2016
PFD Reports
Reports: 472
Areas: 69
65% response rate (above 63% average).
Jean Stockley
All Responded
2016-wp25360
12 Aug 2016
West Sussex
Royal Sussex County Hospital
Concerns summary (AI summary)
Despite a deteriorating respiratory condition and a rising NEWS score, a junior doctor did not review the patient, and it was unclear whether the appropriate doctor had been contacted; the coroner suggested a potential training need.
1 response
from Brighton and Sussex University Hospitals NHS Trust
Thomas Gallagher
All Responded
2016-wp25354
11 Aug 2016
Greater Manchester (North)
Greater Manchester Police
Concerns summary (AI summary)
Staff lacked formal training in risk assessment and child mental health, and there was intentional disregard of force policies; also, decisions not to allocate additional cover or resources lacked documented rationale, and a 'Golden Hour' was missed due to delays.
Action Taken
(AI summary)
GMP has implemented a programme of staff training emphasizing vulnerability, safeguarding, and risk mitigation. Locally, Bury has introduced a demand/triage desk and intelligence support to conduct Golden Hour tasks, including service calls to informants. The escalation policy has been amended to require recall to the informant within 40 minutes.
Susan Hamlett
All Responded
2016-wp25372
4 Aug 2016
Bedfordshire and Luton
Network Rail
Concerns summary (AI summary)
The British Transport investigation revealed that the deceased gained access to the railway line through an access gate that provided little deterrence, and the area around the gate should be replaced with a more significant fence as a matter of urgency.
1 response
from Hamlette Network Rail
Winston Harris
All Responded
2016-wp25349
3 Aug 2016
Birmingham and Solihull
Birmingham City Council
Kerria Court residential home
Sandwell and West Birmingham Hospitals …
Concerns summary (AI summary)
The care plan for Mr Harris did not address his risk of absconding, and hospital staff did not consider an emergency DOLS despite his dementia and previous attempts to leave; the DOLS application was not processed before his death.
2 responses
from Birmingham City Council, Sandwell and West Birmingham NHS Trust
Pamela Gressman
All Responded
2016-wp25347
1 Aug 2016
County Durham and Darlington
Tees, Esk and Wear Valley
Concerns summary (AI summary)
There was insufficient consideration of physical effects from reported foreign body ingestion, leading to an absence of a clear treatment and observation plan for physical symptoms.
1 response
from Tees Esk amd Water Valleys NHS Trust
Joshua Knox-Hooke
All Responded
2016-wp25346
1 Aug 2016
London Greater (East)
North Middlesex University Hospital NHS…
Concerns summary (AI summary)
The patient was not kept within eyesight at all times as required by Trust policy, and it is common for patients to leave A&E prior to psychiatric assessment; the triage nurse was unaware of nurses' holding power under the Mental Health Act.
1 response
from Knox Hooke
Miles Abel
All Responded
2016-wp25345
29 Jul 2016
Wiltshire and Swindon
Department of Health and Social Care
Endless Street Surgery
Concerns summary (AI summary)
The procedure for GPs to refer patients to the Community Mental Health Team lacked an audit trail to confirm faxes were sent, and follow-up phone calls were not always made.
2 responses
from The Endless Street Doctors Surgery, Department of Health
Danny Sweet
All Responded
2016-wp25341
29 Jul 2016
Cornwall and the Isles of Scilly
Cornwall Partnership Foundation Trust
Concerns summary (AI summary)
The coroner questioned whether it was appropriate to presume the best-case scenario for patients presenting inconsistently and whether there should be a check to ensure consistency in treatment decisions; the Serious Incident Report was also incomplete.
Action Planned
(AI summary)
The Trust will launch a review of clinical risk assessments for people presenting with suicidal thoughts or acts, particularly focusing on the use of the STORM risk assessment tool. They will also review the Trust's Serious Incident Investigation process.
Cerith Pugh
All Responded
2016-0271
27 Jul 2016
Carmarthenshire and Pembrokeshire
Hywel Dda University Health Board
Concerns summary (AI summary)
Referrals to consultants were inappropriately handled by middle-grade doctors, and essential liver function tests were declined due to a rigid demand management policy, lacking a mechanism for clinical override.
Action Taken
(AI summary)
The University Health Board has asked consultants to review their practice regarding consultant referrals. Medical staff have also been reminded that clinically justified test requests should be undertaken regardless of guidance about repeating tests.
James Hedge
All Responded
2016-wp25334
27 Jul 2016
South Wales Central
Medicines and Healthcare Products Regul…
NHS England
NHS Wales
+1 more
Concerns summary (AI summary)
Insulin pump guidance inadequately highlights misuse dangers from incorrect cartridge insertion, and patient education fails to emphasize the rapid life-threatening nature of hyperglycaemia.
