2015
PFD Reports
Reports: 477
Areas: 69
62% response rate (below 63% average).
Patrick Carrick
All Responded
2015-0374
9 Oct 2015
Newcastle Upon Tyne
North Tyneside General Hospital
Concerns summary (AI summary)
There was an unexplained departure from the patient's management plan during rapid deterioration, crucial blood results were not actioned, and nursing/medical notes were inadequately completed.
Action Taken
(AI summary)
Northumbria Health Care NHS Trust has implemented monthly audits by Matrons to check adherence to management plans, provided NEWS training, and is procuring an electronic track and trigger system for NEWS. They have also reported NEWS compliance monthly and made changes to NEWS to incorporate sepsis management.
Suzanne Greenwood
All Responded
2015-0370
9 Oct 2015
Manchester (West)
Priory Hospital
Concerns summary (AI summary)
Lack of systems and protocols for contacting patients who miss appointments, informing GPs of non-attendance or discharge, and ensuring continuity of care when patients are lost to follow-up.
Action Taken
(AI summary)
The Priory Group amended its policy regarding independent doctors, requiring prompt GP contact for missed appointments and detailed discharge letters. The amended policy has been circulated, discussed at meetings, and will be included in a learning bulletin.
Maureen Chatterley
All Responded
2015-0404
8 Oct 2015
Manchester (West)
Royal Bolton Hospital
Concerns summary (AI summary)
Lack of investigation into alleged medication overdose and inadequate stock control for non-controlled drugs on wards, preventing verification of medication quantities and increasing risk of misuse or error.
Action Planned
(AI summary)
Bolton NHS Trust will introduce a new Wardex for pharmacists to record reviews and develop a local endorsement policy by February 2016. Safe and Secure Handling of Medicines Audits (Duthie) will be presented to Medicines Safety Group for discussion and agreement of action plans by December 2015.
Solomon Bealey
All Responded
2015-0403
8 Oct 2015
Norfolk
Norwich Practices Health Centre
Concerns summary (AI summary)
Despite initial concerns about a patient's suicidal ideation and a history of self-harm, no effective follow-up action was taken after failed contact attempts.
Action Taken
(AI summary)
Norwich Practices Health Centre will have a standing agenda item called 'Patients of Concern' at their weekly clinical meeting, and have agreed to have a 'Patients of Significant Concern' register with immediate effect. A reflective discussion with the Designated Nurse for Safeguarding Children took place.
Rebecca Jones
All Responded
2015-0504
8 Oct 2015
Hertfordshire
Department of Health and Social Care
Concerns summary (AI summary)
Concerns involved the failure to conduct a Section 136 mental health assessment within the expected three-hour timeframe, and the need for facilities to ensure safe containment for vulnerable individuals.
Action Planned
(AI summary)
NHS England will spend £15m in 2016/17 to boost provision in areas that lack adequate health-based places of safety and is developing commissioning guidance for effective crisis response. HEE is undertaking a root and branch review of its workforce development spend.
Naiya Diarra
Historic (No Identified Response)
2023-0412
7 Oct 2015
Inner North London
National Institute for Health Care Exce…
Concerns summary (AI summary)
The report identifies that relevant information about the deceased's illness was in disparate records, making it difficult for clinicians, especially the psychiatric team, to access and share.
Edward Gascoigne
All Responded
2015-0401
7 Oct 2015
London Inner (North)
Department of Health and Social Care
Concerns summary (AI summary)
The report identifies that relevant information about the deceased's illness was in disparate records, making it difficult for clinicians, especially the psychiatric team, to access and share.
Noted
(AI summary)
The Department of Health describes the Summary Care Record (SCR) system and planned enhancements, stating that it is designed to improve access to patients’ GP records.
Geoffrey Parry
All Responded
2015-0400
7 Oct 2015
Cardiff and the Vale of Glamorgan
Cardiff and Vale University Health Board
Concerns summary (AI summary)
Critical ECG test results were unavailable pre-surgery due to systemic record management issues. An unlabelled intravenous line was accidentally disconnected, highlighting a lack of clear labelling protocols.
Action Taken
(AI summary)
The University Health Board has reviewed systems for ECG storage, reinforced the use of the MUSE system, and implemented training on intravenous infusion labelling. The learnings from this incident will be shared, and the Regulation 28 report will be shared with all Clinical Boards.
