2016

PFD Reports
Reports: 472 Areas: 69

65% response rate (above 63% average).

472 results
Leslie Summerfield
Historic (No Identified Response)
2016-0019 20 Jan 2016 Manchester (South)
Central Manchester NHS Trust
Concerns summary (AI summary) The withdrawal of urgent endoscopy services at a hospital, despite available resources, forces critically ill patients to be transported, causing unnecessary discomfort and potentially aggravating their conditions.
Derek Hare
All Responded
2016-0018 20 Jan 2016 Manchester (South)
Tameside Hospital NHS Trust
Concerns summary (AI summary) The use of two separate patient note systems caused confusion and errors, and repeated denials of hospital appointments led to a significantly delayed diagnosis of a critical abdominal issue.
Action Taken (AI summary) The Trust has provided clarification on the issue of separate sets of notes and the actions taken to address the Senior Coroner's concerns, including reinforcement of the record-keeping policy.
Steven Rogers
All Responded
2016-0017 20 Jan 2016 Manchester (South)
Stockport NHS Foundation Trust
Concerns summary (AI summary) A doctor discharged a patient without seeing them, indicating a fundamental lack of understanding of discharge importance, and staff erroneously omitted long-acting insulin during the patient's hospital stay.
Action Planned (AI summary) The Trust is moving towards a Trust-wide electronic patient record (EPR) which should resolve issues around paper charts. In the meantime, a specialist "Task & Finish Group" is in place to further review the issue and develop an effective interim solution.
Lee Rushton
Historic (No Identified Response)
19 Jan 2016 Liverpool and Wirral
102 Petty France SW1H 9AJ The Secretary of State for Justice
Concerns summary (AI summary) There is a lack of clear policy and training regarding how ACCT care plans and mandatory reviews should integrate with Cell Sharing Risk Assessments requiring single cell occupancy for prisoner protection.
Irene Pearson
Partially Responded
2016-0014 19 Jan 2016 Manchester (South)
Churchgate Surgery Macmillan Cancer Support Takeda UK Ltd
Concerns summary (AI summary) Matrifen patch warnings about hot baths are obscure and vague, and dangerous advice was given to use baths for patch removal. Poor liaison on opiate prescribing and unclear, scanty GP electronic notes contributed to unsafe care.
Action Planned (AI summary) Takeda has reported the coroner's concerns about heat exposure and fentanyl patches to Johnson and Johnson and requested they conduct a review to determine if changes to product information are required. Following the inquest, the Macmillan team sent a 'Trust Alert' out to all hospital and community staff reminding them not to advise patients to take a bath to aid removal of fentanyl patches.
Norah Fairhurst
All Responded
2016-0012 18 Jan 2016 Manchester (West)
Department for Transport
Concerns summary (AI summary) Older large goods vehicles, not mandated to have Class VI "cyclops" mirrors, have a dangerous blind spot directly in front, making pedestrians invisible to the driver and increasing collision risk.
Action Planned (AI summary) The Department for Transport is working to improve direct and indirect vision for drivers, including international agreement to allow camera systems instead of mirrors, developing aerodynamic HGVs, and working with stakeholders on safer lorry designs.
Jasmine Lapsley
All Responded
2016-0022 15 Jan 2016 North West Wales
EMERGENCY AMBULANCE SERVICE COMMIT-TEE … Welsh Ambulance NHS Trust Welsh Assembly Government
Concerns summary (AI summary) Emergency services in rural NW Wales suffer from a lack of nighttime air support, ineffective rostering and communication for Community First Responders, and inadequate resource planning for seasonal population increases.
Noted (AI summary) This response is not classifiable due to being unreadable. The Welsh Air Ambulance is expanding by an additional helicopter in July 2016 and has funding for three more in early 2017. The Welsh Ambulance Services NHS Trust has piloted hand-held devices to improve communications for community first responders.
Lee Rigby
Historic (No Identified Response)
2016-0011 14 Jan 2016 Manchester (West)
United Response
Concerns summary (AI summary) The report identifies potential risks in resident care, including support workers not having keys for timely access, adequacy of staffing levels, review of risk procedures and staff training.
Arenijus Nedzelskies
Partially Responded
2016-0010 13 Jan 2016 South Lincolnshire
Driver and Vehicle Licensing Agency Home Office
Concerns summary (AI summary) Specific synthetic cannabinoid receptor agonists (5F AKB-48, 5F PB-22) are not controlled substances, and the deceased's chronic misuse was not reported to the DVLA.
Action Taken (AI summary) The Home Office highlights that the Psychoactive Substances Act 2016 restricts the production, supply and importation of psychoactive substances, and notes over 500 new drugs have already been banned. It also mentions toolkits and clinical guidelines for psychoactive substance use.
Anne Scott
Historic (No Identified Response)
2016-0024 12 Jan 2016 Cornwall
Cornwall and Isles of Scilly Safeguardi…
Concerns summary (AI summary) Community care providers lacked training to correctly interpret and act upon data from health monitoring devices, and county-wide safeguarding recommendations for such training remain unconfirmed.
Colin Williams
Historic (No Identified Response)
2016-0008 11 Jan 2016 Cornwall
Cornwall Council Local Adult Safeguardi…
Concerns summary (AI summary) A client with complex health and social needs, exacerbated by alcoholism, experienced "agency blindness" and lacked consistent support due to fragmented services, funding changes, and administrative difficulties.
Nicholas Milligan
Historic (No Identified Response)
