2016

PFD Reports
Reports: 472 Areas: 69

65% response rate (above 63% average).

Response Status
Responded 307 Historic 165
AI Classification
Action Taken 42%
Action Planned 43%
Noted 14%
Disputed 1%
Based on 394 classified responses
Top Categories
Hospital Death (Clinical Procedure… (226) Community health care and emergenc… (59) Other related deaths (50) Suicide (from 2015) (44) Road (Highways Safety) related dea… (40)
472 results
Tommi-Ray Vigrass
Partially Responded
2016-0241 28 Jun 2016 Black Country
Care Quality Commission Walsall Healthcare NHS Trust
Concerns summary (AI summary) A paediatric doctor made an erroneous extubation decision without consulting a consultant. There were also delays in contacting a tertiary unit and an inadequate handover for the premature baby's arrival.
Action Taken (AI summary) Walsall Healthcare NHS Trust has implemented a Regional Cot Locator service, and given medical staff access to the Maternal Badgernet System in addition to the Neonatal system. They have also established a Maternity and Neonatal Task Force and are sharing lessons learned with Neonatal staff.
Anielka Jennings
Historic (No Identified Response)
2016-0236 27 Jun 2016 Gloucestershire
Gloucestershire Clinical Commissioning … Gloucestershire County Council
Concerns summary (AI summary) No lead professional was identified for a child transitioning to adult services with multiple agency involvement, leading to a breakdown in communication and continuity of care.
Beverley Devanney
Historic (No Identified Response)
2016-0485 24 Jun 2016 West Yorkshire (West)
West Yorkshire Police
Concerns summary (AI summary) Police officers lacked formal training for handling complex situations like Miss Devanney's, raising concerns about appropriate responses in similar future circumstances.
Kirsty Childs
Historic (No Identified Response)
2016-0497 24 Jun 2016 West Yorkshire (West)
Department of Health and Social Care NHS England
Concerns summary (AI summary) At the inquest, it was not possible to trace an appropriate individual from the now defunct NHS direct organisation to give evidence although an internal enquiry report which had been undertaken prior to.
William Nute
Partially Responded
2016-0229 24 Jun 2016 Cornwall
Devon and Cornwall Police South Western Ambulance Service
Concerns summary (AI summary) Delays in emergency service attendance and patient transfer, coupled with inadequate 999 call triage and police notification, led to an unmanaged incident scene and increased risk of death.
Noted (AI summary) South Western Ambulance Service NHS Trust provides context on the ambulance delay and describes the NHS England Ambulance Response Programme (ARP), a clinically led review of call coding systems being trialled in two sites.
Richard Hinchliffe
Historic (No Identified Response)
2016-0234 24 Jun 2016 London Inner (South)
Network Rail
Concerns summary (AI summary) Concerns include inadequate security of railway platform barriers and a lack of monitoring for a passenger asleep on the platform for an extended period at a 24-hour staffed station.
Michael Younghusband
All Responded
2016-0235 23 Jun 2016 Exeter and Greater Devon
Great Western Railway
Concerns summary (AI summary) A railway crossing point was in a poor state, with a section standing proud of the track, presenting a significant tripping hazard for users.
Action Taken (AI summary) Network Rail completed ballast surface improvement works at the East Devon Way crossing point on 20 July 2016, and edges of any trip hazards have been clearly marked.
Malcolm Bennett
All Responded
2016-0232 22 Jun 2016 Manchester (South)
Borough Care Ltd
Concerns summary (AI summary) Staff at the care home delayed calling an ambulance for three hours after a significant injury, despite the care plan requiring immediate emergency department transfer, potentially contributing to the death.
Action Taken (AI summary) Borough Care has updated risk management plans for residents on Warfarin, placed anti-coagulant warnings on care plans and MAR sheets, discusses medication at handovers, reviewed medication training to include anticoagulant use, and will review the 'Falls Prevention' and medication audit procedures by the end of September 2016.
Olive Wilmott
Historic (No Identified Response)
2016-0231 21 Jun 2016 Nottingham
Ideal Care Home Ltd
Concerns summary (AI summary) An alleged assault was not effectively investigated or safeguarded, and the care home failed to meet observation requirements due to insufficient night staff for residents' needs.