4 responses
from Medicine and Healthcare Products Regulatory Agency, Welsh Government, NHS England
Leslie Matthews
All Responded
2016-0276
26 Jul 2016
County Durham and Darlington
Medicines and Healthcare Products Regul…
Patient Safety Lead, County Durham and …
Noted
(AI summary)
The MHRA has brought the Coroner's concerns to the attention of the manufacturer and requested that they evaluate whether additional clarity in information could be incorporated at the next Instructions for Use review. They have not identified a systemic problem with cracks associated to Oxylitre flowmeters. All oxygen flowmeters across the Trust have been checked and faults logged. Equipment Controllers/Department Managers are now performing weekly checks of all flowmeters, using a checklist devised by the Medical Devices Nurse.
Margaret Tuck
All Responded
2016-0273
26 Jul 2016
London Inner (North)
Royal London Hospital
Concerns summary (AI summary)
Multiple failures included an absent falls prevention care plan, incomplete post-fall observations, confusion over nurse responsibility, and delayed investigation of confusion, contributing to undetected deterioration.
Action Taken
(AI summary)
Barts Health NHS Trust has re-instructed staff on falls risk assessments and care plans, clarified nursing responsibilities, reinforced post-falls procedures, and implemented measures to improve communication between medical teams. They have also addressed Datix reporting procedures for agency nurses.
Lee Grimes
All Responded
2016-wp25332
26 Jul 2016
Manchester West
5 Boroughs Partnership NHS Foundation T…
Next Stage
Concerns summary (AI summary)
Home health care failed to act on overdose disclosures and ensure follow-up with mental health services, compounded by inadequate staff training in managing overdose reports.
2 responses
from Next Stage, Response 5 Borough Partnership NHS Trust
Rebecca Gilbank
All Responded
2016-wp25329
26 Jul 2016
Surrey
Independence Homes Limited
Concerns summary (AI summary)
A check was missed because staff were busy with other service users, and staff lacked knowledge about how to obtain an outside telephone line to call emergency services; the coroner suggests providing sufficient staffing resources and clear guidance on obtaining an outside line.
Action Taken
(AI summary)
The organisation has changed its telephone system so staff no longer need to dial 9 for an outside line when calling emergency services. This change was communicated to staff verbally, by email, and in the Clareville Lodge Communications Book.
Marjorie Nesbitt
All Responded
2016-0263
25 Jul 2016
South Yorkshire (West)
Sheffield City Council
Concerns summary (AI summary)
Carers lacked training and clear guidance on how to manage unusual and difficult situations, specifically regarding an overheating client from a heater, leading to a fatal outcome.
Action Planned
(AI summary)
The council has prepared documents including a case study overview and practical advice for support workers, which it intends to share as a training tool with internal and commissioning services, Sheffield Teaching Hospitals, social workers, care managers, and council quality and safeguarding teams.
Alfie Gray
All Responded
2016-0262
25 Jul 2016
West Sussex
British Travel Agents
Concerns summary (AI summary)
Inadequate lifeguard provision, including insufficient numbers, lack of medical training, and uncommunicated off-duty periods, created significant safety risks for holidaymakers.
Noted
(AI summary)
ABTA highlights its role as a trade association and provides context about its guidance to members on health and safety. They have drawn the concerns to the attention of consultants reviewing the Technical Guide and are calling for a European Tourism Accommodation Safety Directive.
Patricia Cleghorn
All Responded
2016-0270
25 Jul 2016
Birmingham and Solihull
Birmingham and Solihull Mental Health T…
Care Quality Commission
NHS England: Department of Health
Concerns summary (AI summary)
The unavailability of acute mental health beds led to a vulnerable patient being cared for in the community with limited resources, alongside a failure to conduct a formal risk assessment despite repeated threats of overdose.
Noted
(AI summary)
NHS England highlights the establishment of an adult mental health programme taking a whole system approach and reiterates the national ambition of reducing suicides, with Clinical Commissioning Groups expected to develop local multi-agency suicide prevention plans by 2017, supported by further national investment from 2018/19. The Department of Health acknowledges the concerns raised, refers to the government's mandate for accessible and high-quality crisis services, and notes that the availability of mental health beds is a matter for local commissioners, addressed by NHS England's response. The Senior Nurse for Professional Standards issued a formal practice alert regarding risk assessments, and a Clinical Risk Management Group has been established. The Head of Pharmacy will review the Medicines Code by the end of November 2016. The CQC is requiring the Trust to clarify the role of non-registered staff in the crisis team. The CQC will formally review the actions put in place by the Trust and their impact of those actions on patients at the quarterly meeting with the Trust in December 2016.
Alan Stead
All Responded
2016-0261
22 Jul 2016
Staffordshire (South)
Care UK
Concerns summary (AI summary)
Delays in taking and testing blood samples from prisoners at HMP Dovegate were identified, which could have serious clinical consequences.