2016-0007 11 Jan 2016 Cornwall
British Maritime Federation Royal Yachting Association
Concerns summary (AI summary) The increasing speed and power of power boat leisure craft creates additional risks that users should be aware of to prevent accidents.
Emily Milligan
Historic (No Identified Response)
2016-0007-wp25057 11 Jan 2016 Cornwall
British Maritime Federation Royal Yachting Association
Concerns summary (AI summary) The increased speed and power of modern power boat leisure craft introduce additional risks, requiring greater awareness from users to prevent accidents.
Robin Brett
Historic (No Identified Response)
2016-0013 11 Jan 2016 Wiltshire and Swindon
Great Western Hospital NHS Foundation T…
Concerns summary (AI summary) A missed steroid dose went unnoticed due to a lack of system alerts on both paper and electronic drug charts for patients on long-term steroid therapy.
Norman Dorn
Historic (No Identified Response)
2016-0006 8 Jan 2016 Cornwall
Care Quality Commission Cornwall and Isles of Scilly Safeguardi…
Concerns summary (AI summary) Cornwall care homes may lack adequate or updated policies for recognising and confirming death and for resuscitation, with staff often lacking awareness and proper training.
Stefen Boswell
All Responded
2016-0005 8 Jan 2016 Shropshire, Telford and Wrekin
West Mercia Police
Concerns summary (AI summary) Inconsistent police pursuit policies between local and national guidelines on wrong-way driving, coupled with inadequate communication systems for critical pursuit details, created unnecessary risks.
Action Taken (AI summary) West Mercia Police and Warwickshire Police have harmonised policies and procedures with the Authorised Professional Practice (APP) for police pursuits. All police vehicles entering service are now fitted with an Information Data Recorder (IDR) with plans to roll out a new telematics system and dash cams.
Joanne French
Historic (No Identified Response)
2016-0004 7 Jan 2016 West Sussex
Sussex Partnership NHS Trust
Concerns summary (AI summary) Early patient discharge was hampered by unclear assessment requirements, a failure to include family input in decision-making, and inaccurate or incomplete discharge assessment notes.
Thomas Burchell
Partially Responded
2016-0002 4 Jan 2016 Plymouth Torbay and South Devon
Hospital NHS Trust Derriford Hospital Borchardt Medical Centre
Concerns summary (AI summary) Inadequate and incomplete medical and nursing record-keeping, particularly a poorly maintained seizure chart, failed to accurately document a patient's critical seizure events.
Action Taken (AI summary) The practice changed its policy so staff must add a code to computerised records the same day they arrive, alerting clinicians. A clinical meeting reviewed NICE and local guidelines for suspected brain tumours; clinicians added reflections to appraisal documents.
Matthew Wood
Partially Responded
2016-0001 4 Jan 2016 London Inner South
Civil Aviation Authority Department for Transport London Heliport
Concerns summary (AI summary) There is no policy of reporting anything encroaching flight paths to the Heliport; the London Heliport should be a safeguarded aerodrome. The local planning authority did not respond to concerns.
Action Planned (AI summary) The London Heliport is pursuing officially safeguarded status and working with the CAA/EASA, local government, and NATS. They are awaiting a response from the DfT regarding the case for official safeguarding. The CAA is reviewing the safety of onshore helicopter operations in the UK, will work with the helicopter community, and is planning a seminar on safety culture for the commercial helicopter industry. They will also actively engage with the DfT and DCLG regarding building obstacle impact assessments.
Peter Barnes
Partially Responded
2016-0001-wp25050 4 Jan 2016 London Inner South
Civil Aviation Authority Department for Transport London Heliport
Concerns summary (AI summary) Inadequate planning policies for tall buildings around the London Heliport fail to ensure safety, lacking in-depth consultation with the Heliport and official safeguarding measures, despite clear risks to flight paths.
Action Planned (AI summary) • The London Heliport has continued its correspondence with both CAA and DfT in order to provide information to progress consideration of official safeguarding of the London Heliport and assist them with implementation of AAIB report recommendation 2014-30. • The DfT will treat the email as a formal application for official safeguarding whilst asking for further documentary evidence to support the application. • The DfT will consult the CAA and the Department for Communities and Local Government to determine what other measures, if any, are available to ensure that local planning authorities give due regard to safeguarding concerns the London Heliport when granting planning permission. • The Flight Operations team is conducting a review of the safety of onshore helicopter operations in the UK this year. • The review will include a post implementation review of the Standardised European Rules of the Air (SERA). • The CAA will work with the helicopter community to consider whether there are any recommendations or industry best practice that could be incorporated into regulation or regulatory guidance material.
Mark Holdsworth
Historic (No Identified Response)
2016-0003 4 Jan 2016 Central Lincolnshire
Lincolnshire Police
Concerns summary (AI summary) Police failed to communicate critical information about the deceased's recent suicide threat to arresting officers and custody staff, resulting in an incomplete risk assessment upon release.
Gary Peel
Historic (No Identified Response)
4 Jan 2016 West Yorkshire (West)
SUSTRANS
Concerns summary (AI summary) The need for deterrent measures on viaduct walls should be reviewed to prevent future deaths from individuals jumping.