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
Vinod Kumar
Historic (No Identified Response)
2016-0369 17 Oct 2016 Black Country
New Cross Hospital
Concerns summary (AI summary) Initial triage over-relied on the patient's fall, leading to delayed recognition of potential infection symptoms, missed observations, and inadequate prolonged assessment before priority categorization.
Peter Keep
All Responded
2016-0362 14 Oct 2016 Surrey
Frimley Park Hospital
Concerns summary (AI summary) The hospital lacked a clear sedation policy for cardiac procedures, leading to inconsistent drug use, inadequate staff training on anxiolytics, and no action plan for patient intolerance or airway emergencies.
Action Taken (AI summary) Frimley Health NHS Trust relaunched the Trust Safe Sedation Committee and is reviewing and revising the Trustwide Guideline for Intravenous Conscious Sedation of Adults.
Brandon Arnold
Historic (No Identified Response)
2016-0365 14 Oct 2016 Bedfordshire and Luton
Luton Borough Council
Concerns summary (AI summary) Motorcycles frequently use residential pathways at excessive speeds, posing a significant and constant risk of death to pedestrians, especially children and vulnerable individuals.
Robert Davidson
All Responded
2016-0363 13 Oct 2016 Birmingham and Solihull
Aran Court Care Centre Care Quality Commission Department of Health and Social Care +2 more
Concerns summary (AI summary) Care home staff lacked basic emergency training, including 999 procedures and CPR. Health Care Assistants had insufficient experience, and vital patient information like PICA behaviour was not transferred between facilities.
Noted (AI summary) Priory Group will raise the need for effective communication at resident transfer in their Safety 1st bulletin and highlight the requirement to complete Form AM32 Transfer/Discharge record. Avery acknowledges shortcomings at Aran Court under previous management and has implemented an additional action plan and timetable to fully embed Avery's policies and procedures. NHS England outlines its commissioning role and refers to the Care Certificate as a new minimum standard for care workers. They state that the commissioning organisation should be satisfied that the organisation to which Mr Davidson was being admitted were able to meet his care needs. The CQC details inspections carried out at Aran Court Care Centre and Jubilee Gardens, noting expectations around risk assessments and handover documents when patients transfer between services. The Department of Health acknowledges the importance of workforce skills development and highlights the introduction of the Care Certificate and funding for training.
Roy Hoey
All Responded
2016-0360 13 Oct 2016 Liverpool and Wirral
National Offender Management Service
Concerns summary (AI summary) Concerns arose from staff confusion regarding the interpretation and application of safer custody guidance, specifically when to open an ACCT plan, requiring clarification on mandatory assessment before initiation.
Action Planned (AI summary) NOMS acknowledges potential confusion regarding ACCT guidance and will resolve this in the revision of PSI 64/2011, due for completion by the end of April 2017; the revised version will be easier for staff to read and understand.
Philip Evanson
Historic (No Identified Response)
2016-0359 13 Oct 2016 Cheshire
Cheshire Council, Vale Royal Area Highw…
Concerns summary (AI summary) Road markings on the A49 Tarporley Road, specifically the ghost island, lane dividers, and right turn arrows, are significantly worn and indistinct, posing a safety risk.
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.
Calam Atour
Historic (No Identified Response)
2016-0461 12 Oct 2016 Wiltshire and Swindon
National Offender Management Service
Concerns summary (AI summary) Chronic understaffing in the prison system compromises officer safety and prisoner welfare. The method for determining staffing levels also fails to account for the specific risks posed by the inmate population type.
Rohid Shergill
Historic (No Identified Response)
2016-0364 12 Oct 2016 Nottinghamshire
Nottingham University Hospitals NHS Tru… Nottinghamshire Healthcare NHS Trust
Concerns summary (AI summary) Lack of clear protocols for NGT feeding parental competence, poor information sharing between trusts, and inadequate training for staff on pH testing and syringe hygiene compromised care for a child in the community.
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.
Barry Thompson
Historic (No Identified Response)
2016-0354 11 Oct 2016 Blackpool and Fylde
Blackpool Teaching Hospital NHS Trust
Concerns summary (AI summary) The patient's high-priority triage was not followed by timely review by a doctor or antibiotic administration per national standards, the NEWS score was not actioned, and there were issues managing a diabetic patient's monitoring and basic needs, along with inaccurate and incomplete record-keeping.
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.
