2015
PFD Reports
Reports: 477
Areas: 69
62% response rate (below 63% average).
John Moreton
Historic (No Identified Response)
2015-0430
9 Nov 2015
Stoke-on-Trent and North Staffordshire
Highways Agency
Concerns summary (AI summary)
A pedestrian stile leads directly onto a busy dual carriageway with a national speed limit, and there are no warning signs for pedestrians or motorists regarding this dangerous crossing point.
Vera Williams
Historic (No Identified Response)
2015-0428
6 Nov 2015
North East and North Central Wales
Betsi Cadwaladr University NHS Trust
Concerns summary (AI summary)
Emergency Department doctors and staff lack a digital system to support their work.
Brian Shillinglaw
Historic (No Identified Response)
2015-0427
6 Nov 2015
Brighton and Hove
Brighton and Sussex University Hospital…
Care Quality Commission
NHS England
+5 more
Concerns summary (AI summary)
The provided text is incomplete and does not contain specific concerns.
Carl Hughes
All Responded
2015-0429
6 Nov 2015
Blackburn, Hyndburn & Ribble Valley
Motor Cross Federation
Concerns summary (AI summary)
Motorcross events do not mandate body protection for competitors, which could prevent fatal injuries.
Noted
(AI summary)
The response explains the MC Federation's role in motorsports event safety and states that they will not mandate the wearing of body protection at their events, arguing it's impractical and may displace participants to less regulated events.
Michael Logue
All Responded
2015-0426
4 Nov 2015
Birmingham and Solihull
Central Surgery
Concerns summary (AI summary)
A general practitioner failed to conduct a physical examination during a home visit for a post-surgery patient complaining of pain and ill health.
Action Planned
(AI summary)
Following a significant event review, the practice agreed to share the event with clinicians to improve practices, undertake more detailed patient examinations with full documentation, and for Dr. Eedle to contact the hospital to improve post-operative patient care communication.
David Pooley
Partially Responded
2015-0421
3 Nov 2015
Essex
South Essex Mental Health Partnership T…
Lancashire Care NHS Trust
Concerns summary (AI summary)
A named nurse was not allocated until the day before death, breaching trust policy and resulting in a failure to carry out essential risk assessments and care plans.
Action Planned
(AI summary)
• All staff have been briefed on the referral process, and learning from the joint investigation has been shared.
• The Trust is exploring using the CRISP board in the Emergency Department to record referrals to specialist teams.
• The Trust is exploring the development of a system whereby East Lancashire Hospital NHS Trust staff email the Mental Health Liaison Team with the patient's details and a brief.
Peter Buckle
All Responded
2015-0425
3 Nov 2015
Norfolk
Wayland Farms Limited
Concerns summary (AI summary)
An unsafe work method was adopted without a risk assessment, and a strong health and safety culture was absent among employees despite training.
Action Taken
(AI summary)
Wayland Farms implemented new health and safety programs including a behavioral safety training program ('stop and think'), and will provide further training with external consultant input. They acknowledge the need for disciplinary action for breaches, greater written documentation, and are undertaking measures on a continual improvement basis.
Connor Sparrowhawk
Partially Responded
2015-0445
2 Nov 2015
Oxfordshire
CQC
Southern Health NHS Foundation Trust
Concerns summary (AI summary)
The bath time observation policy for epileptic patients is inadequate, with concerns about the effectiveness of sound-only monitoring and potential staff distraction. The RIO system also lacks sufficient fields for comprehensive epilepsy information, hindering staff access.
Action Planned
(AI summary)
A new protocol for safe bathing and showering of people with epilepsy has been drafted, and is undergoing consultation. A change request has been made for a prompt in the overarching RiO risk assessment form for physical health risks.
Richard Green
Partially Responded
2015-0456
2 Nov 2015
Cumbria
Ministry of Justice
National Offender Management Service
Concerns summary (AI summary)
Prison medical professionals failed to act on recorded self-harm history in SystmOne due to system usability issues, workload pressure, and a lack of clear display for critical historical information.
Action Planned
(AI summary)
Greater Manchester West Mental Health Foundation Trust have commissioned a review of available assessment tools for the prison setting. NHS England are re-procuring the healthcare electronic healthcare system, SystmOne, which will include sharing of risk indicators.
