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)
Clear 222 results
Wayne Cornlouer
All Responded
2016-0356 12 Oct 2016 Dorset
HMP Portland
Concerns summary (AI summary) An emergency coding system for medical emergencies was not initially in Night Orders, raising concerns if all staff are now aware of its recent inclusion and proper use.
Action Taken (AI summary) A notice to staff was re-issued on 28 September 2016 reminding staff about emergency codes and ambulance requests; the local emergency code protocol has been distributed and displayed. The induction programme for new staff is being updated to include guidance on the local emergency protocol and all existing staff will receive a personal briefing.
Tyrone Lock
All Responded
2016-0355 11 Oct 2016 Shropshire, Telford and Wrekin
National Police Air Service West Mercia Police
Concerns summary (AI summary) Police failed to classify a vulnerable person exhibiting clear distress as such, treating him as an absconding suspect. This led to a missed opportunity for a crucial helicopter deployment, potentially preventing death.
Action Planned (AI summary) NPAS will support West Mercia Police in a critical incident debrief and offer opinions on improvements in awareness or training. They will also discuss the matter with the NPAS Independent Assurance Group and the NPAS Local Strategic Board. West Mercia Police has undertaken an extensive programme to raise awareness of vulnerability, piloting a programme in Telford and rolling it out across West Mercia in 2017. They have also provided clear guidance relating to NPAS call out procedures and capability to all officers.
Vichal Tonpradit
All Responded
2016-0380 11 Oct 2016 Hertfordshire
Highways England
Concerns summary (AI summary) A raised section of tarmac separating a motorway slip road from the main carriageway caused a motorcyclist to fall, leading to fatal injuries.
Action Taken (AI summary) National Highways obscured a redundant road marking with bituminous material. A Smart Motorway scheme is planned for 2020 that will alter the road layout.
Ann Hardman
All Responded
2016-0350 10 Oct 2016 Isle of Wight
Isle of Wight NHS Trust
Concerns summary (AI summary) The DVT scan protocol relies on GP referrals for follow-up, risking patients missing re-scans. An automatic re-booking system from the ultrasound department is needed to improve compliance.
Action Taken (AI summary) The Isle of Wight NHS Trust now books a repeat ultrasound scan for patients with a D-Dimer positive blood result but a negative initial scan, and will inform the GP if the patient doesn't attend. A joint letter with a GP has been sent to all Island GPs to inform them of this new procedure.
Colin Wellings
All Responded
2016-0348 5 Oct 2016 South Wales Central
Department for Transport
Concerns summary (AI summary) Current legislation exempts older, powerful vehicles from essential safety requirements like helmets or seatbelts, posing significant risks to riders and other road users.
Noted (AI summary) The Department for Transport acknowledges the concerns, explains current regulations regarding tricycle helmets and licensing, and notes that changes to collision reporting codes and helmet regulations are not planned but will be kept under review.
Amy El-Keria
All Responded
2016-0347 3 Oct 2016 East Sussex
Department of Health and Social Care Hounslow Borough Council
Concerns summary (AI summary) Hounslow Social Services misunderstood their ongoing welfare role for a child placed far from home and failed to assess for support, neglecting family contact issues.
Action Planned (AI summary) NHS England and Health Education England (HEE) are working to improve the capacity and capability of the workforce delivering mental health care for children and young people. The Royal College of Psychiatrists and NCCMH were commissioned in 2016 to develop guidance on staffing for inpatient and community mental health care for children, young people and adults. NHS England and Health Education England are working to improve the capacity and capability of the workforce delivering mental health care for children and young people. NHS England commissioned the Royal College of Psychiatrists and National Collaborating Centre for Mental Health (NCCMH) to develop guidance on staffing. The London Borough of Hounslow has updated its Thresholds Guidance & Assessment Protocols, with specific reference to children in need under S17 of the Children Act 1989 for those in hospital or other settings. Staff will receive briefings to reinforce awareness of their duties and the importance of family contact. Priory Group has enhanced observation recording forms and clarified its policy on information sharing. Monthly simulation drills are undertaken for BLS and ILS. A new tool for better assessment of behavioural risk prior to admission is being introduced with staff briefings underway. Priory Group has enhanced observation recording forms and clarified its policy on information sharing. Monthly simulation drills are undertaken for BLS and ILS. A new tool for better assessment of behavioural risk prior to admission is being introduced with staff briefings underway.
Denis Cronin
All Responded
2016-0332 16 Sep 2016 Leicester City and South Leicestershire
British Sub Aqua Club Dulwich Dive Club
Concerns summary (AI summary) Significant failings in dive training, planning, and risk assessment led to an unqualified diver teaching an inexperienced individual. Important safety information was ignored, and equipment design posed a release risk.