Action Taken
(AI summary)
Care UK implemented a training program for nurses and HCAs in phlebotomy at HMP Dovegate, completed in March 2016, to ensure timely blood tests. The Governance team also shared learning from the case at a National Quality and Improvement Meeting.
Stephen Bird
All Responded
2016-0265
22 Jul 2016
Buckinghamshire
BMI The Shelburne Hospital
Concerns summary (AI summary)
Patient records were incomplete and inconsistent, and the hospital's internal investigation report contained factual assumptions conflicting with documentation, undermining its learning process.
Action Taken
(AI summary)
South Buckinghamshire Hospitals has taken several actions including re-auditing patient records, implementing mandatory training on documentation, and introducing a monthly audit of discharge documentation; a RCA report was also completed.
Nathan Charman
All Responded
2016-0267
21 Jul 2016
County Durham and Darlington
Durham County Council
Concerns summary (AI summary)
The winter maintenance policy and decision-making process inadequately addressed extreme or "microclimatic" road conditions, and the incident failed to prompt a formal review or learning.
Action Taken
(AI summary)
Durham County Council reviewed the incident and has amended the Winter Maintenance Operational Plan to align gritting route 28 to the Low Pennines weather forecasting domain and to confirm that Duty Managers and Decision Validators must not use professional judgement to reduce the margin of safety.
Patricia Mercieca
All Responded
2016-0260
19 Jul 2016
London Inner (West)
Tunstall Response
Concerns summary (AI summary)
Call handlers required refresher training on contacting resident managers during emergencies and lacked a protocol for raising immediate concerns when unable to get a response from emergency call system users.
Noted
(AI summary)
The London Ambulance Service states that based on their understanding of the call records, no changes to the questions asked of 999 callers would have enabled them to triage the call differently, unless they had been informed that contact with the patient had been lost.
Margaret Gleeson
All Responded
2016-0255
15 Jul 2016
Manchester (West)
Wrightington, Wigan and Leigh Teaching …
Concerns summary (AI summary)
Hospital weekend staffing levels were inadequate, leading to poor patient care. The MEWS tool was inaccurately scored and poorly understood, indicating a need for refresher training.
Action Taken
(AI summary)
The Trust reviewed staffing levels, provided refresher training on the MEWS tool, and conducted sepsis training, including drop-in sessions and mandatory attendance at a Sepsis Study Day for nursing staff, and is monitoring these actions via the Quality and Safety Committee.
Sydney Neil
All Responded
2016-0256
15 Jul 2016
Birmingham and Solihull
Birmingham Cross City Clinical Commissi…
NHS England
Wychall Lane Surgery
Concerns summary (AI summary)
After a patient collapsed in a GP surgery, there was inadequate ventilation, no suction, and no oxygen provided for 8 minutes, raising concerns about resuscitation expertise and equipment in GP practices.
Action Planned
(AI summary)
Following a SUDIC case discussion, the practice incorporated continuous oxygen saturation readings during nebulisation into their acute asthma management protocol and implemented outcomes from a serious case review into their emergency protocol. NHS England acknowledges the concern regarding suction equipment and oxygen at the GP surgery, and highlights ongoing work to improve asthma management in primary care by communicating updated guidelines to GP practices and CCGs. They have also requested that the CQC ensure primary care services carry the necessary equipment and skills to address respiratory emergencies. The CCG reviewed guidance on basic equipment requirements for GP practices, including CPR training and equipment such as AEDs and oxygen, and will ensure practices adhere to this guidance via contract visits and disseminate learning from this incident to other CCGs.
Leilani Chute
All Responded
2016-0251
15 Jul 2016
West Sussex
St Richard’s Hospital
Western Sussex Hospital NHS Trust
Concerns summary (AI summary)
Junior doctors used non-standard medical practice without consultant knowledge, and consent for women in labor was not truly informed. Crucially, these issues were not identified by the Trust's internal investigation.
Action Taken
(AI summary)
Western Sussex Hospitals NHS Trust has audited the practice of manually pushing back the cervix, provided feedback to staff involved, and is offering additional training on cardiotocograph (CTG) interpretation and consent; they are also reviewing processes for planning investigations when perinatal deaths have occurred.
James Kane
All Responded
2016-0253
15 Jul 2016
County Durham and Darlington
County Durham and Darlington NHS Trust
Department of Health and Social Care
Concerns summary (AI summary)
A patient died due to a drain, and a scan potentially could have reduced this risk, indicating a need for further consideration of policy changes regarding such procedures.
Noted
(AI summary)
County Durham and Darlington NHS Trust will provide all trainees with a copy of the guidance regarding large volume paracentesis, ensure a clear audit trail of patients undergoing paracentesis (including a proforma and database), and perform all procedures between 8am and 8pm; a patient information leaflet will also be available. The Department of Health consulted NICE and the Royal College of Radiologists and concluded that there is no case for the routine use of ultrasound prior to or during paracentesis, but highlighted the concerns to the NICE guideline surveillance team for consideration in future updates.