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
Timothy Jones
Partially Responded
2016-0421 24 Nov 2016 Birmingham and Solihull
Bright and Hove Clinical Commissioning … Pavillions Richmond Medical Centre +1 more
Concerns summary (AI summary) GP practice had poor record-keeping, unclear home visit request procedures, misclassified clinical tasks as 'admin', and a policy discouraging home visits for complex patients, leading to inadequate assessment.
Action Planned (AI summary) The CCG will send a communication and learning alert to all Solihull member practices highlighting concerns and learning in relation to recording requests for home visits, GP home visit policies, and classifications of administrative tasks. The CCG will ask the Local Medical Committee to discuss with its members the consideration of a Solihull wide home visiting policy and the BAAG to consider the inclusion of aspiration pneumonia within the local version of the Primary Care Guidelines.
Flavio Pizarro
Historic (No Identified Response)
2016-0419 23 Nov 2016 Manchester (North)
Canal and River Trust
Concerns summary (AI summary) Lack of warning signs about swimming dangers and absence of safety aids at canal locks, despite previous assurances, creating ongoing risks for children playing near the water.
Patrick Steer
All Responded
2016-0427 23 Nov 2016 Manchester (West)
Warrington, Wigan and Leigh NHS Trust
Concerns summary (AI summary) Significant communication breakdown and lack of liaison between different specialist medical teams (surgical and coronary care) when providing shared patient care, risking adverse treatment outcomes.
Noted (AI summary) Response could not be classified due to illegible document.
Frazer Livesey
All Responded
2016-0418 21 Nov 2016 Cumbria
Impact Housing Association
Concerns summary (AI summary) Defective window stays prevented emergency escape from inside, potentially contributing to the deceased's death and a friend's injuries.
Action Planned (AI summary) Impact will survey all residential properties with staff on site by the end of March 2017 to identify window styles and sizes, and will commence removing fixed restrictors and replacing them with override-able restrictors in April 2017, completing by end-March 2018, prioritising based on risk and funding availability.
Denis Plater
Historic (No Identified Response)
21 Nov 2016 Mid Kent and Medway
MEDICSPRO MEDWAY NHS FOUNDATION TRUST
Concerns summary (AI summary) Incomplete medical records, an agency nurse's failure to correctly apply and escalate patient conditions using the NEWS scoring system, and inadequate monitoring of agency staff training.
Brian Mills
All Responded
2016-0416 17 Nov 2016 Hertfordshire
East of England Ambulance Service
Concerns summary (AI summary) Consistently high levels of outstanding emergency calls and excessively long waiting times, far exceeding target response times, pose a significant risk.
Action Taken (AI summary) The trust is delivering training to Coroner's Officers around the country in relation to the coding and resourcing of 999 calls. It has also increased clinicians in the Emergency Operations Centres, introduced a process to release ambulance crews from queues in A&E, and is implementing a revised operating model with a new clinical career pathway.
Christopher MacMorland
All Responded
2016-0415 16 Nov 2016 Portsmouth and South East Hampshire
Portsmouth Hospitals NHS Trust
Concerns summary (AI summary) Despite being under the care of gastroenterologists, the patient was not treated in a specialist gastroenterology ward despite multiple requests, and consultant requests for patient transfer to specialist wards are commonly not implemented.
Action Taken (AI summary) The Trust implemented a 'buddy' ward system where patients of certain specialties are cohorted only into the appropriate specialist ward or specific buddy ward.
David Knight
All Responded
2016-0414 14 Nov 2016 Cornwall and the Isles of Scilly
Department for Health NHS England
Concerns summary (AI summary) National bed shortages led to out-of-county mental health placement, resulting in inadequate risk assessment for S17 leave, poor communication, and lack of family involvement.
Action Planned (AI summary) The Department of Health is working towards eliminating clinically unnecessary out of area placements for adult acute mental health care by 2020/21 and reducing significantly delayed transfers of care and is committed to community-based mental health pathways of care. NHS England's adult mental health programme is taking a whole system approach including developing access and quality standards for acute mental health care, reducing out of area placements and developing local multi-agency suicide prevention plans.
Margaret Wakefield
All Responded
2016-0413 14 Nov 2016 Cornwall and the Isles of Scilly
Royal Cornwall Hospital
Concerns summary (AI summary) Critical care haemofiltration was unavailable in a timely manner, leading to patient deterioration and death, indicating a failure in access and contingency planning for vital treatments.
Action Taken (AI summary) The Trust has increased the funded establishment for registered nurses in the Critical Care Unit, increased hours of operation for the Critical Care Outreach Team to cover the full 24 hour period, implemented the SAFER Patient Flow Bundle, introduced a new Patient Flow Policy, and appointed a Clinical Director with responsibility for maximizing patient flow.
Martyn Watkins
Partially Responded
2016-0409 14 Nov 2016 Avon
Avon and Wiltshire Mental Health Partne… Care Quality Commission
Concerns summary (AI summary) Concerns highlight a need for thorough review of the Trust's care, and for the CQC to ensure all deficiencies in care and facility safety on Aspen Ward are identified and addressed.
Action Taken (AI summary) The Trust had learnt from the death and implemented changes to manage future risks on Aspen Ward, though details of changes not provided in this extract.
Benjamin Wylie
Partially Responded
2016-0407 14 Nov 2016 Berkshire
Federation of Piling Specialists Health and Safety Executive Soilmec Limited
Concerns summary (AI summary) Design flaws in piling rig grease nipples, inadequate warnings, insufficient training, and manual deficiencies pose significant operator safety risks.
Action Planned (AI summary) The HSE will issue a Safety Alert regarding the risks associated with grease being expelled from grease nipples at high pressure, the risks associated with the re-use of damaged hydraulic components, and the need for proper training of persons required to undertake track tensioning.
