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)
Clear 181 results
Tommy Faisali
Historic (No Identified Response)
6 Jul 2015 London Inner (West)
Central and North West London NHS Found…
Concerns summary (AI summary) Psychiatric GP referrals are handled by unqualified staff, and risk assessments are not consistently completed or documented, leading to uncommunicated patient risks and a lack of care continuity within mental health teams.
Gail Prentice
Historic (No Identified Response)
2015-0253 2 Jul 2015 Powys, Bridgend and Glamorgan Valleys
Cwm Taf University Health Board National Assembly for Wales
Concerns summary (AI summary) There is no mandatory requirement for surgeons to acknowledge reading relevant Health Board and national clinical guidelines, potentially leading to inconsistencies in surgical practice and patient care.
David Hallett
Historic (No Identified Response)
2015-0250 2 Jul 2015 Powys, Bridgend and Glamorgan Valleys
HMP Parc HMP Rye Hill National Offender Management Service +1 more
Concerns summary (AI summary) HMP Rye Hill's healthcare was inadequately resourced and unprepared for its re-roll to house sex offenders, resulting in substandard patient care. This raises concerns about similar risks in future national prison re-rolls.
Blaise Farry
Historic (No Identified Response)
2015-0269 30 Jun 2015 London (West)
HMP WORMWOOD SCRUBS
Concerns summary (AI summary) Insufficient staffing levels at HMP Wormwood Scrubs prevent the implementation of a nominated Officer scheme, despite prior recommendations, impacting prisoner welfare and safety.
Michael Bovell
Historic (No Identified Response)
2015-0248 29 Jun 2015 London (North)
Rail Safety and Standards Board
Concerns summary (AI summary) The RSSB Rule Book's provisions for stopping trains are insufficient, prioritizing potential train damage over human life. Even cautioned trains can strike individuals, highlighting a gap in preventing harm to trespassers on the line.
Alec Mathias
Historic (No Identified Response)
2015-0247 26 Jun 2015 Exeter and Greater Devon
Royal Devon and Exeter Hospital
Concerns summary (AI summary) Critical drug sensitivity information was not included in discharge letters sent to the patient's GP, nor was it highlighted in hospital records, posing a significant risk.
Brian Gillard
Historic (No Identified Response)
2015-0244 26 Jun 2015 Manchester (West)
Royal Bolton Hospital
Concerns summary (AI summary) A critical breakdown in patient handover between hospital departments led to ward staff being unaware of a patient's need for ambulatory oxygen, resulting in the patient being left unsupervised without oxygen and suffering a cardiac arrest.
Summer Robertson and Alice Barnett
Historic (No Identified Response)
2015-0243 26 Jun 2015 Shropshire, Telford and Wrekin
Lattitude Global Volunteering
Concerns summary (AI summary) There was a critical lack of awareness and specific risk assessment for rip currents, inadequate warnings for those entering the water, and no clear guidance on how to escape them.
Richard Turner
Historic (No Identified Response)
2015-0242 26 Jun 2015 Derby and Derbyshire
Department for Transport
Concerns summary (AI summary) Light goods vehicles with significant rear blind spots are widely used without mandatory reversing aids like cameras or audible warnings, increasing the risk of fatal collisions with pedestrians.
Steven Curtis
Historic (No Identified Response)
23 Jun 2015 Oxfordshire
Derbyshire Trading Standards Division
Concerns summary (AI summary) There are safety concerns regarding Maplin N19KJ telescopic ladders, with 43,000 sold, warranting investigation into a potential catastrophic failure and the origin of the accident ladder.
Jan McLean
Historic (No Identified Response)
2015-0237 22 Jun 2015 Surrey
Surrey Police
Concerns summary (AI summary) Police officers require full and adequate training to thoroughly interrogate all details relating to warning markers held on the PNC to prevent future deaths.
Kathleen Eaton
Historic (No Identified Response)
2015-0236 22 Jun 2015 Manchester (South)
Peaks and Plains Housing Trust
Concerns summary (AI summary) An emergency trust link officer lacked formal medical assessment training and head injury policies, with no written guidance for ambulance summoning, raising doubts about the adequacy of emergency response from a distant base.
