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
Casey Garrett
Partially Responded
2015-0305 30 Jul 2015 Bedfordshire and Luton
Health Education East of England LET Board
Concerns summary (AI summary) Inappropriate midwifery care by a student and midwife, including insufficient fetal monitoring, misinterpretation of CTG, and failure to escalate, led to an infant's death and raised questions about the hospital's clinical learning environment.
Action Planned (AI summary) Health Education East of England describes actions planned by Bedford Hospital NHS Trust and the University of Bedfordshire to improve the learning environment for student midwives, including a student forum, revisiting the mentorship program, and reviewing serious incidents, with HEEE continuing to provide support and share learning.
Giuseppina Incisivo
All Responded
2015-0303 30 Jul 2015 West Sussex
Department for Transport
Concerns summary (AI summary) Blind spot mirrors on high-fronted vehicles offer insufficient visibility for pedestrians, especially the elderly. A lack of secondary warning systems leads to over-reliance on mirrors and dangerous assumptions by pedestrians.
Action Planned (AI summary) The Department for Transport explains vehicle safety standards and states they intend to produce a new chapter of the Traffic Signs Manual on traffic lights and pedestrian crossings, bringing together and updating existing advice, but cannot give a precise date for publication.
William Bows
All Responded
2015-0301 28 Jul 2015 South Yorkshire (East)
Northern General Hospital
Concerns summary (AI summary) The report identifies a lack of protocols for advising primary care providers on monitoring patients prescribed Amiodarone, specifically concerning liver function, thyroid tests, and respiratory difficulties.
Action Taken (AI summary) Sheffield Teaching Hospitals NHS Trust states that an appropriate policy was in place at the time of the prescription of amiodarone and that this was followed during the inpatient stay and communicated to the GP. Since this case, but not because of it, an Amiodarone Passport and Patient Handheld Information Booklet has been developed which provides information about the drug, including the monitoring regime and the potential life-threatening side effects.
Arthur Cook
Historic (No Identified Response)
2015-0300 27 Jul 2015 Powys, Bridgend and Glamorgan
Aneurin Bevan University Health Board Bryntirion Surgery Cwm Taf University Health Board +2 more
Concerns summary (AI summary) Low staffing of Tissue Viability Nurses, inadequate pressure ulcer documentation, and a lack of integrated skin care across services contributed to progression of MRSA-infected pressure ulcers.
Miriam Smith-Cox
Partially Responded
2015-0475 24 Jul 2015 Cornwall and the Isles of Scilly
Cornwall Council Devon and Cornwall Police Adult Safegua… Pluss Work Choice
Concerns summary (AI summary) A safeguarding concern regarding the deceased's unsuitable accommodation and living conditions was not received or acted upon by a key support stakeholder, preceding a fatal fall.
Noted (AI summary) Pluss states they have a Safeguarding policy and that staff complete 'Alerters' training every 2 years. Pluss will be utilising learning from this unfortunate episode to provide a case study to raise awareness with all Pluss staff, reinforcing their understanding regarding the Safeguarding policy and their responsibilities within it and they will also be carrying out additional Safeguarding, Alerters and Lone Working training with the Truro Team with the company specialist within September. The DWP expresses condolences and explains the benefits claimed by the deceased, as well as detailing the support offered by DWP and its service provider, Pluss. It concludes that Ms Smith-Cox received extensive assistance and was never left without benefit payments.
Simon Reynolds
Historic (No Identified Response)
2015-0296 24 Jul 2015 Avon
Avon and Wiltshire Mental Health NHS Tr…
Concerns summary (AI summary) Lack of documented risk assessments on admission, inadequate record-keeping, and insufficient staff training on setting observation levels, assessing suicide/self-harm risk, and communicating risks were identified.
Carl Smith
Partially Responded
2015-0298 24 Jul 2015 Exeter and Greater Devon
Dorset Health Care University NHS Found… HMP Exeter
Concerns summary (AI summary) Custodial and welfare checks for a prisoner on an ACCT and Methadone Stabilisation Programme were insufficient, and information sharing related to these checks was deficient.
Action Taken (AI summary) Dorset HealthCare NHS Trust implemented new policies and procedures to improve the quality of service in Devon Prisons. An education package has been put in place for all staff regarding substance misuse awareness.
Lynn Poyser
Historic (No Identified Response)
2015-0295 23 Jul 2015 South Lincolnshire
Lincolnshire Community Health Services Medicines and Healthcare products Regul… National Institute for Health and Care …
Concerns summary (AI summary) Existing guidance for co-prescribing Lisinopril and Spironolactone may not sufficiently highlight the risks of renal deterioration and hyperkalaemia, indicating a need for more caution and a holistic patient view.
