2015
PFD Reports
Reports: 477
Areas: 69
62% response rate (below 63% average).
Mark Daniels
All Responded
2015-0208
1 Jun 2015
London Inner (North)
Camden and Islington NHS Foundation Tru…
Concerns summary (AI summary)
The crisis team failed to conduct planned patient visits, adequately record actions, communicate within the team, promptly refer to crisis houses, or consider hospital admission despite the patient's severe suicide risk.
Action Taken
(AI summary)
Camden and Islington NHS Foundation Trust have put in place a comprehensive action plan to address the concerns raised regarding failures by the Crisis team, with measures implemented across all Crisis Teams and Crisis Houses and a plan to monitor their implementation.
Elizabeth Lester
All Responded
2015-0204-wp24868
29 May 2015
Manchester (South)
Department of Health and Social Care
Concerns summary (AI summary)
The ambulance service's call-handler script for 'breathing difficulties' critically omits questions about chest pain, potentially delaying appropriate emergency response for cardiac-related issues.
1 response
from Department of Health
Matthew Hoare
All Responded
2015-0203
27 May 2015
London (Inner South)
National Rail
Concerns summary (AI summary)
Ineffective security equipment allowed easy access to the station and tracks after operational hours, with individuals able to climb through widely spaced yellow tape.
Action Taken
(AI summary)
Network Rail reports that following the incident, the roller shutters at the station entrance have been reinstated and are now locked during non-operational hours, and anti-trespass grids have been installed at the Denmark Hill end of the platforms. LOROL are working on a system allowing their stations to be opened remotely from the central control centre.
Oliver Asante-Yeboah
All Responded
2015-0201
27 May 2015
London Inner (North)
Care Quality Commission
Concerns summary (AI summary)
Concerns were raised about the lack of formal regulation for non-medical providers of circumcision, a procedure considered surgical with increased infection risk in non-medical settings.
Noted
(AI summary)
The CQC states it has no regulatory remit over non-therapeutic circumcisions performed for religious purposes by non-healthcare professionals, as the regulations would require amendment by the Secretary of State. The Department of Health acknowledges concerns about non-medical settings for male circumcision and notes that a change in legislation would require consultation. They will copy the letter to clinical leads of CCGs in England to highlight the case and reiterate the advice that circumcision should be carried out by a regulated healthcare professional.
Barbara Patterson
All Responded
2015-0198
21 May 2015
Northumberland (North)
Care Quality Commission
Department of Health and Social Care
North East Ambulance Service NHS Founda…
Concerns summary (AI summary)
The Pathways system has a fault preventing timely CPR advice for agonal breathing, and ambulance dispatch was delayed due to paramedic shortages and handover issues at hospitals.
Noted
(AI summary)
NHS Pathways has provided a response to concerns and will be meeting to discuss these issues. NHS England plans to publish guidance to help ambulance services develop new ways of working, and will work to increase the number of Physician Associate training programmes. HEE will also ensure that paramedic training provides an additional 16% growth. The CQC will include concerns about ambulance dispatch procedures as part of their planned comprehensive inspection, and will discuss ambulance dispatch management and handover processes with the North East Ambulance Service in September 2015. They will also meet to monitor NEAS staffing levels and recruitment. The North East Ambulance Service refers to their attached response which repeats the evidence given at the inquest and highlights the national operational standard for ambulance trusts.
Wanda Stachurska
All Responded
2015-0199
20 May 2015
West Sussex
Surrey and Borders Partnership NHS Foun…
Surrey and Sussex Healthcare NHS Trust
Concerns summary (AI summary)
Mental health risk assessments were diminished by untrained interpreters and staff unaware of policies. Furthermore, a serious incident review was not undertaken, delaying learning opportunities.
Action Taken
(AI summary)
The Trust has worked with East Surrey Hospital to ensure a shortcut to SASH policies is loaded onto Psychiatric Liaison staff computers, and has mandated that two staff members undertake assessments when a translator is required. An audit tool to review compliance with the translation policy will be embedded in supervision sessions.
Irene Hamilton-Parker
All Responded
2015-0197
20 May 2015
Staffordshire (South)
Department of Business Innovation and S…
Concerns summary (AI summary)
Clothing made of easily flammable man-made fabrics poses a risk, and steps should be considered to reduce the flammability of manufactured or imported clothing.
Noted
(AI summary)
The Department for Business Innovation and Skills acknowledges concerns about clothing flammability but states that most clothing is flammable and reducing it would require flame retardants with their own risks. They don't believe there's sufficient evidence to extend flammability requirements to other types of clothing but will keep the issue under review.
Sheila Johnson
All Responded
2015-0238
19 May 2015
Derby and Derbyshire
Tameside Hospital NHS Foundation Trust
Concerns summary (AI summary)
The internal investigation into the death was perfunctory, lacked robust inquiry, missed key interviews, and contained factual inaccuracies, risking future patient harm.
