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
Sheldon Woodford
Historic (No Identified Response)
2016-0189 16 May 2016 Hampshire Central
HMP Winchester
Concerns summary (AI summary) Key safety documents (SASH) are not universally identifiable during reception, and officers receive insufficient training in ACCT processes for managing at-risk individuals.
John Crittall
All Responded
2016-0187 16 May 2016 Surrey
BMI Hospitals Care Quality Commission General Medical Council +2 more
Concerns summary (AI summary) An acutely unwell patient was admitted to a private hospital lacking HDU/ITU facilities and emergency protocols. Chest drain insertion was performed against guidelines, without appropriate imaging or confirmation of its position, delaying critical haemothorax management.
Action Planned (AI summary) The Royal College of Radiologists will make its Fellows and members aware of the British Thoracic Society Pleural Disease Guidelines 2010. Following concerns about admitting acutely unwell patients without HDU/ITU facilities, BMI Mount Alvernia Hospital updated its admission policy to ensure all patients meet admission criteria. They also introduced mandatory training details for consultants and conduct monthly audits of consultant input into medical records.
Ronnie Olliffe
All Responded
2016-0224 15 May 2016 Mid Kent and Medway
HMP Rochester
Concerns summary (AI summary) There was a failure to issue a Code Blue appropriately, a lack of understanding about its emergency consequences, and a failure to use an available defibrillator.
Action Taken (AI summary) Following a failure to issue a Code Blue, all night staff at HMP&YOI Rochester were issued copies of PSI 03/2013 and signed to confirm understanding. A Notice to Staff was issued and pocket-sized cards explaining the codes were ordered for all staff, and a defibrillator demonstration was provided.
Geoffrey Ellis
All Responded
2016-0186 13 May 2016 Manchester South
Stockport NHS Foundation Trust
Concerns summary (AI summary) Illegible clinical records and incomplete documentation create a serious risk of communication breakdown and misinformation within patient care pathways.
Action Planned (AI summary) Stockport NHS Trust is installing an electronic patient record system (EPR) called 'TrakCare' with full roll out expected in 2017. In the meantime they will continue monthly 'live' spot audits of inpatient records to improve written records and communication.
Harold Davies
All Responded
2016-0185 13 May 2016 Nottinghamshire
A-ONE+ Highways England Nottinghamshire County Council
Concerns summary (AI summary) A junction has a history of multiple fatalities, but proposed remedial safety works lack funding and commencement dates. There are also concerns about the national speed limit on the approach and insufficient warning signs.
Noted (AI summary) Highways England has discussed the coroner's report with relevant parties and is seeking funding for an accident remedial scheme designed by AOne+ involving interactive signs, clearer markings, and improved signage. They cleared vegetation around the junction to improve visibility and aim to deliver the scheme within the next year if funds are approved. A-one+ acknowledges the coroner's concerns and states that they have made safety recommendations to Highways England regarding the junction. However, they state that it is Highways England's responsibility to secure funding for improvements. A-one+'s contract for the area expired on July 1, 2016 and it no longer has responsibility for the site. Nottinghamshire County Council acknowledges the coroner's concerns regarding accidents at the A46/Station Road junction but states that the Trunk Road is the responsibility of Highways England, and they defer to Highways England's proposed measures. They do not consider a speed limit reduction on Station Road to be effective or appropriate.
Constance Pridmore
All Responded
2016-0491 12 May 2016 Cumbria
Department of Health and Social Care University Hospitals of Morecambe Bay N…
Concerns summary (AI summary) Rib fractures and a subsequent haemothorax were not identified on admission, leading to undetected blood accumulation and death during a chest drain insertion procedure.
Action Planned (AI summary) The Trust has undertaken several actions to address radiology reporting delays, including offering overtime to consultants, supporting undergraduate radiographer training, maximizing advanced practitioner skills, employing locums, introducing advice and guidance for GPs, and workforce planning. Voice recognition technology has been rolled out across all radiology staff. The Department of Health is increasing clinical radiology training posts by 32 in 2016 and is reviewing specialty intakes from 2017 onwards, taking into account the Urgent and Emergency Care Review. NHS England is implementing urgent and emergency care networks.
Archie Hall
All Responded
2016-0495 12 May 2016 Suffolk
Suffolk County Council Highway Departme…
Concerns summary (AI summary) The Orwell Bridge has easily accessible walkways with a low concrete wall offering inadequate fall prevention. There are no physical deterrents or handholds, posing a significant risk of falls that has led to multiple deaths.
Action Planned (AI summary) Highways England commissioned a review of preventative measures for suicides on the Orwell Bridge and are reviewing the effectiveness of the telephones located at either end of the bridge, and will implement changes at the earliest opportunity. They are not intending to take further action regarding toe holds on the outer face of the bridge.