Ashley Matthews
All Responded
2015-0297 23 Jul 2015 Black Country
British Transport Police
Concerns summary (AI summary) Insecure perimeter fencing allowed unauthorized access to the railway site, and there was a lack of warning signs for high voltage cabling on the bridge.
Action Taken (AI summary) Palisade fencing has been extended to prevent access, and regular inspections and repairs are being conducted. Signs warning of electrocution dangers have been placed on the overbridge.
Michael Hanlon
All Responded
2015-0294 23 Jul 2015 Cumbria
Plateus Ltd
Concerns summary (AI summary) An inefficient boat entry system, potential crew tiredness from additional shifts, and inadequate monitoring of working hours raised safety concerns for crewmembers.
Action Taken (AI summary) A keyless entry system has been installed to address concerns around access, and a 24-hour watch system is in place when owners/guests are onboard. A Captain's Standing Order is to be issued to ensure procedures are in place to monitor working hours and rest periods.
Doreen England
Partially Responded
2015-0291 23 Jul 2015 Birmingham and Solihull
Birmingham and Solihull Mental Health T… Department of Health and Social Care NHS England
Concerns summary (AI summary) The patient at high risk of pressure sores lacked a care plan, staff lacked knowledge and training in prevention, and the ward suffered from inadequate leadership and medical cover. RMN training also failed to cover pressure sores sufficiently.
Action Planned (AI summary) NHS England will oversee a specific action plan to address deficiencies in care, particularly regarding pressure sore risk assessment. The matter has been tabled for discussion in the Quality Surveillance Group.
James McGeown
Historic (No Identified Response)
2015-0506 22 Jul 2015 Worcestershire
Worcestershire County Council
Concerns summary (AI summary) An undulation in the road surface caused a loss of vehicle control at higher speeds, posing a significant risk to unsuspecting drivers.
Anne Wilson
Partially Responded
2015-0293 21 Jul 2015 London (South)
London Ambulance Service Metropolitan Police
Concerns summary (AI summary) Changes in police welfare check policy were not communicated to ambulance services, and police staff lacked training on managing mental health requests, leading to critical information not being acted upon or shared with the requesting GP.
Action Planned (AI summary) A Control Services Bulletin will be issued by the end of September 2015 about the MPS welfare checks policy to mitigate the risk of a call to a vulnerable patient closed prior to assessment. Joint meeting governance arrangements are to be reviewed to ensure they are robust.
Rachel Hollister
Historic (No Identified Response)
2015-0288 21 Jul 2015 Gwent
Aneurin Bevan University Health Board
Concerns summary (AI summary) The report identifies that medical staff and porters either did not follow or were unaware of the Health Board's Protocols.
Edward Maher, James Dunsby and Craig Roberts
Partially Responded
2015-0228 20 Jul 2015 Birmingham & Solihull
Special Forces Defence
Concerns summary (AI summary) A new tracker system failed to identify static soldiers, commanders lacked awareness and training on critical heat illness guidance, and risk assessment staff were untrained. A disjointed reporting system also impedes accurate heat illness data.
Action Planned (AI summary) An upgrade to the tracker system is scheduled to take place before the end of the calendar year to address data volume issues. The policy for endurance exercises will be reviewed and revised by March 2016, and two further inquiries will be conducted by the Ministry of Defence.
Luke Myers
All Responded
2015-0292 20 Jul 2015 Liverpool
National Offenders Management Service
Concerns summary (AI summary) HMP Liverpool miscalculated the deceased's sentence, which was a likely factor in his death. Additionally, prison discipline staff lacked current first aid training, raising concerns for lone working officers.
Action Taken (AI summary) HMP Liverpool has reviewed sentence calculations and found no other miscalculated sentences. First aid training is being provided to all Custodial Managers who carry out orderly officer duties, and Operational Support Grade staff will also be trained.
Paul Coxon
All Responded
2015-0286 20 Jul 2015 Newcastle Upon Tyne
Gateshead Council
Concerns summary (AI summary) Inadequate signage for safe pedestrian crossing, lack of illuminated signs, and an inappropriate 50 mph speed limit on a complex slip road where driver visibility is limited create significant hazard.
Action Taken (AI summary) An additional sign will be erected at the top of the steps indicating a pedestrian route. Infill panels have been installed on the guardrail to minimise the hazard relating to the presence of pedestrians on the carriageway.