Action Planned (AI summary) BSAC is rewriting its core Diver Training Programme to include a skills sheet for instructors to sign off individual skills. BSAC will also produce a guidance document on weightbelt removal and remind instructors of the importance of teaching this skill. Dulwich BSAC 102 will develop a means of recording partial training completion. They will also seek clarification from BSAC regarding sequencing of lessons and guidance on DSMB use.
Arthur Adley
All Responded
2016-0358 13 Sep 2016 London (North)
Department of Health and Social Care
Concerns summary (AI summary) Safeguarding systems in care homes were inadequate to prevent a resident who posed a risk to others from causing harm.
Noted (AI summary) The Department of Health acknowledged the concerns and forwarded the report to the Care Quality Commission (CQC), the independent regulator of health and adult social care providers in England.
Louise Turner
All Responded
2016-0322 7 Sep 2016 Exeter and Greater Devon
Department of Health and Social Care Devon Partnership Trust NHS Northern Eastern and Western Clinic…
Concerns summary (AI summary) Inadequate post-discharge mental health care, ineffective support systems, and inappropriate expectations for patients to initiate contact were identified. Devon also lacks female intensive psychiatric care beds.
Action Planned (AI summary) The CCG outlines expected service responses from Devon Partnership NHS Trust related to safe service delivery and care planning. A proposal to build a local 10-bedded PICU facility at Wonford Hospital, adjacent to the Cedars Mental Health Acute Unit by April 2018, was reviewed and agreed.
Christopher Jones
All Responded
2016-0319 7 Sep 2016 North Wales (East and Central)
Betsi Cadwaladr University Health Board
Concerns summary (AI summary) Inadequate mental health care planning resulted in patients being without consultant review for extended periods post-discharge. Increased demand on services also created staff cover deficiencies.
Action Taken (AI summary) The Division produced a multi-agency document which became operational in August 2013 and has been reviewed regularly. MHM administrators send a report to managers of all CTPs due for review, 3 months in advance with a view to avoiding any CTPs becoming out of date and patients have reviews in a timely manner.
David Wade
All Responded
2016-0324 6 Sep 2016 Blackburn, Hyndburn and Ribble Valley
NHS England
Concerns summary (AI summary) The provided text is incomplete and does not detail specific concerns.
Noted (AI summary) NHS England highlights the existence and availability of the 'yellow book' which sets out symptoms requiring urgent medical advice for patients on anti-coagulant therapy. They emphasize the importance of not deterring patients from taking necessary anticoagulants.
Samantha Hopkins
All Responded
2016-0316 6 Sep 2016 Portsmouth and South East Hampshire
South Central Ambulance Service Warwick Medical School
Concerns summary (AI summary) Critical trial exclusions, such as for pregnant women, were overlooked due to insufficient prominence on drug packet warnings and lack of guidance for highlighting these exclusions.
Action Planned (AI summary) New labels detailing exclusion categories will be placed on further issues of the trial drug packs. SCAS has committed that by January 2017 that all trial drugs in circulation will have the new labels affixed to the trial drugs bag or external bag. The University has instructed participating Ambulance Services to issue a reminder to all participating staff, to reiterate the inclusion and exclusion criteria for the trial. Compliance with this instruction shall be specifically audited during annual Quality Assurance Site visits.
Harry Gill
All Responded
2016-0323 30 Aug 2016 Blackburn, Hyndburn and Ribble Valley
NHS Digital
Concerns summary (AI summary) The NHS 111 vomiting pathways were not robust, leading to inappropriate responses in most calls and failing to ensure adequate patient care.
Action Taken (AI summary) NHS Pathways has amended the vomiting questions to be more specific, focusing on the nature of the vomit and the presence of coffee ground-like material. They have also enhanced the site training package for managing vomiting.
Raymond Woodward
All Responded
2016-wp25391 26 Aug 2016 Birmingham and Solihull
Medicines and Healthcare Products Regul…
Concerns summary (AI summary) The risk of adverse cardiovascular reactions to Buscopan, especially in patients with ischaemic heart disease, is not widely known, and the Summary of Product Characteristics (SPC) for intravenous Buscopan could be more specific regarding this risk.
Action Taken (AI summary) The Summary of Product Characteristics (SmPC) for Buscopan Ampoules has been updated to more clearly communicate and minimise the risk of serious adverse reactions in patients with underlying cardiac disease. These recommendations have also been communicated to healthcare professionals through an article in the MHRA newsletter, Drug Safety Update.
Maureen Flynn
All Responded
2016-0310 26 Aug 2016 Manchester (South)
Stepping Hill Hospital
Concerns summary (AI summary) A critical falls risk assessment was not completed, and staff were unaware of this omission due to a lack of system to alert them. The patient safety investigation also failed to identify this issue.