Melanie Lowe
All Responded
2016-0404 11 Nov 2016 Essex
North Essex University NHS Trust
Concerns summary (AI summary) The Trust's action plan is inadequate, lacking specific detail, supporting evidence, and requiring a far more rigorous approach to prevent future deaths.
Action Taken (AI summary) The Trust updated its action plan with supporting evidence and will complete a further audit to ensure that all the actions identified have been embedded into practice.
Karen Thorne
All Responded
2016-0408 11 Nov 2016 Manchester (West)
Department of Health and Social Care
Concerns summary (AI summary) Severe delays in neuroradiology reporting due to a national radiologist shortage prevent timely diagnosis and treatment, necessitating an increase in training positions.
Action Planned (AI summary) Health Education England is working in partnership to develop a shared vision and strategy for the diagnostics workforce and is committed to recruiting more trainees into diagnostics, including radiologists.
Daniel Willington
All Responded
2016 10 Nov 2016 Carmarthenshire  and Pembrokeshire
Maritime and Coastguard Agency
Concerns summary (AI summary) The lack of mandatory personal flotation device wearing on fishing vessel decks at sea unnecessarily increases the risk of death.
1 response from Maritime and Coastguard Agency
Gareth Willington
All Responded
2016-wp25435 10 Nov 2016 Carmarthenshire  and Pembrokeshire
Maritime and Coastguard Agency
Concerns summary (AI summary) The lack of mandatory personal flotation device wearing on fishing vessel decks at sea unnecessarily increases the risk of death.
1 response from Maritime and Coastguard Agency
Mark Yafai
Historic (No Identified Response)
2016-0403 9 Nov 2016 Coventry
Office of The Police and Crime Commissi… West Midlands Police
Concerns summary (AI summary) Custody policies use unclear terminology for drug influence, granting officers excessive discretion in risk assessments and leading to inadequate Health Care Professional involvement.
Simon Harper
Historic (No Identified Response)
2016-0410 9 Nov 2016 South Yorkshire (West)
Department for Health
Concerns summary (AI summary) Insufficient and undocumented training for nurses on portable oxygen cylinder use, following task reassignment, resulted in a critical error during patient transfer.
Michelle Lawrence
Historic (No Identified Response)
2016-0412 8 Nov 2016 London Inner (West)
DWF LLP Metropolitan Police MOJ +1 more
Concerns summary (AI summary) Key concerns include lack of independent investigations for deaths after private custody, inadequate concealment questioning, and insufficient strip-search facilities.
Maurice Isaacs
Partially Responded
2016-0411 7 Nov 2016 South Wales Central
Cardiff and the Vale University Health … Minister for Health Welsh Assembly Gove…
Concerns summary (AI summary) Inadequate falls risk assessment, inconsistent 1:1 supervision, understaffing, and untrained staff performing neurological observations contributed to multiple falls and missed assessments.
Action Taken (AI summary) Following an internal investigation, the UHB has already completed an action plan including measures to improve falls risk assessment and recording, neurological observations, and escalation procedures. A Falls Delivery Group has also been established to review and monitor practice, and the Regulation 28 report will be shared with all Clinical Boards.
Michaela Thompson
All Responded
2016-0392 2 Nov 2016 West Yorkshire (East)
Leeds and York Partnership NHS Foundati…
Concerns summary (AI summary) Multi-disciplinary team meetings were inadequately documented, and critical patient phone calls were not recorded or communicated to relevant mental health staff.
Action Planned (AI summary) The trust acknowledges the need for clear documentation of MDT meetings and recording phone calls. They propose a meeting to discuss the practicalities of recording calls before implementing a solution.
William Marson
All Responded
2016-0394 2 Nov 2016 Wiltshire and Swindon
Avon Care Home Limited
Concerns summary (AI summary) Staff were inadequately trained in ventilator use, unaware of the manual's location, and the provided extracts lacked crucial information for fault recognition and rectification.
Action Planned (AI summary) The care home outlines a process for managing residents requiring specialist equipment or interventions, including staff training, competency assessments, clear documentation, and reviews. This process will be communicated and implemented across all Avon Care Homes.
Ivy Morris
Historic (No Identified Response)
2016-0393 2 Nov 2016 Shropshire, Telford and Wrekin
Shrewsbury and Telford NHS Trust
Concerns summary (AI summary) Foetal heart rate was not monitored, midwifery guidelines for CTG assessment and obstetric review were not followed, and a midwife lacked recent experience for an essential procedure.
Trevor Hunking
All Responded
2016-0391 1 Nov 2016 Plymouth Torbay and South Devon
Health Education England
Concerns summary (AI summary) A shortage of Cardiac Intensive Unit Specialist Nurses puts post-operative patients at risk.
Action Planned (AI summary) While primarily stating the employer's responsibility, the response outlines opportunities for collaboration with HEE to support training, development, and retention of specialist critical care nurses, including protecting CPD budgets and evaluating nursing associates.
Anthony McManus
Historic (No Identified Response)
2016-0388 31 Oct 2016 Milton Keynes
Priory Group
Concerns summary (AI summary) The system of patient observations was flawed, with nurses performing non-random, fixed-time checks, some observations not conducted, and charts completed retrospectively.
Frederick Squires
All Responded
2016-0389 31 Oct 2016 Milton Keynes
N.I.C.E
Concerns summary (AI summary) A lack of clear clinical guidance on when to reintroduce Warfarin after a head injury risks either premature commencement leading to bleeding, or delayed commencement causing stroke.
Action Planned (AI summary) NICE acknowledges the lack of guidance on when to restart Warfarin after a head injury. They will consider extending the scope of their existing head injury guideline in 2017 to address this.