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
Karen O’Brien
Historic (No Identified Response)
15 Jul 2015 London (City)
First Response Team, South Essex Partne… NICE
Concerns summary (AI summary) The mental health service (SEPT) made clinical determinations without adequate inquiry or face-to-face assessment, overriding a GP's referral. The coroner questioned the rigid application of NICE guidelines.
Emma Carpenter
All Responded
2015-0276 14 Jul 2015 Nottinghamshire
Department for Education Department of Health and Social Care NHS England
Concerns summary (AI summary) Critical specialist eating disorder services for children lacked long-term funding and inpatient bed provision. Insufficient funding for school nurses caused poor communication between mental health and education systems.
Action Taken (AI summary) The Department of Health provided NHS England with £7 million in 2014/15 to increase CAMHS Tier 4 bed provision and improve access. Health Education England plans to commission 340 training places for school nurses in 2015-16, representing a 71.7% increase, and will review curriculums to include recognised areas of health. NHS England has invested in inpatient CAMHS beds, developed national service specifications for acute inpatient mental health units, and is planning to commission inpatient beds based on need. They highlight the MindEd e-portal and are piloting a single point of access programme for CAMHS and schools. The Trust has communicated with Nottinghamshire Health Care Foundation Trust, offering a formal service level agreement and a named consultant to support patients from the Bassetlaw area receiving treatment at Thorneywood Adolescent Unit. Although not required, the Trust has identified a consultant and will actively engage with Nottinghamshire Healthcare Trust as needed.
Kenneth Bailey
All Responded
2015-0275 14 Jul 2015 Manchester (South)
Greater Manchester Fire and Rescue Serv…
Concerns summary (AI summary) Limited manning hours at a local fire station caused delayed emergency response times, which encouraged untrained neighbours to undertake dangerous rescues, increasing their risk of injury or death.
Action Planned (AI summary) Greater Manchester Fire and Rescue Service is undertaking internal and external recruitment to establish a new duty system at Mossley Fire Station, expected to be in place by November 2015. This involves approaching other fire and rescue services and exploring inter-brigade transfers.
Janine Kaiser
Partially Responded
2015-0272 14 Jul 2015 Stoke on Trent and North Staffordshire
New Park Residential Home Stoke-on-Trent City Council
Concerns summary (AI summary) A pressure sore management plan was poorly followed, with falsified records, missed turns, and inadequately trained staff in record-keeping and mattress management. Referrals to specialists were also delayed.
Noted (AI summary) Stoke on Trent Council details its involvement with Mrs Kaiser's care, noting that Staffordshire County Council had primary responsibility. They state that concerns about SSOTP TVN staff actions were raised with the Safeguarding Lead Nurse for the Stoke on Trent CCG, and that learning from the investigation has been shared with the home.
Thomas Farrell
Historic (No Identified Response)
2015-0273 14 Jul 2015 Nottinghamshire
Springfield Care Home
Concerns summary (AI summary) The care home failed to obtain a full prescription history from the GP, resulting in critical medications not being administered and creating a clear risk of harm to residents.
Douglas Birch
All Responded
2015-0274 13 Jul 2015 Mid Kent and Medway
HMP Swaleside
Concerns summary (AI summary) Prison officers were either unaware of or failed to follow instructions requiring them to elicit a response from prisoners upon cell unlocking. They also did not consistently receive or read crucial Prison Service Orders.
Action Taken (AI summary) HMP Swaleside issued a notice to staff on 10 August 2015 setting out local procedure for welfare checks and requiring staff to sign to confirm checks have taken place. NOMS is compiling a learning bulletin for all staff on their intranet by the end of September.
Wiktoria Was
All Responded
2015-0271 13 Jul 2015 London (Inner South)
Metropolitan Police
Concerns summary (AI summary) Police pursuits showed insufficient regard for injured third parties, and lessons from previous pursuit-related deaths were not adequately learned or disseminated. Officers lacked sufficient and rigorous refresher training.
Action Taken (AI summary) The Metropolitan Police Service has rolled out an RT Operators Course since 2011 to selected elements of the uniformed workforce and since July 2014 to all new recruits. They are also planning to implement enhanced driver training, pending release of funds, and are working to ensure officers serving prior to the course introduction may have an opportunity to take the course in the near future, most likely re-worked as a computer-delivered package.
Barbara Harrison
Historic (No Identified Response)
2015-0277 13 Jul 2015 Manchester (South)
BMI Healthcare Limited
Concerns summary (AI summary) Inappropriate physiotherapy contributed to surgical complications, and critical equipment failed during emergency surgery due to flat batteries, leading to a 'panic situation'. Family members were also distressed by public disclosure of a cardiac arrest.
