, improved lighting, clear warning notices, and readily available flotation equipment.
Dean Boland
Partially Responded
2015-0486
25 Nov 2015
Birmingham and Solihull
Birmingham Community Healthcare NHS Tru…
Birmingham Prison
National Offender Management Service
Concerns summary (AI summary)
Pervasive drug issues in the prison are exacerbated by a lack of officer awareness, poor multi-disciplinary communication, and insufficient drug administration checks. Inadequate cell searches, lack of overnight monitoring, and poor external security measures allow widespread drug use and concealment.
Action Taken
(AI summary)
Detox unit staff completed training on supervising opiate substitution medication, and awareness training is scheduled for completion in January 2016. Monthly strategy meetings are held to discuss drug misuse, and attendance from prison officers on B Wing is mandatory. Widespread testing for psychoactive substances as part of the MDT process is planned for April 2016.
Thomas Collins
All Responded
2015-0469
25 Nov 2015
Manchester (South)
Haughton Thornley Medical Centres
North West Ambulance Service
Concerns summary (AI summary)
The attending paramedic lacked confidence in making a clinical decision and inappropriately deferred to an out-of-hours service, indicating a potential training or support gap.
Noted
(AI summary)
The North West Ambulance Service describes its existing 'Paramedic Pathfinder' algorithm and referral process to Acute Visiting Services, asserting it is a considered and auditable system. The practice will ensure that when accidents happen with Thomas and Amy Senior and Tony Swales, they will obtain more information surrounding the circumstances of the fall and will clearly record their findings. In cases of suspected stroke the hospital will be contacted.
Piotr Kucharz
All Responded
2015-0465
24 Nov 2015
Blackpool and Fylde
Lancashire Care NHS Foundation Trust
Concerns summary (AI summary)
Mental health staff displayed a critical lack of consistency and clarity on what constitutes an effective patient observation, with some failing to enter rooms or engage. This systemic ambiguity puts vulnerable patients at risk due to inadequate monitoring.
Action Planned
(AI summary)
The Trust is planning an external review of its new clinical risk assessment tool and policy in April 2016. A revised observation policy and procedure will be implemented by 31 March 2016, and an internal patient safety alert has been issued to remind staff of the current policy.
Jonathan Hawes
All Responded
2015-0466
24 Nov 2015
Isle of Wight
Islands Roads
Concerns summary (AI summary)
The 60 mph speed limit on Cowleaze Hill is unsafe due to blind bends and cambers. There is a critical need to reconsider the speed limit and install appropriate road signage.
Disputed
(AI summary)
Island Roads argues that existing signage is adequate and the collision record doesn't indicate excessive speed, so a reduced speed limit is unlikely to have a measurable impact. The police do not support a reduced speed limit.
Thomas Black
Historic (No Identified Response)
2015-0467
24 Nov 2015
Gwent
HMP Usk
Concerns summary (AI summary)
Prison staff failed to seek timely medical advice for a clearly unwell prisoner, indicating a critical lapse in duty of care and health monitoring.
Alan Ludlow
Historic (No Identified Response)
2015-0470
23 Nov 2015
Mid Kent and Medway
Kent County Council
Concerns summary (AI summary)
Critical information about residents' past incidents and risks is not adequately exchanged between care providers during placement. This leads to new homes being unaware of vital safety history for vulnerable individuals.
Frank Mellers
Partially Responded
2015-0464
17 Nov 2015
Black Country
Care Quality Commission (CQC)
Walsall Manor Hospital
Concerns summary (AI summary)
The report identifies that the patient's DNAR status was fixed without family consultation, poor communication between staff led to resuscitation attempts despite the DNAR, and guidelines for DNAR communication may need examination.
Action Taken
(AI summary)
Following a Root Cause Analysis, the importance of ward rounds has been reiterated, a DNAR indicator has been developed on ward boards, the DNAR policy has been reviewed, and a DNAR leaflet has been developed for patients and families. Peer audits are being carried out to review the effectiveness of DNAR forms, and the findings of the inquest have been shared with relevant staff.
Nadine Brookes-Walker
All Responded
2015-0463
16 Nov 2015
Manchester (North)
Teva UK Ltd
Concerns summary (AI summary)
Packaging for Fentanyl patches may not adequately convey the severe risks associated with using damaged patches, potentially leading to patient misuse.
Noted
(AI summary)
Takeda believes the existing patient information leaflet adequately addresses the issue of damaged patches, and they have requested a review to determine if changes are needed; the MHRA also reviewed product information for fentanyl patches in April 2015.