Dilys Jenkins
Historic (No Identified Response)
2015-0399
7 Oct 2015
Cardiff and the Vale of Glamorgan
Intensive Care Society of England and W…
Concerns summary (AI summary)
Tracheostomy tube manufacturers may not be keeping pace with population changes, leading to tubes of potentially inappropriate length which could increase dislodgement risk.
Peter Furness
All Responded
2015-0398
5 Oct 2015
North Wales (East and Central)
Nant y Gaer Hall Nursing Home
Concerns summary (AI summary)
The care home lacked a documented process for escalating incidents and concerns to trigger multi-disciplinary team meetings for reviewing vulnerable residents' risk assessments and care plans.
Action Taken
(AI summary)
Nant Y Gaer Hall has implemented a new alert system for changes in residents' conditions, with training and supervision for staff. The new system includes forms, flow charts, and posters, and is supported by red alert files.
Rosina Drury
Historic (No Identified Response)
2015-0397
2 Oct 2015
London Inner (South)
Kings College Hospital
Concerns summary (AI summary)
The absence of a pre-operative orthogeriatric review for patients with femoral neck fractures risks inappropriate cemented hemiarthroplasty, potentially leading to fatal bone cement implantation syndrome.
Charles Rayner
Historic (No Identified Response)
2015-0367
1 Oct 2015
County Durham and Darlington
Highways England
Concerns summary (AI summary)
The report identifies that the crossover point lacks a deceleration lane and there is no prohibition on right turns with appropriate signage.
Kenneth McCurdy and Mary McCurdy
All Responded
2015-0369
1 Oct 2015
County Durham and Darlington
Highways England
Concerns summary (AI summary)
The absence of clear signage at a central reservation gap fails to indicate prohibited right turns or U-turns for east-bound vehicles, creating a significant highway safety risk.
Action Planned
(AI summary)
Highways England will work with Durham Constabulary to investigate enhancements to signing and road markings on the A66 by March 2016. They will also place a bid for funding to undertake the work recommended by the investigations.
John Lomas
All Responded
2015-0396
1 Oct 2015
Stoke-on-Trent and North Staffordshire
Sports Camp Tirol
Concerns summary (AI summary)
Inadequate risk assessment of river conditions, lack of essential safety protocols for white water rafting (e.g., training, safety kayak, appropriate raft capacity), and poor communication between organisers and the Army contributed to the death.
Disputed
(AI summary)
Sport Camp Tirol disputes several factual points in the coroner's report, asserts its guides acted appropriately, and blames the army for allowing a non-swimmer on the trip. It will require evidence of swimming qualifications from participants in the future, and says that the HYDRO Company are now obligated to inform the rafting companies well in advance about "stowage discharge".
Jean Hannon
All Responded
2015-0458
30 Sep 2015
Blackburn, Hyndburn and Ribble Valley
East Lancashire Healthcare NHS Trust
Concerns summary (AI summary)
A critical diagnosis (autonomic dysreflexia) was not sufficiently highlighted in medical records, leading to a consultant's unawareness during a later admission and potentially inappropriate management.
Action Taken
(AI summary)
The Trust now uses 'EMIS web' to include a printed summary of the patient's GP record for urgent and emergency admissions (since April 2015). A consultant geriatrician is also piloting daily problem lists to document ongoing concerns during ward rounds.
Lee Boden
All Responded
2015-0394
29 Sep 2015
Milton Keynes
National Probation Service
Concerns summary (AI summary)
Lack of pre-release planning, delayed discovery, and the absence of a protocol for continuous monitoring of vulnerable new residents contributed to the death.
Action Planned
(AI summary)
The Probation Service acknowledges shortcomings in informing the deceased of his placement and will focus on earlier planning and better liaison with probation areas. It will also explore additional training options for AP staff in responding to suspected drug overdoses, including the potential administration of heroin antagonists.
Parv Patel
All Responded
2015-0457
29 Sep 2015
London (North)
Department of Health and Social Care
Concerns summary (AI summary)
The report identifies that PEWS scores may not reflect current research into child illness, particularly in cases of sepsis, and may distract doctors from the fact that a child is seriously ill despite a low score.
Noted
(AI summary)
The response acknowledges concerns about PEWS scores and describes ongoing national work by NHS England and the Royal College of Paediatrics and Child Health to develop a framework for recognising and responding to children at risk of deterioration.
Ethan Johnson
All Responded
2015-0393
29 Sep 2015
Milton Keynes
Milton Keynes Hospital
Concerns summary (AI summary)
There was a critical lack of leadership and support for junior staff managing an abnormal CTG trace, compounded by a hierarchical system preventing timely consultant attendance.