Cameron Laing
All Responded
2015-0268 10 Jul 2015 Exeter and  Greater Devon
Ministry of Defence
Concerns summary (AI summary) Soldiers lacked critical understanding of trailer braking systems and safe extraction methods, leading to a fatal accident. The Ministry of Defence irrationally refused to teach alternative maneuvers not in official publications.
Action Taken (AI summary) The Ministry of Defence improved the training package for DROPS operators qualified to tow the KINGS trailer, supported by a video detailing coupling and uncoupling procedures. The Army will include clearer guidance for operation of the Shunt Valve in the AESP, and amend the Trainer instructor Specifications (ISpec).
Colin Moulton
Partially Responded
2015-0267 10 Jul 2015 Manchester (North)
Department of Health and Social Care Messrs. Weightmans North West Ambulance Service
Concerns summary (AI summary) Critical patient information was lost during verbal paramedic-to-triage nurse handovers. Additionally, the ambulance service failed to notify the hospital of their presence when responding to a patient already on hospital grounds, missing a crucial connection.
Noted (AI summary) The Department of Health acknowledges the concerns, noting local resolution and NWAS response. They provide national context including handover procedures, NHS England review of urgent and emergency care, enhanced summary care records, and the NMC's role in regulating nurses.
Dorothy McDermott
Historic (No Identified Response)
2015-0266 10 Jul 2015 Manchester (North)
Department of Health and Social Care Littleborough Care Home Pennine Care Trust +1 more
Concerns summary (AI summary) A vulnerable patient was inappropriately placed in a residential care home without nursing care or staff trained for her needs. A lack of formal guidance for agencies led to unsuitable placements for vulnerable individuals.
Michael George
All Responded
2015-0264 9 Jul 2015 London (Inner South)
South London and Maudsley Trust
Concerns summary (AI summary) Senior management may have attached insufficient importance to previous PFD reports regarding the physical healthcare of mentally ill patients, and there was a lack of domiciliary visits from consultant physicians to mental health wards.
Action Planned (AI summary) South London and Maudsley NHS Trust outlines planned improvements to policies, audits, and risk management related to physical health monitoring for patients on anti-psychotics, including actions related to diabetes screening and refusal of tests. They are considering adding the Glasgow Anti-psychotic Side-effects Scale (GASS) to their electronic patient record and have set up a working group as part of the London Strategic Clinical Network.
Toni Piel
Partially Responded
2015-0263 9 Jul 2015 Manchester (North)
Department of Health and Social Care Pennine Acute Hospitals NHS Trust
Concerns summary (AI summary) A patient was discharged home after a head injury without assessing their home circumstances or documenting discharge risk factors, violating NICE guidelines on patient observation.
Noted (AI summary) The Department of Health acknowledges the concerns and Pennine Acute Hospitals NHS Trust's review, highlighting actions to improve management, supervision, assessment, and discharge of head injury patients. They note the work of Patient Safety Collaboratives, NICE guidance, and the Falls and Fragility Fracture National Audit Programme.
Alun Walters
Historic (No Identified Response)
2015-0262 9 Jul 2015 Powys, Bridgend and Glamorgan Valleys
Aneurin Bevan University Health Board Cwm Taf University Health Board National Assembly for Wales +2 more
Concerns summary (AI summary) The medical practice failed to use computer software for prescription decisions, breached its anti-coagulation register contract, and lacked systems for notifying GPs of missed INR tests or Warfarin withdrawal.
Ronald Laidiar
Historic (No Identified Response)
2015-0270 8 Jul 2015 Manchester (South)
Greater Manchester Police
Concerns summary (AI summary) The police investigation was severely inadequate, failing to secure the scene, account for missing items, properly investigate the source of blood, or identify a key head injury, significantly raising the risk of undetected violent crime.
Meryl Parry
Partially Responded
2015-0259 8 Jul 2015 Cumbria
Cumbria County Council Green Lane Care Homes Limited
Concerns summary (AI summary) A lack of mandatory system for residential homes to seek Social Services advice before discharging residents creates a serious risk that discharged individuals will not have appropriate safety and welfare arrangements in place.
Action Taken (AI summary) Greenlane Care Homes Limited confirms their Discharge Pack has been changed to include the procedure to follow for an unanticipated discharge.
Yvonne Davies and Andrew Davies
Historic (No Identified Response)
2015-0261 7 Jul 2015 Manchester (South)
Greater Manchester Police
Concerns summary (AI summary) An off-duty police officer, personally involved with the deceased, compromised the crime scene by breaking in and contaminating evidence before and after on-duty officers arrived, who then failed to secure the scene.