Stephanie Marks
Historic (No Identified Response)
2016-0233 20 Jun 2016 Avon
Clevedon Medical Centre
Concerns summary (AI summary) There was no evidence of a system to ensure daily GP messages were consistently countersigned and acted upon by general practitioners.
Michael Hutchence
All Responded
2016-0228 20 Jun 2016 Manchester (South)
Stockport NHS Foundation Trust
Concerns summary (AI summary) Concerns included frequent, unnecessary ward transfers, poor medical record-keeping, care by unqualified staff, and inaccurate anticoagulant dosing due to weight recording issues. Equipment shortages and non-sterile surgical kits also caused dangerous operational delays and increased DVT risk.
Noted (AI summary) The Trust provides context regarding patient transfers and staffing levels, but does not describe specific actions taken or planned in response to the coroner's concerns.
Zawdie Bascom
Historic (No Identified Response)
2016-0227 20 Jun 2016 London (East)
Barts Health NHS Trust
Concerns summary (AI summary) Inadequate pain assessment and management in A&E, including missing pain scores on triage and after analgesia, led to unmitigated severe pain at discharge. Audit plans also failed to address general severe pain cases.
Reece Atkinson
Historic (No Identified Response)
2016-0226 16 Jun 2016 Surrey
Surrey County Council
Concerns summary (AI summary) The accumulation of wet soil and sandy deposits on the A25 Sheer Road, near a sandpit entrance, creates a road hazard for drivers.
Valerie Ellis
All Responded
2016-0252 16 Jun 2016 West Sussex
IC24 SECAMB Western Sussex Hospital NHS Trust
Concerns summary (AI summary) Inadequate discharge counselling for a vulnerable patient on medication, coupled with concerns about 111 health advisor training and imprecise algorithms. A call-back was prematurely closed and a joint investigation has not occurred.
Disputed (AI summary) The Ambulance Service states it has met NHS Pathways training requirements and believes further algorithm concerns should be directed to the Department of Health. They are open to sharing their Serious Incident report with IC24. The Trust launched a NOAC alert card in October 2015 and introduced a Standard Operating Procedure for pharmacy staff. They will also place a NOAC card in the medication bag given to patients on discharge, document discussions with relatives, and are revising their anti-coagulants policy. IC24 has implemented new Failed Contact Guidance and software to prevent premature call closure. They have reviewed their induction training program and specifically included information on accessing NHS 111 reports and sent an alert to out of hours GPs reminding them about accessing this information.
Christina O’Brien
Historic (No Identified Response)
2016-0221 14 Jun 2016 London Inner (South)
Department of Health and Social Care South London and Maudesley NHS Trust
Concerns summary (AI summary) Limited community respite care options for mentally ill individuals, with the withdrawal of beneficial facilities like "Dove House" without alternative provision, preventing comprehensive support for their distress.
Andrew Peebles
Historic (No Identified Response)
2016-0484 13 Jun 2016 Preston and West Lancashire
Lancashire Care NHS Trust
Concerns summary (AI summary) Significant failures by RMNs included inadequate documentation of mental health assessments, insufficient review of critical patient information, and a lack of follow-up on referrals. Additionally, no internal investigation was conducted into the death.
Laura McRory
All Responded
2016-0223 13 Jun 2016 London (East)
North East London Foundation Trust
Concerns summary (AI summary) The Trust lacked a clear process for employees seeking mental health care, especially regarding confidentiality and external referrals. There was also an inadequate safety plan on discharge and deficiencies in the internal investigation.
Action Planned (AI summary) The Trust states it has carefully considered the report and is fully cognisant of the issues and committed to continuously review its service and has enclosed the Trust's action plan to prevent the reoccurrence of the shortcomings identified in your Regulation 28 report
Kinga Cieciorska
Historic (No Identified Response)
2016-0222 13 Jun 2016 Black Country
Walsall Healthcare NHS Trust
Concerns summary (AI summary) A missed opportunity to investigate abnormal ECG trace and tachycardia; systemic failings in recording and transmission of information, with GP medical notes not seen by the Junior Doctor; details of medication including the significance of the drug, Diclofenac, was not considered.