David Aughton
Historic (No Identified Response)
2016-0183 12 May 2016 Blackburn, Hyndburn and Ribble Valley
East Lancashire Healthcare NHS Trust
Concerns summary (AI summary) The concerns text for this report is incomplete, so specific issues cannot be identified.
Sally Froggatt
Historic (No Identified Response)
2016-0481 11 May 2016 Preston and West Lancashire
BMI Health Care
Concerns summary (AI summary) There was a failure to comply with the Duty of Candour, inadequate staff training, contradictory corporate guidelines, and nursing staff did not communicate known patient risk factors to consultants.
Mia Gibson
Historic (No Identified Response)
2016-0180 11 May 2016 Nottinghamshire
Chair of Association of Ambulance Chief… East Midlands Ambulance Service NHS Tru… NHS Hardwick Clinical Commissioning Gro… +1 more
Concerns summary (AI summary) Over-reliance on maternal observations in obstetric emergencies overlooked fetal risk, and ambulance dispatch suffered from poor meal break management and resource shortages. This led to critical delays in emergency response and hospital transfer.
Gillian Taylor
All Responded
2016-0178 11 May 2016 South Wales Central
Department of Health and Social Care Powys Teaching Health Board
Concerns summary (AI summary) A lack of acute mental health facilities in Powys forces patients to be moved far from home, causing discontinuity of care and negatively impacting patient engagement, thus increasing self-harm and suicide risk.
Action Planned (AI summary) Following the report, Welsh Government facilitated a meeting between all Health Boards mental health managers to discuss using Welsh NHS beds whenever possible. They also highlighted the existing requirement for care coordinators and treatment plans for all patients in Wales receiving secondary mental health services, even when placed 'out of area'. Powys Teaching Health Board is working to repatriate Mental Health Services for direct delivery, expecting to treat more patients within Powys and reduce out-of-county placements. Kent and Medway NHS Trust revised its 'Unable to Contact' Protocol, launched it at the Acute Leadership Forum, and cascaded training to CRHT teams. The new Protocol is being piloted in CRHTs trust wide for 3 months to ensure the changes are robust and workable.
Christine Street
All Responded
2016-0177 10 May 2016 Brighton and Hove
Brighton and Sussex University Hospital…
Concerns summary (AI summary) Incomplete documentation and a care assistant's failure to adhere to observation policy for a vulnerable patient led to an unwitnessed fall. There was also a complete lack of documentation for specialling observations, contravening Trust and national policies.
Action Taken (AI summary) Brighton and Sussex University Hospitals NHS Trust held study days for nurses on LBAW covering topics including Deprivation of Liberty, falls prevention, one-to-one care, and end of life care, after the inquest. An audit has been carried out of every patient specialled and the findings are being collated for action.
Jack Susianta
Historic (No Identified Response)
2016-0176 6 May 2016 London Inner North
East London NHS Foundation Trust
Concerns summary (AI summary) Critical information about Jack's expected recovery, symptom recurrence, and urgent help protocols was not communicated to his family, preventing them from seeking timely hospital readmission.
Lee Nauman
All Responded
2016-0175 6 May 2016 Yorkshire West Western
Bradford Metropolitan Borough Council
Concerns summary (AI summary) The road surface had a crumbling edge, pothole, and debris, which may have contributed to a loss of control. Review and remedial action on these road conditions are needed.
Noted (AI summary) Bradford Metropolitan District Council filled potholes and patched the carriageway on Lee Lane following an inspection related to the Regulation 28 notification. They suggest the accident was likely caused by gravel washout from a private drive due to flooding, rather than potholes.
Carole Lovett
Historic (No Identified Response)
2016-0174 6 May 2016 London Greater North
North Middlesex Hospital
Concerns summary (AI summary) Staff lacked competence and training in NEW Score usage and communication, leading to alarms not being properly responded to by senior staff, and no consideration for alternative patient monitoring.
Ahmedreza Fathi
Partially Responded
2016-0173 5 May 2016 Leicester City and Leicestershire South
Leicestershire Partnership NHS Trust Northamptonshire Healthcare NHS Foundat… East Midlands Ambulance Service NHS Tru… +1 more
Concerns summary (AI summary) Healthcare complex case planning was inadequate and not updated, multi-disciplinary meetings lacked formalisation and information access, and a prior overdose was not investigated as a safeguarding opportunity.