Michael Thorley
All Responded
2015-0260 7 Jul 2015 Manchester (South)
Greater Manchester Police
Concerns summary (AI summary) There was an inexcusable delay in emergency entry and a lack of clear policy for forced entry. Police failed to thoroughly investigate the scene, overlooked crucial evidence, and did not consider potential third-party involvement, compromising the investigation.
Action Taken (AI summary) Greater Manchester Police has provided feedback and management advice to the officers concerned. The officer who attended is to remain on an action development plan to be managed by their line manager, and Detective Inspector Stainton is to remain on an action development plan which will continue to be managed by his immediate line manager.
Arthur Fry
All Responded
2015-0258 7 Jul 2015 Stoke on Trent and North Staffordshire
University Hospital of North Staffordsh…
Concerns summary (AI summary) A communication breakdown between the MRI department and the consultant's team led to a critical MRI scan being cancelled due to unknown consent requirements, potentially impacting patient care. Tighter controls are needed for procedure requisitions.
Action Planned (AI summary) University Hospitals of North Midlands NHS Trust is incorporating a phrase into the MRI safety questionnaire about MRI compatibility. The Department of Imaging has applied for transformation funding for Imaging Assistants to visit patients on the ward pre-scan. Escort nurses have a written handover on return to the ward from MRI.
Phyllis Broomhead
All Responded
2015-0290 6 Jul 2015 South Yorkshire (East)
Rotherham Metropolitan Borough Council
Concerns summary (AI summary) Care home staff lacked training in head injury protocols and record-keeping, while safeguarding screening was insufficient. There's a systemic gap in monitoring high-risk residents when nursing care isn't deemed necessary, leaving them vulnerable.
Action Planned (AI summary) Rotherham Metropolitan Borough Council will provide a detailed action plan regarding recommendations made under Regulation 28, outlining actions taken, actions to be achieved, and timescales to conclude any uncompleted actions.
John Clarke
All Responded
2015-0256 6 Jul 2015 London Inner (West)
City Of Westminster
Concerns summary (AI summary) The City Council's highway inspection system and asset database were ineffective, failing to identify a missing road sign and defective lighting for years, significantly hindering remedial action and posing a risk to road safety.
Action Taken (AI summary) The City Council has measures in place or to be implemented to maintain an accurate inventory of traffic signs, ensure remedial work is ordered promptly, and update the inventory database. Additional training on regulatory signage is being provided to inspectors in January 2016.
George Boulton
Partially Responded
2015-0255 6 Jul 2015 Leicester City and Leicestershire South
East Midlands Ambulance Service NHS England University Hospital Leicester
Concerns summary (AI summary) Delays in emergency stroke care arose from the GP failing to escalate, a bed bureau lacking emergency re-routing, and ambulance services not classifying a stroke as an immediate emergency, risking critical treatment windows.
Noted (AI summary) East Midlands Ambulance Service acknowledges the coroner's concerns and explains their current processes for urgent patient transfers. NHS England describes a broader review of urgent and emergency care and the establishment of urgent and emergency care networks.
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.
Davina Tavener
All Responded
2015-0252 3 Jul 2015 Manchester (West)
Civil Aviation Authority European Aviation Authority Irish Aviation Authority
Concerns summary (AI summary) Current aviation regulations fail to mandate critical medical equipment like defibrillators and airway adjuncts on aircraft, significantly reducing a passenger's chance of survival during in-flight cardiac arrest despite such equipment being available and simple to operate.
Action Planned (AI summary) The IAA notes the current practices of Irish air operators regarding AEDs and aircraft, and states that the Chief Executive of the IAA has written to the Chief Executive of Ryanair on the matter of carrying AED's on their fleet. Ryanair is now positively reviewing this carriage on their fleet. EASA acknowledges the concerns and will engage with Member States to reconsider the situation through analysis of available data, launching a first discussion at the next meeting with air operations thematic advisory group in September 2015. The CAA will raise the issue of mandatory medical equipment on aircraft, including defibrillators, at the Flight Operations Liaison Group, to obtain an industry view and assess whether operators should review their risk assessments. They will share data with EASA and support legislative changes if an evidence-based case emerges.
Patricia Holmes
All Responded
2015-0254 2 Jul 2015 Kent Central and South East
East Kent Hospitals University NHS Trust
Concerns summary (AI summary) The A&E doctor failed to recognize the serious risk of internal bleeding in a patient with multiple fractured ribs and on anticoagulation therapy, leading to inadequate action for their condition.
Action Taken (AI summary) East Kent University Hospitals NHS Trust has an approved algorithm in place to assess and treat patients with trauma and bleeding risk. A governor's order was issued at HMP Wayland on June 30, 2015, instructing staff to record medical issues in the wing observation book and the Local Security Strategy has been amended to reflect this procedure.