Debrata Sircar
Partially Responded
2016-0352 7 Oct 2016 London Inner (South)
London Royal Borough of Greenwich Oxleas NHS Mental Trust
Concerns summary (AI summary) A significant delay in securing a mental health bed and conducting an MHA assessment, coupled with the absence of an interim care plan, compromised care for a patient at high risk of falls.
Action Taken (AI summary) Oxleas NHS Foundation Trust has changed its practice so that a referral for a MHA assessment triggers a review of zoning and risk management plan, and the client should be rezoned into Red until the MHA has been completed. Zoning meetings take place three times per week and regular weekly interface meetings between community and home treatment teams now take place.
Norman Beard
Historic (No Identified Response)
2016-0438 7 Oct 2016 Stoke-on-Trent and North Staffordshire
Care First Homes
Concerns summary (AI summary) Poor management, staff shortages, and lack of policies contributed to neglected pressure ulcers and significant weight loss. Delayed specialist referrals and ignored medical advice compounded the patient's deteriorating condition.
Helen Millard
Historic (No Identified Response)
2016-0482 6 Oct 2016 East Riding and Kingston-upon-Hull
NHS Improvement
Concerns summary (AI summary) The "traffic light" ligature risk classification system in psychiatric facilities is flawed; all ligature points, regardless of height, pose an extreme risk and should be categorized as "red" for urgent elimination.
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.
Haydn Burton
Partially Responded
2016-0346 4 Oct 2016 Hampshire (Central)
HM Prison Service Samaritans
Concerns summary (AI summary) Prison staff failed to implement ACCT plans effectively and observations were inadequate. Confidentiality rules for Listeners were unclear regarding active suicide plans, and the NOMIS database inadequately records past ACCT information.
Action Taken (AI summary) HMP Winchester is providing local ACCT refresher training and Safety Awareness training, including lessons learned from previous deaths in custody. Wing Supervising Officers are informed of ACCT post closure reviews, and Case Managers have been reminded to update NOMIS case notes following an ACCT case 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.
Karnel Haughton
Historic (No Identified Response)
2016-0339 23 Sep 2016 Birmingham and Solihull
Department for Education National Society for the Prevention of …
Concerns summary (AI summary) Uncensored online videos promote dangerous 'choking game' activities, yet there is no national guidance for schools or support for parents, risking further injuries and deaths.
Liam Lambert
Partially Responded
2016-0335 20 Sep 2016 Leicester City and Leicestershire South
HMP YOI Glen Parva Secretary of State for Justice National Offender Management Service
Concerns summary (AI summary) ACCT documents were incomplete, not properly utilized, and closed prematurely. Resourcing issues compromised officers' ability to ensure prisoner safety, especially for vulnerable young men.
Action Taken (AI summary) Following the death, a Safer Custody toolkit was introduced, and staff were reminded of ACCT document completion and prisoner supervision. Additional funding was received for security measures and partnership working. The Secretary of State announced additional prison officers to be employed, and intention to redevelop Glen Parva prison.
Daphne McCorkle
Partially Responded
2016-0337 19 Sep 2016 London Inner (South)
London Borough of Lewisham Adult Care S… NHS Lewisham Clinical Commissioning Gro…
Concerns summary (AI summary) A critical gap exists in night-time care provision for patients requiring frequent turning to prevent pressure sores, as neither district nurses nor agency carers provide night visits.
Action Taken (AI summary) The CCG has established a Community Pressure Ulcer Panel and an acute pressure ulcer panel to review pressure ulcers acquired in the community. They will monitor risk assessment of patients discharged from hospital with pressure ulcers through contract management processes.
Charles Pitcher
Historic (No Identified Response)
2016-0336 19 Sep 2016 Plymouth, Torbay and South Devon
Cornwall County Council Devon County Council Tamar Bridge & Torpoint Ferry joint Com…
Concerns summary (AI summary) The bridge barrier is too easy to bypass, leading to multiple suicides, and current safety measures are inadequate compared to other significant bridges.
Martha Davies
Historic (No Identified Response)
2016-0331 16 Sep 2016 Essex
Anglian Community Enterprise
Concerns summary (AI summary) Serious communication breakdowns, over-reliance on junior/agency staff, and a lack of prompt response to patient deterioration contributed to significant care failings and poor documentation.
David Phillips
Historic (No Identified Response)
2016-0334 16 Sep 2016 Swansea Neath and Port Talbot
Mitie NHS Wales South Wales Police
Concerns summary (AI summary) An inappropriate healthcare professional conducted the mental health assessment for a vulnerable older person, and the assessing professional lacked critical access to the detainee's medical records.