Bradley Hooper
Partially Responded
2015-0285 20 Jul 2015 Hampshire (Central)
M C Federation Portsmouth Motocross Club
Concerns summary (AI summary) An inexperienced marshall, distracted by a mobile phone and improperly positioned, failed to observe a fatal collision. Club rules for marshall allocation were not followed, and the MCF Code of Practice lacks smartphone use guidance.
Action Taken (AI summary) Updated Rules of Marshalling have been implemented, with briefings at every race meeting. Experienced marshals are placed on "high-risk" points, and less experienced marshals on "low-risk" points; marshals will be observed to ensure they are acting correctly.
Adam Connelly
Partially Responded
2015-0284 17 Jul 2015 Manchester (West)
British Transport Police Network Rail
Concerns summary (AI summary) The low height of walls accessing a railway footbridge allowed easy public access to tracks, creating a significant risk of future fatalities that Network Rail needs to address.
Action Planned (AI summary) Network Rail will install shorter palisade pales and raise the height of the stepped parapet with engineering brick. The works are expected to be completed by the end of October 2015.
Masoud Ghaderi
Partially Responded
2015-0283 17 Jul 2015 Avon
Avon and Wiltshire Mental Health Partne… Care Quality Commission
Concerns summary (AI summary) Inconsistent record-keeping for service user engagement and the absence of a dedicated staff member for reviewing risk assessments prevented identification of changing patient risks. Ward rounds relied on inadequate, brief summaries, risking errors and omissions in care.
Action Planned (AI summary) The Trust Engagement and Observation Policy will be reviewed to ensure consistent recording of engagements. The Clinical Executive has commissioned an audit of reviewing risks across inpatient units and will design a framework of staff responsibilities.
Isabella Drew
All Responded
2015-0289 16 Jul 2015 South Yorkshire (East)
Department of Health and Social Care NHS England
Concerns summary (AI summary) Inadequate national guidance and audit procedures prevent healthcare providers from consistently advising pregnant women about whooping cough vaccination. Poor communication links between antenatal healthcare providers also pose risks.
Noted (AI summary) The Department of Health acknowledges the coroner's concerns regarding advice and support for pregnant women about whooping cough vaccination. They note that NHS England is responding on behalf of the Department of Health, Public Health England and NHS England. NHS England will consider the coroner's concerns about integrating pertussis and immunisation services into routine maternity care as part of an independent review of maternity services in England. Public Health England also manages the situation as a national level incident.
John Lloyd
Historic (No Identified Response)
2015-0282 16 Jul 2015 Cardiff and the Vale of Glamorgan
University of Wales, Cardiff University Hospital of Wales
Concerns summary (AI summary) Frequent failures in the hospital's electronic system to notify GPs of patient admissions jeopardised continuity of care and could lead to inappropriate treatment courses and poorer outcomes.
Stanley Oliver
All Responded
2015-0281 16 Jul 2015 Manchester (West)
Department of Health and Social Care Salford Royal NHS Foundation Trust
Concerns summary (AI summary) The hospital lacked an official on-call rota and actual provision for GI Radiologists to perform critical procedures out of hours, particularly on weekends, despite identifying this as a risk.
Action Planned (AI summary) Salford Royal NHS Foundation Trust plans to develop a 7-day consultant-level non-vascular intervention rota by April 2016. In the short term they will use an ad hoc service with support from Central Manchester NHS Foundation Trust, documented in an updated SOP. The Department of Health commissioned the Centre for Workforce Intelligence to gather evidence on possible shortage occupations, leading to radiologists being added to the Shortage Occupation List in April 2015. Health Education England has also increased the number of radiology training places, advertising 212 posts in 2015 with a 100% fill rate.
Joyce Hartford
All Responded
2015-0279 15 Jul 2015 Manchester (North)
Pennine Acute Hospitals NHS Trust
Concerns summary (AI summary) Nursing records, assessments, and discharge summaries were consistently incomplete and inaccurate, demonstrating no material improvement despite ongoing audits and posing recurrent patient safety risks.
Action Taken (AI summary) Pennine Acute Hospitals NHS Trust has been undertaking a review of current documentation and monthly audits of nursing metrics on Ward T7, and implemented measures trust-wide. They are also reviewing and ratifying nursing documents to implement a more rigorous governance process.
Paul Kalnins
All Responded
2015-0278 15 Jul 2015 London (East)
Metropolitan Police
Concerns summary (AI summary) Communications officers lacked current training and struggled with a complex database where critical risk information was not easily accessible or prominently displayed, jeopardising vulnerable persons.
Action Planned (AI summary) The Metropolitan Police Service will implement mandatory refresher training for communications officers on the Merlin database by March 31st 2016, focusing on the 'red flag' marker and incident reports. Line managers have been instructed to monitor training completion.