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)
477 results
Stuart Knight
All Responded
2015-0385 22 Sep 2015 Central Lincolnshire
East Midlands Ambulance Services
Concerns summary (AI summary) Significant and unacceptable delays in ambulance dispatch occurred for an unconscious patient with a serious head injury, potentially prejudicing the outcome.
Action Taken (AI summary) EMAS has increased its frontline resources, implemented a 'hear and treat' system, and introduced a single Ambulance Technician vehicle in East Lincolnshire. These initiatives aim to increase ambulance availability for high clinical need cases.
Liam Smith
Partially Responded
2015-0382 18 Sep 2015 Worcestershire
Governor HMP Hewell Worcestershire Health and Care Trust
Concerns summary (AI summary) Mandatory ACCT procedures for self-harm risk were not followed, critical medical information was poorly disseminated within the prison, and limited healthcare interaction with high-risk drug users led to missed warning signs.
Action Taken (AI summary) HM Prison and Probation Service has reiterated the professional obligation of clinical staff to review relevant parts of prisoner's notes and has changed practices relating to high risk drug users by implementing a follow up ledger to SystmOne within three working days of the detoxification programme ending.
Christianne Shepherd
Historic (No Identified Response)
2015-0338 18 Sep 2015 West Yorkshire (East)
ABTA – The Travel Association Louis Group including the Louis Corcyra… The Federation of Tour Operators +4 more
Concerns summary (AI summary) The report calls for a publicly accessible central register for tour operators to record hotel safety information, improved collaboration between tour operators regarding health and safety, increased awareness of carbon monoxide dangers, and more qualified personnel conducting health and safety checks.
Lee Bates
Partially Responded
2015-0381 17 Sep 2015 London Inner (South)
Guys and St Thomas NHS Trust Cambian Group
Concerns summary (AI summary) A critical lack of communication between psychiatry and sleep apnoea specialists, along with inadequate guidance and monitoring protocols for OSA patients receiving sedative medication, creates an ongoing risk of avoidable deaths.
Action Taken (AI summary) Cambian Group has met with St Thomas' and agreed a protocol to reduce the possibility of inadequate communication or care in the future.
Fiona Lewis
Historic (No Identified Response)
2015-0441 17 Sep 2015 Suffolk
Ipswich Hospital
Concerns summary (AI summary) There's a concern about ensuring healthcare professionals are adequately trained in resuscitation and can respond appropriately to patient collapse.
David Charles
Historic (No Identified Response)
2015-0366 16 Sep 2015 Essex
Essex County Council Essex Highways Agency
Concerns summary (AI summary) Street lighting was switched off on a dark night, significantly reducing pedestrian visibility and contributing to a fatal collision, despite drivers being unable to avoid it.
Adil  Habib
Partially Responded
2015-0380 16 Sep 2015 London Inner (North)
HMP Pentonville London Ambulance Service NHS Trust National Offender Management Service
Concerns summary (AI summary) Lack of specific gate location information for prisons during 999 calls, compounded by London Ambulance Service's system not uniformly supporting alternative gate selection across all London prisons.
Action Taken (AI summary) HM Prison and Probation Service has completed a DVD covering principles of safe restraint, medical complications, and actions to take when prisoners conceal items in their mouths, which will be sent to all prison Governors by Christmas. The London Ambulance Service has augmented its computer system with additional gate information for HMP Pentonville and shared learning about confirming addresses when taking calls from prisons in a team talk.
Karen Clayton
Partially Responded
2015-0388 15 Sep 2015 Manchester (South)
Secretary of State for Transport Trafford Metropolitan Borough Council
Concerns summary (AI summary) The road layout has insufficient segregation for mixed traffic, with a confusing contra-flow cycle lane and unclear signage, creating a dangerous environment compounded by weak guidance on pedestrian use of cycle paths.
Disputed (AI summary) Trafford Council states that the current road layout was designed in accordance with guidance, does not concur that there is insufficient room for traffic segregation, and does not consider that there are any improvements required.
Stephen O’Malley
All Responded
2015-0363 14 Sep 2015 Liverpool & Wirral
SubCPartner
Concerns summary (AI summary) Rescue was delayed due to the standby diver being unable to locate a critical harness c-clip, as pre-dive protocol checks do not include verifying its accessibility.
Noted (AI summary) SubC Partner refers to Danish authority findings, states it performs pre-dive checks according to standards and customer approval, and uses certified personnel. The response appears to be a pre-dive checklist form.
Anthony Cleveland
Historic (No Identified Response)
2015-0442 14 Sep 2015 Suffolk
Health and Safety Executive
Concerns summary (AI summary) A gym lacked immediate problem recognition, adequate resuscitation, risk assessments for users, qualified first aiders, and formal national guidance on fitness centre safety.