Action Taken
(AI summary)
The Trust has strengthened the preceptorship period for newly qualified midwives, implemented 2-hourly 'intentional rounding' by a Band 7 Coordinator, and implemented a daily 'safety huddle' on the delivery suite.
John Roberts
Historic (No Identified Response)
2015-0389-wp25035
28 Sep 2015
Essex
Highways Agency
Concerns summary (AI summary)
The current junction design encourages dangerous pedestrian crossings over the central reservation due to an unclear, distant designated crossing, posing significant risk.
Tania Hristova
All Responded
2015-0392
28 Sep 2015
Wiltshire and Swindon
New Court Surgery
Concerns summary (AI summary)
The patient received antidepressant medication for over five years without adequate review and was not offered additional psychological therapies such as counselling or CBT.
Action Taken
(AI summary)
The surgery has taken steps to ensure regular medication reviews are undertaken for patients on SSRIs and that patients are made aware of mental health support services, including raised awareness about medication review codes, a mailshot to patients, and updating the practice website.
Harry Pryal
All Responded
2015-0391
28 Sep 2015
Manchester (West)
5 Boroughs Partnership NHS Trust
Wrightington Wigan & Leigh, Royal Alber…
Department of Health and Social Care
+1 more
Concerns summary (AI summary)
A significant lack of recorded medical advice between trusts, conflicting interpretations of service agreements, and failure to hold mandated liaison meetings resulted in poor inter-trust communication.
Noted
(AI summary)
The response acknowledges concerns, noting that local providers are best placed to address system issues. It highlights the move to digital care records and the development of standards for clinical structure and content of patient records by the Academy of Royal Medical Colleges. The CCG has requested that SBP have a service agreement in place with a provider for physiotherapy and occupational therapy; SBP has confirmed that all requests for these therapies will be flagged to their Clinical Director. The Trust has developed a standardised proforma for transfer between Trusts, shared with colleagues in Wrightington, Wigan and Leigh NHS Foundation Trust and discussed at the Wigan Medical Staff Committee. Discussions are taking place between 5 Boroughs Partnership NHS Foundation Trust and Bridgewater NHS Foundation Trust to clarify arrangements for the provision of physiotherapy and occupational therapy. The Trust has developed a proforma for telephone advice, has updated the radiology information system and implemented 'hot reporting' during weekdays. Specialist Radiographer chest X-ray reporting has been introduced.
Violet Cloudsdale
Historic (No Identified Response)
2015-0387
25 Sep 2015
Cumbria
Care Quality Commission
Risedale Estates Limited
Concerns summary (AI summary)
The care home lacked risk assessments and consent for wheelchair lap-belt use, and unclear guidance on their application raised concerns about unlawful restraint, contributing to a fall.
Dorothy Delaney
Historic (No Identified Response)
2015-0402
23 Sep 2015
Manchester (West)
Alexander House Health Centre
Platt Bridge Health Centre
Concerns summary (AI summary)
The concurrent prescription of antiplatelet and anticoagulant medications without specialist advice contradicted national guidelines, significantly increasing haemorrhage risk, especially given the patient's amyloid angiopathy.
William Harnell
All Responded
2015-0384
22 Sep 2015
Plymouth, Torbay and South Devon
Department of Health and Social Care
Plymouth Hospitals NHS Trust
Social Services Truro Cornwall
Concerns summary (AI summary)
Significant national delays in X-ray reporting due to a shortage of qualified radiologists pose a risk to patient care across the UK.
Noted
(AI summary)
Plymouth Hospitals NHS Trust has reviewed processes so that all Emergency Department films and inpatient films between Sunday am and Friday 5pm are reported within 24 hours. They have also developed a fast code for radiologists and sent out a safety alert to physicians regarding MR protocols for potential hip injuries. The Department of Health acknowledges the concerns regarding delays in X-ray reporting and highlights actions being taken by Health Education England to increase the number of radiologists. Cornwall Council is asking for guidance to be produced and disseminated to staff regarding timely placements for people who need such placements.
Emma Waring
All Responded
2015-0383
22 Sep 2015
Manchester (North)
Department for Communities and Local Go…
Concerns summary (AI summary)
The absence of compulsory automatic water suppression systems in residential properties, especially for vulnerable individuals, represents a significant fire safety risk.
Action Taken
(AI summary)
Rochdale Boroughwide Housing has delivered domestic sprinklers in properties occupied by some of their most vulnerable tenants and is working with Rochdale Council’s Strategic Housing Service on a project designed to offer additional support to those identified as hoarders.