Noted
(AI summary)
The Department of Health states that officials have made enquiries with the Trust and have been assured that it will respond appropriately. The CQC will follow up any actions identified as a result of the Trust's response and will reinforce the duties of the Trust in relation to its duty of candour. Tameside Hospital has made considerable changes to improve internal investigations and patient discharge processes, including a review of senior nursing and medical staffing and revised procedures for incident investigations. A system for the urgent recall of patients discharged with potentially life-threatening conditions has been addressed by the Patient Flow Manager.
Diana Hughes
All Responded
2015-0195
18 May 2015
Gloucestershire
Not Listed
Action Planned
(AI summary)
The Trust is considering amending the WHO surgical checklist and reviewing its documentation policy to improve recording of special instructions for post-operative care. Progress will be monitored through the Safety Experience and Risk Group.
Sara Green
All Responded
2015-0190
15 May 2015
Manchester (South)
Priory Group
Concerns summary (AI summary)
Delays of up to 24 hours in 'writing up' medical consultations risk important information being unavailable or misinterpreted, potentially harming patients.
Action Taken
(AI summary)
The Group Medical Director reminded Hospital Medical Directors of the requirement to ensure service user records were completed during or shortly after consultations. An entry has been made on the Healthcare Division Risk Register to ensure that the required actions are itemised and that a plan is in place.
George Richardson
All Responded
2015-0189
15 May 2015
Sunderland
Department of Health and Social Care
Concerns summary (AI summary)
Lack of a consolidated catheterisation record meant staff were unaware of previous challenges, and national standards may be needed for safe catheterisation skills.
Noted
(AI summary)
The Department of Health acknowledges the concerns, highlights existing national guidance on catheterisation from NICE and RCN, and states that ensuring staff are aware of guidance and how to seek help is for hospital trusts to action locally.
Jacques Lakeman and Torin Lakeman
All Responded
2015-0191
15 May 2015
Manchester (West)
Home Office
Concerns summary (AI summary)
Easy access to anonymous 'Dark Web' sites for unregulated illicit drugs with unknown potency and content poses a significant and ongoing risk of future deaths.
Noted
(AI summary)
The Home Office acknowledges the concerns, describes actions taken by the NCA and Border Force to combat online drug supply, and states that law enforcement agencies have powers to act against suppliers, but does not commit to new actions.
Hana Elhamid
All Responded
2015-0194
13 May 2015
London (North)
Department of Health and Social Care
Concerns summary (AI summary)
Lack of routine blood tests for sugar in a patient on Clozapine treatment led to an undiagnosed diabetic coma, with resultant trachea injury, directly causing death.
Noted
(AI summary)
The Department of Health acknowledges concerns and explains existing NICE guidelines for monitoring patients on antipsychotic medication. NHS England is working with the Royal College of Psychiatrists to investigate patient safety incidents associated with Clozapine.
Paul Murray
All Responded
2015-0193
13 May 2015
London (North)
Department of Health and Social Care
Concerns summary (AI summary)
Insufficient resources were available for the London Ambulance Service to meet demand on the day of the incident.
Action Taken
(AI summary)
The London Ambulance Service carried out a serious incident investigation, resulting in plans to increase capacity through its modernisation programme, implementation of 'Intelligent Conveyance', consideration of a process for clinical review of repeated calls, and reminders to call takers to free text relevant information.
Paul McGuigan
All Responded
2015-0185
12 May 2015
Manchester (South)
Greater Manchester Police
Home Office
Ministry of Defence
+5 more
Concerns summary (AI summary)
General concerns were raised across relevant agencies about risks that could lead to future deaths, requiring action.
Action Planned
(AI summary)
The Home Office states that the Notifiable Occupations Scheme (NOS) was withdrawn and replaced with a new police-led scheme, the Common Law Police Disclosure (CLPD) scheme, which provides greater consistency across forces in the disclosure of information. The Trust states that following the Bradley Report (2009), the MDO teams transferred into single line management and implemented operational policy and approved documentation for assessment of needs and risks. They are rolling out an electronic clinical record (PARIS) and clinical staff have adequate time to access information from case notes. GMP will train officers in understanding their responsibilities under the pressing social need test, including classroom and NCALT training. They will be entering and holding notifications on the intelligence file of offenders. The SIA offered training and guidance to all UK police forces.
Lydia Corah
All Responded
2015-0181
11 May 2015
Nottinghamshire
Nottingham University Hospitals NHS Tru…
Concerns summary (AI summary)
An error led to a patient undergoing an X-ray intended for another, causing delay in assessment, unnecessary radiation, and adversely affecting the intended patient.
Action Taken
(AI summary)
Enhanced induction training has been implemented to reduce patient identification errors. The RCA generated an action plan that included reflection by the member of staff involved and updating of checking procedures.
John Lobo
All Responded
2015-0182
11 May 2015
London (South)
Exora Medical Limited
Concerns summary (AI summary)
Assessing fitness to travel for direct repatriation requires medical expertise beyond a paramedic, and independent medical assessment should be considered in such cases.