Action Taken (AI summary) The Trust has completed actions detailed in an updated Patient Safety Investigation report, including an audit of falls risk assessments, enhanced falls sensors, and sharing investigation findings via ward newsletters, with attention drawn to the need for fall risk assessments to be reviewed when a bed-bound patient starts to sit out in a chair.
Pamela Conway
All Responded
2016-0309 26 Aug 2016 North Wales (East and Central)
Betsi Cadwaladr University Health Board Welsh Ambulance Services NHS Trust
Concerns summary (AI summary) Persistent and unacceptable delays in patient offloading from ambulances at hospitals continue to render ambulance resources unavailable for other calls, creating ongoing risks to public safety.
Action Planned (AI summary) The Welsh Ambulance Service NHS Trust has made progress against key actions identified in an attached action plan, with the most significant impact from the Welsh Health Circular regarding hospital handover guidance. Lessons learned from the case are being monitored through a Task and Finish Group. The University Health Board is scrutinizing two working action plans relating to the case, which will be monitored by the Quality and Safety Group.
Joyce Ravenhill
All Responded
2016-wp25389 24 Aug 2016 Cheshire
North West Ambulance Service Trust NHS
Concerns summary (AI summary) A lack of operational policy prevented effective communication of an urgent doctor's appointment need between triage nurses, relying instead on automated electronic information.
1 response from North West Ambulance Service NHS Trust
Stephen Cahill
All Responded
2016-0304 23 Aug 2016 Bedfordshire and Luton
Network Rail
Concerns summary (AI summary) Easy access to the railway line through inadequate fencing and an access gate poses a risk, and a recommended review of these security measures has not been carried out.
Action Planned (AI summary) Network Rail has commissioned works to enhance the fencing and gates in the area, including installing over 600m of fencing and upgrading the gate height and construction, to deter unauthorised access to the railway by January 15, 2017.
Michael Dundon
All Responded
2016-0305 23 Aug 2016 West Yorkshire (East)
Department of Health and Social Care
Concerns summary (AI summary) Unsupervised liquid-absorbing crystals, mistaken for consumables, caused a patient's death. The risks of these sachets are not fully understood, necessitating improved risk assessment, staff awareness, and training.
Action Planned (AI summary) NHS Improvement is working to identify an effective method of risk reduction regarding the choking hazard of solidifying crystals used in human waste receptacles. They will consider a warning to staff, follow up with the Health and Safety Executive, and explore safer alternatives.
Nathan Lowe
All Responded
2016-wp25387 19 Aug 2016 City of London
Hertfordshire Partnership University NH…
Concerns summary (AI summary) Consideration should be given to whether more could have been done to contact the patient, given the nature of his illness and his non-compliance with follow up.
1 response from Nathan Lowe
Diana Ritchie
All Responded
2016-wp25376 18 Aug 2016 Brighton and Hove
Brighton and Sussex University Hospital…
Concerns summary (AI summary) Mrs Ritchie was recovering from major surgery and on her second day post operatively was suspected of having an Ileus.
1 response from Brighton and Sussex University NHS Trust
Jonathan Sellman
All Responded
2016-0395 17 Aug 2016 South Yorkshire (West)
Rotherham Borough Council
Concerns summary (AI summary) Water pooling on a busy road and verges that could propel cars over safety barriers create hazardous driving conditions, despite the drainage being considered operative.
Noted (AI summary) Rotherham MBC provides detailed information about its road maintenance and inspection regimes, but does not commit to any changes as a result of the coroner's concerns.
Harry Glibbery
All Responded
2016-wp25368 16 Aug 2016 Plymouth Torbay and South Devon
Plymouth Hospitals NHS Trust
Concerns summary (AI summary) The doctor did not prescribe Clexane in accordance with Derriford Protocol, this was not identified during Pharmacy reviews, and there were difficulties weighing patients whose medication is weight-dependent.
1 response from Plymouth Hospital NHS Trust
Saleh Al-Awlaki
All Responded
2016-wp25366 15 Aug 2016 Plymouth, Torbay and South Devon
Highways Department, Torbay Council
Concerns summary (AI summary) Please review the suitability of pedestrian railing between the Railway Station and Bus Station at Paignton to reduce the effect of vehicular collisions with pedestrians.
1 response from Al Awlaki
Oliver Ford
All Responded
2016-0306 15 Aug 2016 Avon
Avon and Wiltshire NHS Trust
Concerns summary (AI summary) The telephone triage process lacked a robust risk assessment, and any assessments were often undocumented. Insufficient PCLS weekend cover led to crucial follow-up delays for patients triaged on Fridays.
Action Taken (AI summary) The telephone triage process now includes the access trigger tool, which assesses risk. There are now two clinicians on duty at PCLS until 8pm Monday to Friday, and the clinicians are required to document on RIO a full rationale for decision making.