Marie Quinn
Historic (No Identified Response)
2015-0423
2 Nov 2015
Manchester (West)
HC-One Limited
Richmond House Nursing Home
Concerns summary (AI summary)
Sub-optimal DVT prophylaxis, including delayed medication and missing mechanical treatment, was provided. Incorrect discharge instructions led to early cessation, and the nursing home failed to query excess medication.
Steven Jackson
Historic (No Identified Response)
2015-0422
2 Nov 2015
Essex
Bevan Brittan Law Firm
East of England Ambulance Service NHS T…
General Medical Council
+3 more
Concerns summary (AI summary)
A paramedic failed to effectively use the sepsis screening tool, indicating a need for better training for ambulance staff on its use and appropriate patient conveyance to hospital.
Jacqueline Williams
All Responded
2015-0421-wp25020
2 Nov 2015
Blackburn, Hyndburn and Ribble Valley
East Lancashire NHS Trust
Concerns summary (AI summary)
The mental health referral system was prone to human error, failing to provide ED staff with confirmation of accepted referrals or assessment times. The Mental Health Liaison Team also lacked a process to identify patients awaiting assessment.
Action Taken
(AI summary)
• All staff were briefed on the referral process to ensure full understanding, and learning from the joint investigation was shared.
• The Trust met with East Lancashire Teaching Hospitals NHS Trust to explore in detail how to improve the referral process.
• The Trust is looking to utilise the CRISP board within the Emergency Department to record referrals made to specialist teams.
Jean Gillespie
All Responded
2015-0419
2 Nov 2015
Blackpool and Fylde
Alexandra Court Care Home
Concerns summary (AI summary)
Senior care staff lacked awareness of a resident's life-threatening condition and medication, failing to appreciate the urgency of re-ordering supplies. Care home records also lacked critical information about the condition.
Action Taken
(AI summary)
Senior Care Assistants received further medication training and competency assessments, including a supervision after the inquest. The new manager introduced handover and medication count down sheets for improved communication and stock control.
Mary Bloom
All Responded
2015-0417
30 Oct 2015
East London
Barking, Havering and Redbridge Univers…
Concerns summary (AI summary)
Trust policy on heparin administration was not followed, including failure to weigh the patient, consult haematology, or take post-hydration bloods. Critical dosage advice for underweight patients was also easily missed due to poor visibility on posters.
Action Taken
(AI summary)
The trust implemented three new policies and a chart for unfractionated heparin administration. The guidelines now state that if the APTTR at 6hrs is outside the expected range then the Consultant Haematologist should be contacted for further advice in those patients at the extreme ends of the weight ranges i.e. <41kg and >90kg.
Dennis Stark
Historic (No Identified Response)
2015-0420
30 Oct 2015
Blackpool and Fylde
Newton House (formerly Regency Hospital)
Concerns summary (AI summary)
A rehabilitation unit's lack of a lift significantly delayed the emergency removal of an obese patient from a second-floor room, posing a risk of future deaths for individuals requiring urgent medical attention.
Hilda Haughton
All Responded
2015-0460
29 Oct 2015
Manchester (South)
Secretary of State for Health
Tameside Hospital NHS Foundation Trust
Concerns summary (AI summary)
Patient falls resulted from unraised cot sides and were compounded by a lack of hospital staff candour. Concerns were also raised regarding the safety of increased fire-door closing times in hospitals.
Noted
(AI summary)
The Department of Health issued an Estates and Facilities Safety Alert to the NHS in England regarding the speed of closing fire doors. The alert sets out necessary action to be taken to reduce the risk of similar incidents in the future and covers all self-closing fire doors. The trust states that the incident didn't invoke the Statutory Duty of Candour. The trust states they have been proactive in relation to ensuring Duty of Candour and gives information about training workshops.
Tamara Mills
Historic (No Identified Response)
2015-0416
29 Oct 2015
Gateshead & South Tyneside
Farnham Medical Centre
Health Education England
National Institute for Health and Care …
+6 more
Concerns summary (AI summary)
Concerns were raised that the child's asthma care focused only on acute presentations, failing to address the underlying chronic condition holistically across repeated hospital visits.
Florence Lowe
Historic (No Identified Response)
2015-0415
29 Oct 2015
Stoke-on-Trent & North Staffordshire
Staffordshire County Council
Concerns summary (AI summary)
A 60mph speed limit on a road with residential properties and busy amenities is inappropriate, and a major roundabout lacks a pedestrian crossing. Other local roads have adopted lower limits for safety.
