2015
PFD Reports
Reports: 477
Areas: 69
62% response rate (below 63% average).
Eliza Simpson
Historic (No Identified Response)
27 Aug 2015
Birmingham and Solihull
Birmingham City Council
Care Quality Commission
Concerns summary (AI summary)
The care home lacked a system for renewing deprivation of liberty orders, risking unauthorized detention. The absence of CCTV also hindered investigation into an absconding resident.
Andrew Roberts
Historic (No Identified Response)
20 Aug 2015
North Wales (East and Central)
North Wales Police
BCUHB, Ysbyty Gwynedd
Concerns summary (AI summary)
Inaccurate and delayed completion of the Transfer of Care Form by a doctor prevented critical patient information from being immediately available to custody nurses.
Joyce Plested
Historic (No Identified Response)
20 Aug 2015
Manchester (South)
J. Sainsbury PLC
Trafford Metropolitan Borough Council
Concerns summary (AI summary)
The unsafe positioning of a zebra crossing too close to a mini-roundabout creates a high-risk junction for pedestrians and drivers, and a simple relocation would significantly improve safety.
Elsie Clarke
Historic (No Identified Response)
20 Aug 2015
Manchester (South)
GTD Healthcare
Hurst Hall Care Centre
Concerns summary (AI summary)
The report identifies a lack of staff training in calling emergency services or arranging GP visits, poor observation of residents, failure to report matters to the CQC, and inadequate record-keeping and handovers.
Sharon Henshall
Historic (No Identified Response)
20 Aug 2015
Preston and West Lancashire
LTHTR
LTHTR
Concerns summary (AI summary)
The absence of a VTE risk assessment tool in the Emergency Department for patients discharged with lower limb immobilisation, coupled with varied national guidance, creates a 'postcode lottery' for prophylaxis.
Barry Pike
Historic (No Identified Response)
19 Aug 2015
Plymouth Torbay and South Devon
Plymouth Hospitals NHS Trust
Concerns summary (AI summary)
The specific matters of concern are detailed in an external report by Dr Stephen Hoole, which was not provided here.
Stephen Richardson
All Responded
2015-0507
18 Aug 2015
Stoke-on-Trent & North Staffordshire
University Hospital of North Staffordsh…
Concerns summary (AI summary)
Nursing staff consistently failed to adhere to critical dietary and drink restrictions for a patient with Down's Syndrome, despite explicit instructions, raising significant risks of aspiration.
Action Planned
(AI summary)
The ward will look to implement a nurse 'champion' for patients attending with learning disabilities in the future.
Ian Morley
Historic (No Identified Response)
2015-0320
17 Aug 2015
London (West)
Adult Social Services
Greenrod Place
Concerns summary (AI summary)
A patient's deteriorating condition failed to trigger a necessary fresh risk assessment, compounded by inadequate fire risk management at the care facility.
Thelma Jones
All Responded
2015-0318
12 Aug 2015
Brighton and Hove
Brighton and Sussex University Hospital…
Concerns summary (AI summary)
The provided text only states the report concerns the Acute Medical Unit (AMU) where the deceased was admitted, without specifying the issues or failures.
Disputed
(AI summary)
The Trust believes that the medical notes contain appropriate detailed information on the care and treatment given within AMU and in relation to the NEWS scores, therefore remedial action is not necessary.
Dean Joseph
All Responded
2015-0319
12 Aug 2015
London Inner (North)
Metropolitan Police Service
Concerns summary (AI summary)
Inconsistent understanding of armed containment, lack of trained negotiator guidance for first responders, and sub-optimal post-incident procedures undermined the investigation and public confidence.
Action Taken
(AI summary)
The MPS has directed the post incident manager (PIM) to consult with the DPS and the IPCC to decide on what reference materials are proposed to be used by officers when giving their accounts, and the PIM is trained to record his or her decision and reasoning.
Eileen Smith
All Responded
2015-0500
12 Aug 2015
Hertfordshire
Department of Health and Social Care
Concerns summary (AI summary)
The report detailed gross failings of nursing care for a patient with a learning disability and highlighted the risk of making assumptions about health based on external appearance, stressing the need for better communication with carers.