Action Planned
(AI summary)
Exora Medical will give consideration to obtaining a second and independent medical assessment in situations where facilities are not being provided by an insurance company for repatriation, especially from distant countries.
Keith Gallimore
All Responded
2015-0184
11 May 2015
London Inner (North)
Camden and Islington NHS Foundation Tru…
Concerns summary (AI summary)
Potentially important patient information documented by one service was not accessible to other services within the same Trust, especially out-of-hours, risking future deaths.
Action Planned
(AI summary)
IAPTUS training will be provided to a small number of front-line staff in the Acute Division to enable routine checks on all new patients against the IAPTUS system, expected to take place at the end of September.
Margaret Wright
All Responded
2015-0183
11 May 2015
Manchester (West)
Department of Health and Social Care
Concerns summary (AI summary)
Doctors did not routinely telephone patients or families after home visit requests to obtain further information, potentially delaying priority visits and impacting outcomes.
Action Planned
(AI summary)
NHS England's Primary Care Patient Safety Expert Group will consider home visits at their next meeting. NICE is drawing up guidance on Home Care with planned publication in September 2015.
Evelyn Kennedy
All Responded
2015-0178
7 May 2015
Brighton & Hove
Brighton and Sussex University Hospital…
Concerns summary (AI summary)
Acute Medical Unit failed significantly in patient care, with issues including incomplete handovers, poor personal hygiene, missing wristbands, unremoved IVs, incomplete care documentation, development of pressure damage, and unescalated NEWS scores indicating clinical deterioration.
Action Taken
(AI summary)
The Trust has been undertaking work, including improved consultant cover, a working group to address practices and documentation, developing specialist areas, improving signage, improving information handover, and increased monitoring of documentation.
Baby Olsberg
All Responded
2015-0177
7 May 2015
Manchester (North)
Department of Health and Social Care
National Institute for Health and Care …
Royal College of Obstetricians
+1 more
Concerns summary (AI summary)
Antenatal screening for Group B Streptococcus (GBS) and prophylactic intrapartum antibiotics for positive cases are not routinely offered by the NHS, potentially putting babies at risk.
Noted
(AI summary)
The RCOG acknowledges the concerns but refers to their guideline which aligns with the National Screening Committee's recommendation against routine screening for GBS. NICE acknowledges the concerns but refers to the UK National Screening Committee's current position that screening for GBS is not supported by the evidence, and that NICE's guideline does not recommend routine screening for GBS. The Department of Health acknowledges concerns about GBS screening but states that the UK National Screening Committee does not currently support universal screening due to insufficient evidence. They note that the NSC will be reviewing the evidence in 2015/16.
Julios Catachanas
All Responded
2015-0174
1 May 2015
Warwickshire
Warwickshire County Council
Concerns summary (AI summary)
The absence of street lighting at a junction, combined with the layout allowing vehicles to drive 'straight through', creates a significant road safety hazard.
Action Taken
(AI summary)
• Following notification of the collision, a Team Leader and a Road Safety Engineer from the Traffic and Road Safety Group attended the site with the traffic Management Assistant from Warwickshire and West Mercia Police's Road Safety Team.
• At the time of the inspection officers attending agreed that there were no immediate actions that needed to be undertaken.
• The County Council undertakes an annual review of all collision cluster sites across the County.
Derrick Stanmore
All Responded
2015-0172
1 May 2015
Leicester (City & South)
Leicester Partnership Trust
Concerns summary (AI summary)
A registered nurse failed to recognise abnormal patient observations requiring escalation, and lacked access to essential healthcare records to contextualise findings. A system like EWS is needed for recognition and escalation.
Action Planned
(AI summary)
An adapted version of the Track and Trigger system will be introduced, with staff trained in its use across the three Prison Healthcare Teams by October 2015. Staff will be reminded to access clinical information before seeing Prisoners.
Jorge Castro
All Responded
2015-0170
29 Apr 2015
Manchester (West)
Springfield Medical Practice
Concerns summary (AI summary)
A vulnerable patient missed crucial anti-epileptic medication due to uncollected prescriptions, which GPs failed to review during multiple consultations. The surgery lacked a system to highlight uncollected prescriptions, especially for dependent patients.
Action Taken
(AI summary)
Springfield Medical Centre has implemented an alert system in patient records for compliance issues, amended the IT system to highlight overdue prescriptions, created a register of patients on weekly prescriptions, and notified/discussed the event with local pharmacies. They also held a training workshop for staff on repeat prescribing.
Rasharn Williams
All Responded
2015-0168
29 Apr 2015
London North (Inner)
Berger Primary School
Concerns summary (AI summary)
The patient's care plan was unclear regarding emergency actions for breathlessness, potentially causing ambiguity for staff. A vital medical instruction notice for the child was also not displayed due to transitional arrangements.
Action Taken
(AI summary)
Berger Primary School has reviewed care plans, will refer unclear emergency provisions to school nurse/consultant, and amended its policy to ensure clarity in emergency situations. They will place photos and summaries of children with severe medical conditions in the staff and medical rooms.