Emma Bray
All Responded
2015-0438
16 Nov 2015
London (East)
Policy and Patient Safety Directorate
Concerns summary (AI summary)
The report identifies failures to obtain a proper medication history, refer the deceased to a psychiatrist, follow up with the deceased, and share family concerns with the team; also, the report mentions the absence of guidelines for assessment and referral processes.
Action Planned
(AI summary)
NELFT developed an action plan with five broad objectives addressing concerns about assessment, communication with carers, procedures, record keeping, and risk assessment.
Christine McNamara
All Responded
2015-0436
16 Nov 2015
Mid Kent and Medway
Maidstone and Tunbridge Wells NHS Trust
Concerns summary (AI summary)
There is a lack of clear pathways for post-ERCP patients with complications, and out-of-hours radiography is hampered by the absence of a Maidstone surgical consultant for urgent referrals.
Action Taken
(AI summary)
The trust implemented a new pathway in January 2016 for managing patients who develop post-endoscopic surgery complications, with a review scheduled for October 2016.
Irene Scholey
Historic (No Identified Response)
2015-0462
13 Nov 2015
West Yorkshire (East)
Wakefield MDC
Wakefield District Safeguarding Adults …
Concerns summary (AI summary)
No specific concerns were detailed in the provided text, which instead referred to an external narrative conclusion.
Christopher Connor
All Responded
2015-0461
12 Nov 2015
Powys, Bridgend and Glamorgan Valleys
Welsh Ambulance Trust
Concerns summary (AI summary)
Ambulance response was delayed, only arriving after police expedited the call, indicating potential issues with emergency service dispatch or prioritization.
Action Taken
(AI summary)
Following an investigation, the Welsh Ambulance Services NHS Trust addressed failings by an individual staff member and provided additional education and support to call takers involved in the incident; the individual is being managed in line with Trust policies.
Guy Robinson
All Responded
2015-0432
12 Nov 2015
Manchester (North)
Pennine Care NHS Trust
Concerns summary (AI summary)
The 'AWOL' protocol was improperly applied due to staff unfamiliarity, lacking Trust-wide implementation. A significant service gap exists with no inpatient clinical psychology access, disadvantaging vulnerable patients.
Action Taken
(AI summary)
The Trust reviewed and revised the Absence Without Leave (AWOL) policy, including additional guidance and a flowchart, and implemented it Trust-wide on April 1, 2015; Psychological therapies are available on the ward via referral from a Consultant Psychiatrist or nursing staff.
Matthew Groom
All Responded
2015-0503
12 Nov 2015
London Inner (North)
Camden & Islington NHS Trust
Whittington Hospital NHS Trust
Concerns summary (AI summary)
Significant delays occurred in mental health assessment and prescribed medication administration. Staff failed to plan for patient elopement, did not involve hospital security, and inadequately communicated the patient's detention need to police.
Action Taken
(AI summary)
The Trusts strengthened the mental health referral protocol from Whittington ED triage and added a new black phone in Whittington Health ED specifically for the police to pre-alert them to patients who are being brought to WH ED under Section 136 of the Mental Health Act, also creating a new Standard Operating Procedure. The Trusts strengthened the mental health referral protocol from Whittington ED triage and added a new black phone in Whittington Health ED specifically for the police to pre-alert them to patients who are being brought to WH ED under Section 136 of the Mental Health Act, also creating a new Standard Operating Procedure.
David White
All Responded
2015-0437
11 Nov 2015
London Inner (North)
Barts Health NHS Trust
Concerns summary (AI summary)
Critical medication side effects causing confusion were unrecorded and unaddressed. Despite documented fall risks in nursing notes, adequate supervision was absent, and these notes were not reviewed or acted upon.
Action Taken
(AI summary)
Staff have been reminded of the importance of documenting allergies and adverse effects, including in Renal Mortality and Morbidity meetings; the safety briefing during nursing handover will now include care plans for patients at risk of falls, daily auditing of nursing documentation will be carried out, and Multidisciplinary Team meetings on Ward 9F have been changed to earlier in the day.
Alexander Hadley
All Responded
2015-0433
11 Nov 2015
North West Wales
Gwynedd Council
Concerns summary (AI summary)
The absence of warning signs at a public waterfall meant people were unaware of dangerous currents, creating a risk of further accidental deaths.
Action Planned
(AI summary)
Gwynedd Council is arranging to install safety warning signs near the pool at Rhaeadr Afon Arddu, Llanberis, to warn visitors of the danger of underwater currents, with installation expected by the end of January 2016 pending suitable weather.