Noted
(AI summary)
The response acknowledges the concerns raised and references existing guidance and resources, including work by NHS England, NICE and the NPSA, but describes no specific actions taken or planned by the Department of Health.
Ben Hiscox
Historic (No Identified Response)
12 Aug 2015
Avon
The FA Group
Concerns summary (AI summary)
The distance between the football touchline and clubhouse fell below FA safety recommendations, placing players at risk of injury or death, with no action taken by the referee.
Julia Hayward
All Responded
2015-0321
11 Aug 2015
Surrey
Department of Health and Social Care
Concerns summary (AI summary)
Discharged mental health patients' care plans, especially those involving family obligations, were only verbally agreed and not documented or provided, leading to critical misunderstandings.
Noted
(AI summary)
The response explains existing protocols and guidance related to the Mental Health Act and assessment/discharge procedures, but does not describe any specific action taken or planned in response to the concerns.
John Hills
Historic (No Identified Response)
2015-0317
11 Aug 2015
West Sussex
National Patient Safety Agency
Chief Fire Officers Association
Staffordshire Fire and Rescue Service
Concerns summary (AI summary)
Paraffin-based emollient creams lacked fire hazard warnings on labels and prescriptions, and risks were not communicated to a known smoker, highlighting a gap in NPSA guidance for lower percentage creams.
Lorraine Bird
Partially Responded
2015-0315
10 Aug 2015
Bedfordshire and Luton
Coreys Mill Lane
East & North Hertfordshire NHS Trust
Herts. SG1 4AB
+2 more
Concerns summary (AI summary)
There was a lack of protocol for assessing patients at the Plaster Room, and a patient was sent home without a medical review despite complaints and possible DVT development.
Action Planned
(AI summary)
• Colchester Hospital University NHS Foundation Trust worked with the Clinical Commissioning Group to develop a pathway for thromboprohylaxis in ambulatory patients requiring temporary limb immobilisation, signed off in September 2015.
• An education programme for the Emergency Department has been introduced to support the implementation of the guidance.
• The new pathway across primary and secondary care will commence on 2 November 2015, and the commissioning CCG will monitor implementation and compliance. • The working relationship between Devon and Cornwall Police and the local Mental Health Services has been improved, and a Memorandum of Understanding has been drawn up.
• NHS Kernow CCG has agreed to carry out a full review of acute psychiatric beds in Cornwall and the staffing of the place of safety service and will produce an action plan and commissioning strategy.
• The implementation of this plan will be monitored by NHS England.
James Adams
All Responded
2015-0315-wp25966
7 Aug 2015
Cornwall and the Isles of Scilly
Department of Health and Social Care, C…
Concerns summary (AI summary)
A severe shortage of acute psychiatric beds in Cornwall forces inappropriate detention in police cells or distant out-of-county transfers, causing patient deterioration and misallocating valuable consultant time.
Action Planned
(AI summary)
• Colchester Hospital University NHS Foundation Trust worked with the Clinical Commissioning Group (CCG) to develop a pathway for local implementation of guidance for thromboprohylaxis in ambulatory patients requiring temporary limb immobilisation.
• An education programme for the Emergency Department was introduced to support the implementation of the guidance.
• The commissioning CCG will monitor implementation and compliance against the guidance through Quality Review Meetings with the Trust. • The working relationship between Devon and Cornwall Police and the local Mental Health Services has been improved, and a Memorandum of Understanding has been drawn up.
• Kernow CCG has agreed to carry out a full review both of acute psychiatric beds in Cornwall and the staffing of the place of safety service and will produce an action plan and commissioning strategy.
• NHS England will monitor the implementation of this plan.
Amanda Ellams
Partially Responded
2015-0312
7 Aug 2015
Manchester (South)
BMI Healthcare
GTD Healthcare
Concerns summary (AI summary)
Substandard medical record-keeping, inadequate oxygen saturation monitoring, unsafe patient discharge, and a "flawed" unanswered out-of-hours district nursing telephone system collectively contributed to significant care failures.
Action Taken
(AI summary)
The hospital-wide completion of training on documentation and legal aspects for patient records was 95%, and further documentation training has been scheduled; nursing staff will be notified that nursing notes should always include a record of observations taken after patients have been taken off oxygen.