John Bartle
Historic (No Identified Response)
2015-0232 18 Jun 2015 Stoke-on-Trent and North Staffordshire
am Margaret CORONER Jones, Assistant Coroner, for Stoke-on-…
Concerns summary (AI summary) Concerns were raised about a perceived lack of staff over a bank holiday leading to delayed interventions, alongside poor nutritional support, inadequate pain control, and poor communication from nursing staff.
Andre Mickley
Historic (No Identified Response)
2015-0231 17 Jun 2015 Lincolnshire (Central)
Medicines and Healthcare products Regul…
Concerns summary (AI summary) Product information for SSRI drugs fails to adequately inform prescribers about potential adverse pharmacokinetic interactions with cocaine and other illicit substances, or to advise patients to seek caution.
Andrew Nickolls
Historic (No Identified Response)
2015-0230 17 Jun 2015 Plymouth, Torbay and South Devon
Devon County Council Northern Eastern and Western Devon Clin… Plymouth City Council +2 more
Concerns summary (AI summary) The provided text is incomplete and does not contain any discernible coroner's concerns.
Marie Harding
Historic (No Identified Response)
2015-0214 12 Jun 2015 West Yorkshire (West)
NHS England
Concerns summary (AI summary) The trust lacked clear guidelines and up-to-date staff training for chest drain insertion, compounded by an unawareness of interventional radiologist availability, indicating systemic procedural deficiencies.
Deborah Roberts
Historic (No Identified Response)
11 Jun 2015 Mid Kent & Medway
National Highways
Concerns summary (AI summary) The Sheppey Road Bridge has a history of rear-end collisions due to its geometry affecting visibility and high speeds. Despite a safety review recommending a 50 mph limit, the speed limit remains 70 mph.
Amanda Harris
Historic (No Identified Response)
2015-0216 10 Jun 2015 London (North)
Mount Vernon Hospital
Concerns summary (AI summary) Mrs Harris was discharged from the Minor Injuries Unit without a doctor's review, consideration of anticoagulant therapy, or assessment of potential immobility effects from her injury.
Walter Willows
Historic (No Identified Response)
2015-0218 10 Jun 2015 Manchester (South)
Westwood Homecare Limited
Concerns summary (AI summary) Care plans, especially feeding regimes, were reviewed insufficiently frequently for clients with changing needs, specifically regarding swallowing ability, leading to inadequate dietary adjustments.
Lewis Ghessen
Historic (No Identified Response)
2015-0213 9 Jun 2015 London (North)
Rail Safety and Standards Board
Concerns summary (AI summary) The RSSB Rule Book is flawed as it only permits stopping trains to prevent damage, not to protect individuals in danger from a train.
Alice McMeekin
Historic (No Identified Response)
2015-0211 4 Jun 2015 Cumbria
Cumbria Constabulary Cumbria Partnership NHS Foundation Trust
Concerns summary (AI summary) Police failed to act on reported threats and share critical information with mental health services, leading to a flawed psychiatric assessment and early discharge of a high-risk individual with significant mental health issues.
David Price
Historic (No Identified Response)
2015-0210 1 Jun 2015 Manchester (South)
Department of Health and Social Care University Hospital of South Manchester
Concerns summary (AI summary) Problems included uncontrolled warfarin prescriptions without clinic attendance, very poor quality handwritten medical notes, failure to act on a radiologist's finding of a foreign body, and an unsatisfactory swab count policy during surgery.
James Savo
Historic (No Identified Response)
2015-0209 1 Jun 2015 South Yorkshire (East)
Rotherham, Doncaster and South Humber N…
Concerns summary (AI summary) Effective communication systems between families/carers and staff are not routinely followed or audited, and understanding of early discharge plans is inconsistent, hindering seamless patient transitions.
Ronald Smith
Historic (No Identified Response)
2015-0207 1 Jun 2015 London (East)
Barking, Havering and Redbridge Univers…
Concerns summary (AI summary) There was a failure to provide flexible sigmoidoscopy out of hours, and despite a root cause analysis identifying the need for a protocol, one was still not in place 18 months after the death.
Melanie Amundsen
Historic (No Identified Response)
2015-0206 29 May 2015 Sunderland
Advisory, Conciliation and Arbitration …
Concerns summary (AI summary) Not all employers or employees may be aware of mental health issues in the workplace, particularly concerning disciplinary processes, and ACAS resources could be enhanced and better publicised.