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
Lisa Day
Partially Responded
2016-0070 23 Feb 2016 London Inner (North)
London Ambulance Services NHS Trust London Central & West Unscheduled Care … St Charles Hospital
Concerns summary (AI summary) The 111 service failed to discuss alternative hospital transport with the patient's friend and did not explain the severe risks of a vomiting illness in a diabetic.
Action Taken (AI summary) LAS agreed a process with NHS 111 to electronically flag calls with clinical concerns; this system was introduced on 14 March 2016. Training bulletin TB 02/16 and flowchart v2.0 give examples of patient conditions to be flagged. London Central & West Unscheduled Care Collaborative (LCW UCC) has raised concerns regarding additional scripting of condition-specific information for type 1 diabetes with the National NHS Pathways team. Changes to internal processes at LAS now result in a priority being applied to green category ambulance dispatch requests when clinical information is passed over by 111 clinicians.
Edith Kirkham
Partially Responded
2016-0068 23 Feb 2016 Manchester (South)
L and M Healthcare Tameside Hospital NHS Trust
Concerns summary (AI summary) Intermediate care suffered from unclear management standards, inadequate staffing, staff failing to understand notes, and a lack of proper handover from the hospital. Vital records were also unavailable.
Noted (AI summary) Illegible response.
Patricia Medland
All Responded
2016-0102 22 Feb 2016 Exeter and Greater Devon
Bampton Surgery
Concerns summary (AI summary) The patient's daughter was unaware of her designated role as a protective factor in the care plan, potentially preventing her from recognising signs of her mother's mental health relapse.
Action Planned (AI summary) The practice agreed to encourage sharing appropriate information with relatives and carers, always discussing this with the patient, and has informed the NHS Northern, Eastern and Western Clinical Commissioning Group of the issues raised for wider sharing.
Clifford Crofts
All Responded
2016-0066 22 Feb 2016 Surrey
Ashford and St Peter’s Hospital Trust
Concerns summary (AI summary) A critical post-operative care plan went missing, and nursing staff faced unsuccessful attempts to escalate care for acute pain. Significant delays occurred in obtaining a CT scan.
Action Taken (AI summary) The Trust has made several changes including no longer undertaking feeding enterostomies on Fridays or weekends, implementing the RIG care plan in radiology, making care plans available on the intranet, and producing an online training module for staff.
Geoffrey Moyse
Partially Responded
2016-0067 19 Feb 2016 Brighton and Hove
Brighton and Hove Clinical Commissionin… Brighton and Hove Integrated Care Servi… Brighton and Sussex University Hospital…
Concerns summary (AI summary) The report raises concerns that were not detailed in the excerpt.
Action Planned (AI summary) Brighton and Hove Integrated Care Service used Mr Moyes' case as an anonymised example for discussion with their Patient Safety Group. They are ensuring all teams who offer patient choice are implementing protocols for when patients choose to delay their care. The CCG has issued a performance notice to Optum (Referral Management System provider) and is closely monitoring their performance. They will also review service specifications with independent sector providers to ensure clarity around handling incidental findings of cancer and links to multidisciplinary teams.
Brenda Morris
All Responded
2016-0065 19 Feb 2016 London Inner (North)
East London NHS Foundation Trust
Concerns summary (AI summary) Lack of communication with the partner regarding leave conditions and no routine family feedback were identified. There was also confusion about doctor authorisation for unplanned leave and substandard documentation.
Action Planned (AI summary) The Trust has developed an 'In-patient leave agreement' and an 'In-patient leave checklist' to be completed before a patient goes on leave, with a pilot on older persons wards aiming for full introduction by the end of the month and quarterly audits starting in July 2016.
Euphemia Aldred
Historic (No Identified Response)
2016-0062 18 Feb 2016 Blackburn, Hyndburn and Ribble Valley
East Lancashire Healthcare NHS Trust
Concerns summary (AI summary) The report raises concerns that were not detailed in the excerpt.
Matthew Crowley
Historic (No Identified Response)
2016-0063 17 Feb 2016 Mid Kent and Medway
Maidstone and Tunbridge Wells NHS Trust
Concerns summary (AI summary) A&E delays due to short-staffing prevented timely triage and immediate senior doctor review. There was a delay in patient ownership, decision-making, and communication failure during transfer to ITU.
Vanessa Dadswell
Partially Responded
2016-0060 17 Feb 2016 Surrey
Sussex Partnership NHS Foundation Trust West Sussex County Council
Concerns summary (AI summary) Mental health services lacked an intermediate referral option between 4-hour A&E assessment and 5-day appointments, preventing timely intervention for patients requiring urgent but not emergency care.