Gordon Atkinson
Historic (No Identified Response)
2015-0311
7 Aug 2015
Plymouth, Torbay and South Devon
Plymouth City Council
Concerns summary (AI summary)
The report identifies that the deceased appeared to be living in unsuitable accommodation, neglecting himself, and had an inappropriate care package.
Kathleen Neville
Historic (No Identified Response)
2015-0310
7 Aug 2015
Cardiff and the Vale of Glamorgan
Aneurin Bevan University Health Board
Betsi Cadwaladr University Health Board
Cardiff and Vale University Health Board
+6 more
Concerns summary (AI summary)
The absence of a Medication Reconciliation policy allowed medication errors to go undetected for too long, posing a significant risk of future deaths, particularly in other Health Boards without such a policy.
Robert Hogg
All Responded
2015-0313
6 Aug 2015
Buckinghamshire
Department of Health and Social Care
Concerns summary (AI summary)
NHS Pathways' toddler/child assessment tools are failing to identify very sick children, a persistent and unaddressed risk despite prior investigations.
Disputed
(AI summary)
The Department of Health acknowledges the coroner's concerns and provides context about NHS Pathways and SCAS, deferring to the NHS Pathways response for specific actions. NHS Pathways disputes the coroner's concerns, arguing that the system was used correctly and that no similar cases had been reported. They request the allegations be struck from the record and seek opportunity to answer directly in similar cases.
Thomas Thurling
All Responded
2015-0309
6 Aug 2015
Norfolk
Norfolk and Suffolk NHS Foundation Trust
Concerns summary (AI summary)
Inadequate monitoring of medication changes, including lack of awareness and delayed reviews, coupled with the absence of a Care Co-ordinator during a period of mental health deterioration due to staff shortages, posed significant risks.
Action Planned
(AI summary)
The Trust is sharing the issue of monitoring medication changes with a range of leads, including Pharmacy and those leading Triangle of Care; clinical services have been directed to consider how they are consistently meeting guidance for covering staff absences.
Rubel Ahmed
Partially Responded
2015-0308
5 Aug 2015
Lincolnshire (Central)
Home Office
Ministry of Justice
Concerns summary (AI summary)
Detainees were locked in rooms overnight against recommendations, staff lacked robust detention awareness and refresher training, and crucial information like removal directions was not shared.
Noted
(AI summary)
The Home Office acknowledges the concerns regarding the death at Morton Hall IRC. They explain the challenges of unlocking rooms overnight, the existing practices for detention awareness, and the use of electrical items, but offer no concrete action.
Jeffrey Warren
Partially Responded
2015-0307
4 Aug 2015
West Sussex
Crawley Borough Council
West Sussex County Social Services
Concerns summary (AI summary)
Neither council formally reviewed the case, delaying lessons. A hazardous electric fire was left unaddressed, and social work staff inappropriately requested police for non-urgent welfare checks due to lack of training.
Action Taken
(AI summary)
Crawley Borough Council corrected some factual inaccuracies, and stated they will review all door entry systems by 30 September 2015 and then carry out an upgrade program to solve the problem of having to have a large set of door keys for all of their properties. Action has been taken to flag cases where the TSO or floating support team are involved on the repairs system and safeguarding alerts will be followed and reported to senior managers and any future deaths where safeguarding alert has been made will immediately be subject to review.
Michael Quinn
Historic (No Identified Response)
2015-0304
3 Aug 2015
Berkshire
other private hospitals that utilise si…
Royal Berkshire Hospital Trust
Concerns summary (AI summary)
Hospital guidance for pre-operative blood glucose levels was inconsistent with national guidelines and research, highlighting confusion about optimal levels for surgical patients and increasing infection risk.
Anthony Dwyer
All Responded
2015-0249
30 Jul 2015
London (North)
Department of Health and Social Care
Concerns summary (AI summary)
The guidance provided to the Trust for the general management of long-term tracheostomy patients with complex medical needs was inadequate.
Noted
(AI summary)
The Department of Health acknowledges the concerns and states that adequate guidance already exists for tracheostomy management through the UK National Tracheostomy Safety Project and other resources, with NHS England continuing to work with stakeholders.