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
Edward Paddon-Bramley
Partially Responded
2016-0099 6 Mar 2016 London Inner (South)
Department of Health and Social Care National Screening Committee N.I.C.E +1 more
Concerns summary (AI summary) Significant discrepancies exist between national guidelines (NICE) and local Trust practices/consultant views regarding the treatment of prolonged rupture of membranes and Group B Strep screening in pregnancy.
Action Planned (AI summary) The UK NSC commissioned an update review into antenatal screening for GBS in December 2015 and expects to hold a public consultation in the autumn for three months, after which the UK NSC will review its recommendation. Research is also underway to evaluate the value of using rapid tests in labour to detect GBS in women with risk factors. The Department of Health notes concerns about differing guidelines for prolonged ruptured membranes (PROM) and GBS screening. They highlight that NICE guidelines represent best practice and that the RCOG provides updated guidance. They are monitoring developments on GBS vaccines, have completed a national surveillance study on GBS, have carried out an audit of current practice in preventing early onset neonatal Group B Streptococcal disease, and have approved funding for a study on accuracy of a rapid intrapartum test.
Lee Gaunt
All Responded
2016-0092 4 Mar 2016 Manchester South
Greater Manchester Fire and Rescue Serv…
Concerns summary (AI summary) The Fire and Rescue Service failed to provide effective occupational health support, assigning extra duties to a distressed employee after a colleague's death, indicating a general lack of support for staff in stressful situations.
Action Taken (AI summary) GMFRS has amended its procedures to allow employees to self-refer for counselling via its occupational health provider. It has also been piloting a system known as Trauma Risk Management (TRiM) since November 2015, and established a working group with trade union participation examining the facilities available for addressing the effects of dealing with stressful situations.
Elsie Raper
All Responded
2016-0090 4 Mar 2016 County Durham and Darlington
County Durham and Darlington NHS Trust,… Neasham Road Surgery
Concerns summary (AI summary) A patient's severe tibia and fibula fractures remained undiagnosed for four days despite regular medical visits, leading to extreme pain and contributing to her death.
Action Planned (AI summary) The surgery will implement several actions, including investigation of falls in elderly patients and prompt referral for x-rays, as well as regular reviews of factors contributing to falls and discussion of the issues with the staff at Grosvenor Park Care Home. Four Seasons Health Care has initiated 24-hour falls observation charts, completed a list of all residents with a confirmed diagnosis of osteoporosis, reviewed and rewritten residents' care plans to incorporate details associated with a diagnosis of osteoporosis and increased risk of fracture, and now refers residents to the Community Matron for review after low impact falls.
Marjorie Booth
Historic (No Identified Response)
2016-0094 4 Mar 2016 Manchester (South)
Stockport NHS Foundation Trust
Concerns summary (AI summary) Concerns were raised about an apparent hospital policy not to routinely perform CT scans for suspected fractures, even when the risk of missing a fracture outweighs radiation exposure risk for elderly patients.
Ranjan Mistry
All Responded
2016-0093 4 Mar 2016 Manchester (South)
Tameside Hospital NHS Foundation Trust
Concerns summary (AI summary) There was no, or insufficient, assessment of the deceased's Falls Risk, neurological observation charts were incomplete or lost, and medical staff were not reviewing nursing notes or vice versa; handover sheets were being shredded, preventing further reference.
Action Taken (AI summary) The Trust has initiated one-to-one training and support for staff involved and is undertaking a review of the documentation, which aligns with actions following the Trust's participation in the National Falls Audit and the 'Everyone Matters' programme. The Trust has also initiated a Guidance Document available online for staff involved in concise and local falls investigation.
Ronald Bentley
Partially Responded
2016-0086 3 Mar 2016 Birmingham and Solihull
British Cardiac Intervention Society British Society of Interventional Radio…
Concerns summary (AI summary) A previously unrecognised risk of air entering the vascular system during a cardiac procedure with conscious sedation was identified, highlighting a critical lack of awareness and necessary safeguards across cardiac centres.
Noted (AI summary) The British Cardiovascular Intervention Society (BCIS) circulated the report to its members via its official newsletter and passed on details to the British Heart Rhythm Society (BHRS).
Stewart Akins
All Responded
2016-0091 3 Mar 2016 Worcestershire
West Mercia Constabulary
Concerns summary (AI summary) Critical information about the deceased's repeated suicide intentions recorded in police custody was not relayed to the Magistrates' Court, leading to bail being granted without full awareness of the high self-harm risk.