Action Taken (AI summary) The triage system has been improved with direct bookable Priority Appointment slots for Triage Team Leaders and senior staff oversight. A protocol encompassing the improved system is being drafted throughout Coastal West Sussex CDS, and learning from the inquest will be presented to the Adult Management Board.
Philip Denning
Historic (No Identified Response)
2016-0058 16 Feb 2016 Nottinghamshire
Framework CRI NHS England +1 more
Concerns summary (AI summary) Fragmented services for patients with co-occurring substance misuse and mental health issues, a lack of information sharing, and primary care's misunderstanding of available help pose significant risks.
Eric Gaskell
All Responded
2016-0057 16 Feb 2016 Manchester (West)
Royal Bolton Hospital
Concerns summary (AI summary) Hospital policy restricts doctors to issuing only hospital-specific prescriptions. This, combined with a non-24-hour pharmacy, prevents A&E patients from accessing critical medication outside of pharmacy hours.
Action Planned (AI summary) The hospital will review the existing stock list of over-labelled and pre-packed medicines with the Accident and Emergency Department by 31 May 2016. They also plan to advertise the opening hours and process for obtaining medicines out of hours with the Accident and Emergency Department in April 2016.
Adam Withers
All Responded
2016-0059 15 Feb 2016 Surrey
Department of Health and Social Care NHS England Surrey and Borders Partnership NHS Trust
Concerns summary (AI summary) Psychiatric nursing staff failed to sufficiently record patient observations and interactions, lacking understanding of their importance, and made unlabelled retrospective entries after death, compromising patient assessment and care.
Noted (AI summary) The Department of Health states that original paper records should not be destroyed after a patient's death where the death may be subject to investigation. They state that the NHS Records Management Code of Practice is currently under review. The Trust has instigated work to improve the quality of engagement with adult inpatient services using a process of purposeful engagement and revised their Observation Policy to include clearer guidance on recording all clinical interventions. This is a joint strategic statement from NHS Improvement and the CQC about working together to ensure financial rigour while improving quality outcomes for patients. It describes how the two organisations will work together in the future.
James Robertson
Historic (No Identified Response)
2016-0053 15 Feb 2016 Portsmouth and South East Hampshire
Healthcare Management Solutions Ltd
Concerns summary (AI summary) Carers were not required to accurately log check times, delaying understanding of events. DNACPR status was not on shift handover notes, and the emergency resuscitation pack lacked essential equipment.
James Barrett
Partially Responded
2016-0052 15 Feb 2016 Portsmouth and South East Hampshire
Hampshire Constabulary Police Police Crime Commissioner for Hampshire
Concerns summary (AI summary) Ineffective missing persons searches were hampered by reliance on volunteer mapping systems rather than a police stand-alone system, and the lack of tracking devices for searchers.
Action Planned (AI summary) Hampshire Constabulary has submitted a business case for the purchase of a MAPYEX system. Procurement Services has been requested to provide information to identify a timeline for purchase, training requirements and subsequent go-live.
Belinda Wise
Partially Responded
2016-0049 15 Feb 2016 Leicester City and South Leicestershire
Health and Safety Executive Oadby and Wigston Borough Council Sainsbury’s
Concerns summary (AI summary) A lift lacked signs or auditory warnings for its rear doors, which were indistinguishable from the interior, posing a significant safety risk to passengers unaware of their opening mechanism.
Action Planned (AI summary) Sainsbury's is awaiting a response from the HSE regarding lift design, installation, and signage standards and will then take appropriate action at the Glen Road store and other similar stores. The HSE will raise the incident as a concern at a European forum for lifts in 2016 and with the relevant BSi committee, for consideration in future revision of the Lifts Directive.
Eileen Thompson
Partially Responded
2016-0051 15 Feb 2016 Warwickshire
George Eliot Hospital NHS Trust NHS England Welsh Government
Concerns summary (AI summary) A specific bed design flaw allows inner wheels to remain unlocked when the bed is placed against a wall, creating a risk of the bed moving and potentially injuring patients.
Disputed (AI summary) NHS Improvement will work with the College of Occupational Therapists and other stakeholders to drive the development of new national resources. Once new resources are available, they will explore the option of issuing a stage 2 alert to signpost to the new resources. ArjoHuntleigh disputes the need for further action, stating that the root cause was the combination of device use and the patient's health state, and that current warnings are adequate. They conducted a simulation and PMS review but found no similar incidents globally.