Kevin Forster
All Responded
2015-0453
28 Oct 2015
County Durham and Darlington
G4S
National Offender Management Service
Concerns summary (AI summary)
HMP Durham had a serious drug problem, but staff lacked awareness and training on overdose policies, leading to complacent responses, inadequate treatment plans, and delayed emergency calls for prisoners under the influence.
Action Taken
(AI summary)
Healthcare staff have been reminded of the importance of full and contemporaneous notes, and training has been provided on substance misuse; clinical guidelines are being developed for substance misuse issues, including a treatment plan template on SystmOne. Posters are planned for discipline staff areas, and training will be repeated to prison officers on emergency code allocation. All staff have signed to confirm their understanding of the Emergency Code Protocol, and managers have verified their awareness. Pocket-sized cards explaining the protocol have been issued, and the protocol is displayed in prominent areas and explained to new staff during onboarding; the protocol has been an agenda item at team meetings, and the issue has been addressed by the Deputy Governor and the Governor.
Christopher Smith
Historic (No Identified Response)
2015-0455
28 Oct 2015
Manchester (West)
Greater Manchester Police
Concerns summary (AI summary)
A 12-minute ambulance call delay resulted from communication breakdown between police control rooms regarding responsibility. A clear procedure is required to prevent future delays, especially when timely medical intervention is crucial.
Bartosz Bortniczak
All Responded
2015-0452
27 Oct 2015
South Yorkshire (East)
Doncaster Highways Services
Concerns summary (AI summary)
The 40mph speed restriction is placed after a dangerous road bend, rather than before it, despite multiple incidents, unnecessarily increasing the risk of collisions.
Action Planned
(AI summary)
Doncaster Borough Council intends to reduce the speed limit on a stretch of the A630 to 40mph, complemented by additional signage and road markings; this is subject to statutory processes and is anticipated to be implemented by early summer 2016 at the latest.
Charlotte Bevan and Zaani Malbrouck
All Responded
2015-0418
27 Oct 2015
Avon
Avon and Wiltshire Mental Health NHS Tr…
Concerns summary (AI summary)
There was no mandatory multi-disciplinary team meeting or widely circulated care plan for pregnant women with known mental health conditions, risking fragmented and uncoordinated care.
Action Planned
(AI summary)
A consultant perinatal psychiatrist has been tasked to review individual pathway arrangements against NICE guidelines, aiming to agree and implement a Trust-wide pathway. The Trust also plans to prepare and issue a vignette of Charlotte's care as a reflective training exercise, emphasizing multi-disciplinary working and care planning.
Scarlett Jukes
Partially Responded
2015-0449
27 Oct 2015
Avon
Foxhound Association
Health and Safety Executive
Concerns summary (AI summary)
Neither public participants nor paid hunt staff are required to wear protective headgear that complies with recognised safety standards during hunting events, posing a significant injury risk.
Action Planned
(AI summary)
The MFHA has initiated a full review of hats used for hunting and has begun gathering evidence; it plans to issue new Guidance Notes for Hunt Officials and Subscribers, aiming for approval at the MFHA AGM in June 2016.
George Hines
Historic (No Identified Response)
2015-0448
27 Oct 2015
Avon
Bristol City Council
Concerns summary (AI summary)
Defects in the pull-cord alarm system were unaddressed, residents were responsible for smoke detector maintenance, and smoke detectors were not linked to the emergency control room, delaying fire alerts.
Neil Garry
All Responded
2015-0446-wp25121
26 Oct 2015
West Yorkshire (East)
Highways England
Concerns summary (AI summary)
A busy road frequently used by pedestrians, including children, lacks a pedestrian crossing, posing a significant safety risk.
Action Planned
(AI summary)
• A scheme has been designed to provide safe pedestrian assisted facilities across the Ring Road at the Ramshead Approach and Coal Road junction.
• A Highways Board report is to be presented to the Chief Officer (Highways and Transportation) early in the New Year to seek formal funding approval to progress the junction improvement measures at the Ramshead Approach/ Ring Road junction.
• It is currently programmed that the scheme will then be issued to contractors in this financial year, with an expected completion date onsite between May/June 2016.