George Ainsworth
Historic (No Identified Response)
11 Sep 2015 Manchester (West)
Bolton Council
Concerns summary (AI summary) A dangerous road junction has blind spots and limited driver visibility, creating a "pinch point" for large vehicles and putting pedestrians at risk, compounded by potentially insufficient crossing times.
Ronald Bonfield
Historic (No Identified Response)
11 Sep 2015 Powys
England and Wales Cwm Taf Morgannwg University Health Boa… National Assembly for Wales +1 more
Concerns summary (AI summary) Inconsistent practices for monitoring district nurse compliance with delegated INR testing across GP surgeries create a risk of unmonitored over-anticoagulation.
Thomas Nicholls
Historic (No Identified Response)
11 Sep 2015 Manchester (West)
Orchard Care Homes The Hamlet
Concerns summary (AI summary) The report identifies care staff lacking training in PEG feeding, specifically regarding mobility and handling, and the failure to report a related incident, prompting a review of policies and training.
David Efemena
Historic (No Identified Response)
8 Sep 2015 London (East)
Ministry of Defence
Concerns summary (AI summary) A cadet training site lacked defibrillators and AED-trained first aiders, with challenging emergency access. There were also ineffective communication checks between staff and cadets at night.
Ian Emsley
Historic (No Identified Response)
8 Sep 2015 Exeter and Great Devon
HMP Exeter HMP Portland
Concerns summary (AI summary) Inadequate formal guidance for healthcare staff on assessing re-offending and escape risk contributed to delays in compassionate release or transfer decisions for terminally ill prisoners.
Andrew Frere
Historic (No Identified Response)
8 Sep 2015 South Yorkshire (East)
Equalities, Rights and Decency Group, T…
Concerns summary (AI summary) A national prison instruction for 24-hour doctor review is impracticable and ignored. Case managers also fail to read ongoing observations during ACCT reviews, risking missed critical information.
Craig Chappell
Historic (No Identified Response)
8 Sep 2015 East Riding and Kingston Upon-Hull
HMP HUMBER (EVERTHORPE SITE)
Concerns summary (AI summary) Inadequate information sharing and a lack of formal mechanisms for communicating family concerns hindered support. Prison staff also lacked sufficient guidance on supporting potential abuse victims, relying inappropriately on presentation.
Mary James
Historic (No Identified Response)
4 Sep 2015 Powys
Bryntirion Surgery Care & Social Services Inspectorate, We… Aneurin Bevin University Health Board +5 more
Concerns summary (AI summary) Inadequate INR monitoring, uncertainty regarding Warfarin intake, and poor communication between healthcare providers led to unadjusted anticoagulation therapy for a dementia patient, missing a critical hospital admission opportunity.
May Hall
Historic (No Identified Response)
3 Sep 2015 Manchester (South)
Bourne House
Concerns summary (AI summary) Care home staff lacked awareness and clear training on fall reporting policies and how to contact emergency services, indicating a need for regular, confirmed training.
Kala Skinner
Historic (No Identified Response)
3 Sep 2015 Avon
Care Quality Commission South Western Ambulance Service NHS Fou…
Concerns summary (AI summary) Clinical advisors missed critical 'red flags' and gave inappropriate advice due to inadequate training, mentoring, and auditing, leading to failures in recognising serious conditions and safeguarding patients.
Rosalind Baird
Historic (No Identified Response)
2 Sep 2015 Portsmouth and South East Hampshire
Dept. of Health
Concerns summary (AI summary) There is no formal national monitoring scheme for inexperienced surgeons, despite the existence of effective local models, risking patient safety during surgical procedures.
John Robinson
Historic (No Identified Response)
1 Sep 2015 South Yorkshire (West)
Clinical Commissioning Group
Concerns summary (AI summary) The unavailability of a psychiatric bed for Mr Robinson led to his deteriorating condition and death, raising concerns about insufficient mental health resources in the area.
Darren Browne
Historic (No Identified Response)
1 Sep 2015 London Inner (South)
Police of the Metropolis
Concerns summary (AI summary) A vulnerable adult with high suicide risk was prevented from contacting family, a decision that failed to properly balance his acute needs and risks against restrictions.
Isabel Richardson
Historic (No Identified Response)
28 Aug 2015 Norfolk
Hewett School
Concerns summary (AI summary) The school's Pastoral Team lacked clear purpose, operational structure, and adequate staff training, rendering it an insufficiently robust system to address student problems.
Frederick Sutton
Historic (No Identified Response)
27 Aug 2015 Manchester (South)
Stockport NHS Foundation Trust
Concerns summary (AI summary) Suboptimal staffing, poor staff training in drug administration and cardiac arrest response, unread nursing notes, incompatible computer systems, and inaccurate patient information contributed to systemic care failures.