Peter Tye
All Responded
2016-0050 15 Feb 2016 Plymouth, Torbay and South Devon
Department of Health and Social Care
Concerns summary (AI summary) Misplacement of a central venous line into an artery highlighted a need for wider promulgation of improved insertion and removal procedures to reduce deaths.
Action Planned (AI summary) The FICM and ICS Joint Standards Committee are discussing how to monitor incident reports and publicise lessons learnt, and Mr. Tye’s case will be discussed at the next meeting where a mechanism for cascading this information will be agreed.
Joseph Sarkozi
Partially Responded
2016-0055 12 Feb 2016 Avon
Avon Fire and Rescue Services Chief Fire & Rescue Adviser
Concerns summary (AI summary) Fire officers prematurely concluded dust on ceiling lights caused a fire without positive evidence, highlighting a need for improved investigative practices and national learning dissemination.
Action Planned (AI summary) Avon Fire & Rescue will include the incident scenario in training packages for operational crews, notify personnel via the "Fire Alert" system, amend the Domestic and Residential Fires risk card, and distribute the Fire Alert via CFOA to raise awareness.
Margaret Hions
All Responded
2016-0047 12 Feb 2016 Carmarthenshire and Pembrokeshire
West Wales General Hospital
Concerns summary (AI summary) Inadequate adherence to clinical pharmacy policy regarding tinzaparin prescribing, blood level monitoring, and creatinine clearance monitoring posed risks to patient safety.
Action Planned (AI summary) The Health Board has reviewed its practice in the prescribing of tinzaparin and monitoring of blood levels, and a revised guideline has been produced, subject to consultation and approval; the importance of monitoring creatinine clearance is being reiterated to clinicians and pharmacists.
Terence  Brooks
Historic (No Identified Response)
2016-0056 12 Feb 2016 Avon
Bath and North East Somerset Clinical C… Care Quality Commission Royal United Hospitals Bath NHS Foundat…
Concerns summary (AI summary) The hospital misinterpreted Legionella test results and lacked a clear procedure for investigating outbreaks, leading to an erroneous conclusion about the infection source.
Marilyn Anson
Historic (No Identified Response)
2016-0054 12 Feb 2016 Avon
North Somerset Clinical Commissioning G… North Somerset Community Partnership Weston Area Health NHS Trust
Concerns summary (AI summary) Delays in urgent 'hot foot' clinic referrals, coupled with inadequate patient prioritisation and resource allocation, led to patient deterioration and death.
Sandra Wood
All Responded
2016-0048 12 Feb 2016 North West Kent
Maidstone and Tonbridge Wells NHS Trust
Concerns summary (AI summary) The NHS Trust's lack of routine weekend CT scan facilities led to a critical delay in an urgent scan, proving too late for the patient.
Noted (AI summary) The Trust states they do have facilities to provide CT scans during weekends and that scans are carried out on all patients that require them, based on a clinical decision; the Trust has taken the opportunity to re-iterate the processes in place to clinical staff regarding the availability of CT scanning 24/7 for urgent cases.
Marion Howes
Historic (No Identified Response)
2016-0046 11 Feb 2016 Brighton and Hove
Brighton and Sussex University Hospital…
Concerns summary (AI summary) No specific concerns text was provided to summarise.
Eitvydas Zdanys
All Responded
2016-0043 9 Feb 2016 Bedfordshire and Luton
Bedfordshire Police
Concerns summary (AI summary) Police officers responding to a road traffic incident lacked basic life support training, rendering them unable to assess or resuscitate a seriously injured motorcyclist.
Action Planned (AI summary) The officers involved will shortly receive training on when and how to administer CPR, and all officers will be reminded during their annual refresher training of when it is necessary and appropriate to commence CPR; all officers will be trained further as to the management of scenes following a RTC where a major injury is suspected.
David Hughes
All Responded
2016-0040 9 Feb 2016 Leicestershire City and South Leicestershire
Leicestershire Partnership NHS Trust
Concerns summary (AI summary) Critical patient observations were inconsistently performed and recorded, fluid balance charts were meaningless, patient bedrooms lacked call bells, and nursing staff showed insufficient understanding of physical illness signs.
Action Planned (AI summary) The Trust has completed a cycle of recruitment into new general nurse posts at the Bradgate Unit and has commenced a second cycle; the service will review this strategy and consider other workforce diversity options if there are no applicants again.