Action Planned (AI summary) HMP Gartree revised local contingency plans and re-issued instructions in May 2016 to ensure all staff understand that they must not delay calling an ambulance in all cases where there are serious concerns about the health of an offender. The prison is also working with EMAS to ensure effective Joint working and consistency of approach in all the prisons, with a joint emergency response protocol expected by 31 July 2016. East Midlands Ambulance Service (EMAS) has formed a senior regional group to address issues relating to secure environments, such as prisons and secure mental health units. They also plan a meeting with secure environment teams to address access issues, ambulance activation protocols, and partnership working principles.
Tony Jopson and Michael Jopson
All Responded
2016-0172 4 May 2016 Cumbria
Department for Transport
Concerns summary (AI summary) The A66's varied road standard, including single carriageway sections, is inadequate for high traffic volumes, particularly HGVs, leading to head-on collisions; it should be dual carriageway throughout.
Action Planned (AI summary) The Department of Transport commissioned the Northern Trans Pennine study, covering the A66 and A69 and the Chancellor announced in the 2016 Budget his commitment to upgrade the A66 and A69. Safety improvements at specific locations on the A66 are to be delivered this financial year.
Michael Jopson
All Responded
2016-wp25249 4 May 2016 Cumbria
Department for Transport
Concerns summary (AI summary) The A66 is a mix of dual carriageway and winding country road, and the coroner suggests that from a road safety perspective the road should be dual carriageway throughout to avoid avoidable deaths.
1 response from Department of Transport
Shalane Blackwood
Historic (No Identified Response)
2016-0179 3 May 2016 Nottinghamshire
HMP Nottingham National Offender Management Service NHS England +1 more
Concerns summary (AI summary) The prison lacks adequate provision for complex health needs, has insufficient staff for prisoner regimes, faces rife NPS use, and has unclear decision-making tools and staff awareness for physical symptoms alongside mental health issues.
Darren Mindham
All Responded
2016-0170 3 May 2016 London South
Department of Health and Social Care
Concerns summary (AI summary) Pentobarbital, a Schedule 3 drug, is frequently used in suicides due to less strict controls; stricter regulation could reduce suicide rates.
Noted (AI summary) The Department of Health states that the classification of Pentobarbital is a matter for the Advisory Council on the Misuse of Drugs (ACMD), not the Department of Health, and advises redirecting the letter. They continually monitor trends in suicide data and take action to reduce access to means of suicide.
Mihangel ap Dafydd
All Responded
2016-0169 3 May 2016 Carmarthenshire and Pembrokeshire
West Wales General Hospital
Concerns summary (AI summary) Windows in Morlais Ward service user areas are not ligature-free, posing a safety risk, and planned remedial work has not yet been completed.
Action Planned (AI summary) The Welsh Government will issue an addendum to Health Building Note 35, highlighting the requirement for ligature-free design in both new and existing acute mental health unit facilities. They have also requested a formal review of HBN 35 by NHS Shared Services Partnership – Specialist Estate Services (NWSSP-SES). The Health Board will repeat ligature audits across mental health and learning disability in-patient units and submit prioritised recommendations for consideration by the 2016/17 Capital programme regarding replacement, repair or adaptation of windows. In the meantime, inpatient areas will continue to be subject to regular environmental risk assessment.
William Thompson
All Responded
2016-0130 30 Apr 2016 London Inner (North)
London Borough of Hackney
Concerns summary (AI summary) A high-risk service user lacked a smoke detector in his bedroom; social workers failed to assess or address this significant fire safety risk.
Action Taken (AI summary) The Hackney Safeguarding Adults Board commissioned a Safeguarding Adults Review under the provisions of the Care Act 2014, which has twenty six recommendations for improving practice and procedures across all of the partners and agencies involved with the case. Other measures have also been implemented, some in relation specifically to practice in the Council and others with partners to prevent as far as is possible further deaths in similar situations.
Jack Molyneux
Historic (No Identified Response)
2016-0168 29 Apr 2016 Brighton and Hove
Brighton Sussex University Hospitals NH…
Concerns summary (AI summary) VERONICA HAMILTON-DEELEY, LLB_.
Jan Bodnar
All Responded
2016-0166 29 Apr 2016 Hertfordshire
Hertfordshire County Council
Concerns summary (AI summary) Dangerous plant growth on a central reservation severely restricted driver visibility at a junction, requiring regular maintenance and review of similar junctions.
Action Taken (AI summary) The Council cleared vegetation at a specific junction in July 2015. They also carried out an assessment of similar junctions, identifying 6 requiring vegetation clearance, which is planned for July 2016. The Council also revised the remit for highway safety inspectors and revised the maintenance regime for vegetation for the identified length of road.
Thomas Harris
Historic (No Identified Response)
2016-wp25258 28 Apr 2016 Kent Central and South East
Right Honourable Theresa May MP