Action Taken (AI summary) West Mercia Police revised its practice so all Prisoner Escort Forms are signed as accurate by the custody sergeant, who has overall responsibility for ensuring risks are correctly documented and communicated. Mandatory training for custody sergeants includes highlighting known risks to the OIC upon consideration for MG7 remand application.
Aleeza Ahmed
All Responded
2016-0089 3 Mar 2016 Manchester (South)
Stockport Council
Concerns summary (AI summary) Chamfered kerbstones and the absence of a protective Armco barrier on a central reservation were identified as potential factors contributing to a vehicle overturning and posing increased danger to road users.
Action Planned (AI summary) Stockport Metropolitan Borough Council plans to make a bid to the Greater Manchester Casualty Reduction Partnership for funding to install a central barrier on Crookilley Way. They are also planning a review of the speed limit on that road.
Christopher Stubbs
Historic (No Identified Response)
2016-0081 3 Mar 2016 West Yorkshire (West)
Wibsey and Queensbury Medical Practice
Concerns summary (AI summary) The abrupt cessation of critical medication upon hospital discharge, with a follow-up GP review failing to occur, highlighted a need to improve systems for acting on discharge summaries regarding patient medication.
Adam Rice
Partially Responded
2016-0085 3 Mar 2016 West Yorkshire (East)
St James’s University Hospital West Yorkshire Police
Concerns summary (AI summary) There was poor communication between the hospital and police regarding a patient's self-discharge against medical advice, compounded by inconsistent custody care, staff shortages, inadequate handovers, and a lack of understanding of welfare check protocols.
Action Taken (AI summary) West Yorkshire Police has implemented measures to ensure vulnerable persons who come into contact with the Police receive the best possible care, including a full training programme for Custody Staff on PACE and relevant provisions of the College of Policing APP. They have also implemented daily briefings for custody staff and reviewing risk assessment processes.
Christ Morrison
Partially Responded
2016-0084 2 Mar 2016 London Inner (South)
Epsom and St Helier, University Hospita… Queen Mary’s Hospital for Children
Concerns summary (AI summary) Concerns centred on unclear training standards and lack of medical presence during paediatric tracheostomy tube changes, with a policy for emergency transfer rather than onsite re-intubation in case of failure.
Action Taken (AI summary) Epsom and St Helier University Hospitals NHS Trust reviewed and updated the Trust's 2015 Tracheostomy Policy to give clearer sign posting to national guidelines. The updated policy has been submitted to The Royal College of Child Health and The Paediatric Intensive Care Society for review and the Trust continued with its annual training programme for all staff involved in tracheostomy care.
Curt Falk
Partially Responded
2016-0083 2 Mar 2016 London Inner (North)
Joint Committee on Vaccination and Immu… Department of Health and Social Care
Concerns summary (AI summary) A patient died from a viral infection (SCC) preventable by vaccination, but current policy excludes males from this vaccination, indicating a risk of future deaths in men from this infection.
Action Planned (AI summary) Public Health England will submit work on the cost-effectiveness of extending the HPV vaccination programme to adolescent boys to JCVI by early 2017. In November 2015 JCVI advised that a targeted HPV vaccination programme for MSM aged up to 45 who attend GUM and HIV clinics should be undertaken subject to procurement of the vaccine and delivery of the programme at a cost-effective price.
Peter Embra
Historic (No Identified Response)
2016-0087 1 Mar 2016 Warwickshire
Warwickshire County Council
Concerns summary (AI summary) A local authority failed to act on an urgent GP referral for a patient assessment, leading to a significant one-week delay before a social worker visit.
Max Haigh
Historic (No Identified Response)
2016-0082 1 Mar 2016 West Yorkshire (East)
St James’s University Hospital
Concerns summary (AI summary) Inadequate and incomplete surgical notes failed to detail a ventricular septal defect, risking future surgeons lacking vital information for subsequent operations.
Susan George
Partially Responded
2016-0078 29 Feb 2016 Manchester (North)
Pennine Care NHS Trust Rochdale, Heywood and Middleton Clinica…
Concerns summary (AI summary) Failures included an unreviewed discharge despite deteriorating patient condition, poor discharge coordination, inadequate record-keeping, lack of protocol for inpatient emergency calls, and a critical absence of inpatient clinical psychology services.
Action Planned (AI summary) PCFT is working with the CCG on a programme of Transformation for the whole acute care pathway that will include re-design of the service and a review of skills required. PCFT is producing guidance for staff about access to support and patient rights.