Kevin Dermott
All Responded
2016-0220 13 Jun 2016 Cheshire
Department for Health NHS England
Concerns summary (AI summary) While at HMP Durham, the deceased was left in a urine soaked cell during a hypomanic episode and a psychiatric referral was never completed; inadequate mental health cover at HMP Haverigg and a lack of suitable psychiatric care facilities at HMP Kirkham contributed to a failure to recognise relapse into depression at HMP Risley.
Noted (AI summary) NHS England is working with other organisations to address the lack of secure psychiatric beds. Updated guidelines for transferring prisoners to secure mental health hospitals are due for final consultation in autumn 2016. HMP Risley has increased the level and depth of management checks on ACCT documents, will issue a Governor's Order clarifying staff responsibilities, and has informed staff to contact the Safer Custody department for immediate ACCT reviews. Changes are planned for implementation by the end of September 2016. The Department of Health acknowledges the concerns, highlights its commitment to working with NOMS and NHS England, and notes that NHS England and NOMS will be responding separately.
Matthew Gunn
Partially Responded
2016-0217 9 Jun 2016 Gloucestershire
DWF LLP W M Morrisons PLC
Concerns summary (AI summary) An epileptic event experienced by an employee at work was not officially recorded, raising concerns about incident reporting protocols.
Action Planned (AI summary) Morrisons will issue a bulletin to stores instructing employees to report observed epileptic events to a first aider. They will update first aid training and policy, and record epileptic events reported via return-to-work procedures with a reminder to review risk assessments.
Anthony Fraser
All Responded
2016-0225 8 Jun 2016 South Yorkshire (East)
HMP Lindholme
Concerns summary (AI summary) Summary medical information was not conveyed to the receiving A&E department upon transfer, and there is no system for ensuring such information is sent; a system needs to be implemented to convey such information for every inmate transferred with an acute illness.
Action Taken (AI summary) Following concerns raised, the Trust co-authored a procedure with HMP Lindholme to convey summary medical information to A&E departments during inmate transfers, and the procedure has been issued to staff and is now in operation; a review of compliance will be undertaken.
Stephen Hunt
All Responded
2016-0216 8 Jun 2016 Manchester (City)
Chief Fire and Rescue Services Home Office
Concerns summary (AI summary) Fire and Rescue Services lacked adequate measures for managing heat stress in hot environments, had poor communication protocols, and insufficient training/SOPs for incident role handover, hazard recording, and thermal imaging camera use.
Noted (AI summary) DSFRS provides responses to the coroner's questions, but does not describe any specific actions taken or planned by their own service. The Ministry of Justice acknowledges the coroner's concerns regarding legal aid funding but states that funding decisions are made independently and there are no plans to change the current scheme.
Peter Seale
Historic (No Identified Response)
2016-0215 8 Jun 2016 Manchester (North)
Department of Health and Social Care Royal College of Physicians
Concerns summary (AI summary) The absence of national guidance for monitoring patients with pleural plaques leads to inconsistent follow-up, risking delayed diagnosis and treatment.
Gwendoline Clarke
Partially Responded
2016-0218 8 Jun 2016 Gloucestershire
ADL PLC Care Quality Commission
Concerns summary (AI summary) Staff failed to report a resident's injury and delayed escalating allegations of abuse for approximately 12 hours.
Action Planned (AI summary) The organisation plans to re-enforce the safeguarding policy, update job descriptions, include admission process under general screening, audit care plan, re-enforce home's protocols for unwitnessed accidents, plan training and supervision refresher first aid, review the home's management and on-call process.
Ezharul Islam
All Responded
2016-0214 6 Jun 2016 London (North)
Transport for London
Concerns summary (AI summary) There is no system in place to alert bus passengers when the vehicle is about to move, unlike previous methods which involved verbal warnings and a bell.
Action Planned (AI summary) Transport for London will consider the coroner's recommendations about passenger alerts as part of the Bus Safety Standard for London to find the most appropriate solution.