Derrick Twiate
Historic (No Identified Response)
2016-0079 29 Feb 2016 South Lincolnshire
Dispensing Doctors Association Royal Pharmaceutical Society
Concerns summary (AI summary) Dispensing pharmacists continue a practice, contrary to professional advice, of snipping tablets from unit dose packs into multi-dose compliance aids, risking drug integrity and patient safety.
Devinder Seth
All Responded
2016-0075 26 Feb 2016 London (East)
Royal London Hospital
Concerns summary (AI summary) Ward staff lacked clear guidance on recognising and managing the risks and side effects of opiate medication in orthogeriatric patients, leading to unrecognised opiate toxicity.
Action Planned (AI summary) The Pharmacy department at Barts Health NHS Trust is producing guidance for staff relating to the risk of opiate medications, their side-effects and the signs of opiate toxicity, and a 'share the learning' bulletin. Newham University Hospital is planning to review Serious Untoward Incidents reported from 2013 to date to identify if there are any opiate related SUIs and is retraining all nursing staff.
Richard Parkes
Historic (No Identified Response)
2016-0101 26 Feb 2016 Black Country
Black Country Family Practice
Concerns summary (AI summary) Poor GP record-keeping and a rigid policy of refusing to see late patients, even those with known complex medical histories, posed inherent risks to patient care continuity.
Jakovas Fofonovas
All Responded
2016-0077 26 Feb 2016 London Inner (South)
Network Rail
Concerns summary (AI summary) Safety recommendations from a British Transport Police report to restrict public access and enhance safety at a railway bridge remained unaddressed by the time of the inquest.
Action Taken (AI summary) Network Rail demolished and replaced the footbridge at Bostall Manor Way with a new, safer design, including industry standard height railings (1250mm) and acoustic fencing with anti-climb extensions. Old building materials have been removed from the site.
Amy Cooper
Historic (No Identified Response)
2016-0072 25 Feb 2016 Liverpool and Wirral
Department for Health NHS England
Concerns summary (AI summary) Commissioned maternity services lacked compatible, digitally available record-keeping and scan systems, leading to inefficient paper-note transfers and hindering seamless patient care and referrals.
David Palmer
Historic (No Identified Response)
2016-0076 25 Feb 2016 South Lincolnshire
Lincolnshire Police
Concerns summary (AI summary) Unlicensed firearms are often insecurely stored, available for impulsive use. Publicising that surrendering such weapons usually avoids prosecution might encourage their removal.
Betty Addison
Historic (No Identified Response)
2016-0071 25 Feb 2016 Manchester (West)
Cuerden care Homes
Concerns summary (AI summary) A patient at a care home received five additional, unprescribed Dalteparin injections, with no clear explanation for their source or why they were administered.
Marie Rollason
All Responded
2016-0100 24 Feb 2016 Black Country
Royal Wolverhampton, New Cross Hospital
Concerns summary (AI summary) The report identifies a potential lack of recognition of the deceased's repeated loss of consciousness prior to hospital readmission.
Action Taken (AI summary) The Royal Wolverhampton NHS Trust confirms that clinical staff in the Emergency Department receive regular training in the identification and treatment of pulmonary embolism. A training session on venous thromboembolism has recently been delivered, and ECG interpretation is included in training sessions.
Wilfred Pearson
All Responded
2016-0088 24 Feb 2016 Manchester (South)
Tameside Hospital NHS Foundation Trust
Concerns summary (AI summary) Concerns include outdated treatment protocols, poor medical notes, inadequate care escalation, and severe junior medical staff shortages. The patient was also unlawfully detained.
Action Taken (AI summary) Tameside Hospital NHS Foundation Trust revised the Status Epilepticus Policy twice since Mr. Pearson's admission, including references to recent guidance in the Lancet Medical Journal. They have also provided MCA/DOLS training sessions and promote DOLS principles through internal communications.
Freda Weston
All Responded
2016-0080 23 Feb 2016 Manchester (South)
Stockport NHS Foundation Trust
Concerns summary (AI summary) Premature discharge, critical delays in antibiotic administration due to severe staff shortages, and staff unfamiliarity with escalation guidelines were identified. Handover sheets were also destroyed.
Action Taken (AI summary) Stockport NHS Foundation Trust will supply Patient Information Leaflets with monitored dosage systems, including a generic medicine patient information leaflet. All wards in the Medicine Business Group have access to electronic handover, and printed handover sheets are shredded at the end of each shift. The Trust is recruiting European registered nurses.