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
Harold Goulding
All Responded
2016-0248 14 Jul 2016 London (East)
Alexander Court Care Central
Concerns summary (AI summary) Communication breakdown between the care home, GP, and anti-coagulation clinic led to medication mismanagement. The care home lacked systems to inform agencies of new GPs and ensure GPs review medication records.
Action Taken (AI summary) The care home created a handover document for sharing new resident information with GPs, and implemented protocols to ensure nurses accompany GPs on rounds to discuss medication charts and care plans.
Patrick Curran
All Responded
2016-0258 14 Jul 2016 Manchester (South)
South Manchester University Hospital NH…
Concerns summary (AI summary) Hospital practice condoned nurse-led post-operative reviews and patient discharges without adequate medical overview, even for unwell patients, potentially leading to missed diagnoses like pneumonia.
Action Taken (AI summary) The hospital strengthened post-operative clinics by ensuring a consultant is present in the same clinic, along with nurses, and radiology reports X-rays with any concerns.
Alice Gross
All Responded
2016-0488 12 Jul 2016 London Inner (West)
Home Office
Concerns summary (AI summary) UK police lack mandatory foreign conviction checks for all arrestees and UK nationals. There are concerns about inadequate international data sharing, "watch list" management, and potential loss of Europol access post-Brexit.
Action Taken (AI summary) The Home Office details steps taken to improve checks for foreign convictions on arrest, including implementation of the European Criminal Record Information System (ECRIS) and increased use of Interpol I-24/7, and notes arrangements are in place at Border Force to identify individuals who pose a risk.
Steven Billington
All Responded
2016-0247 12 Jul 2016 Manchester (West)
Home Office Secretary for Communities and Local Gov…
Concerns summary (AI summary) No specific concerns are detailed in the provided text.
Noted (AI summary) The Minister offers condolences to the family and friends of Mr. Billington. The Department acknowledges the report and notes that current guidance requires isolators for fire alarm systems to be secured against unauthorised tampering, and suggests the system in question may have been an older system. They suggest any weaknesses in standards be brought to the attention of the British Standards Institution.
Michael Williams
All Responded
2016-0245 11 Jul 2016 Leicester City and Leicestershire South
HMP Leicester
Concerns summary (AI summary) Prison staff missed mandated observations and used predictable intervals for checks. There was an inappropriate delay in responding after a cell observation panel was blocked, indicating a lack of clear training.
Action Taken (AI summary) HMP Leicester reminded staff about conducting observations at unpredictable times, management checks are in place, ACCT documents are quality assured, the contingency plan was revised, and staff were trained to intervene quickly if the observation panel has been blocked.
Thomas Pearson
All Responded
2016-0246 4 Jul 2016 South Yorkshire (East)
Doncaster Royal Infirmary
Concerns summary (AI summary) A patient was prescribed fluticasone, increasing pneumonia risk without benefit due to a non-raised eosinophil count. The coroner recommends reviewing inhaled steroid use in similar patient populations.
Noted (AI summary) The response indicates that the respiratory team is well versed with the current state of the evidence and are following appropriate current guidelines and are unable to produce useable local guideline at this time other than to be aware that possible options must be discussed with the patient.
Henry Hicks
All Responded
2016-0244 4 Jul 2016 London Inner (North)
Metropolitan Police
Concerns summary (AI summary) Police officers failed to identify a situation as a pursuit and seek authorisation, contrary to the jury's determination, implying non-compliance with the Metropolitan Police Service's standard operating procedure.
Noted (AI summary) The Metropolitan Police states that the existing pursuit policy remains unchanged but will be fully explored in the context of a formal disciplinary process for the officers involved, and notes that their guidance is kept under constant review and revision.
George Punton
All Responded
2016-0250 1 Jul 2016 Wiltshire and Swindon
Highway and Transport Wiltshire Council
Concerns summary (AI summary) No specific concerns are detailed in the provided text.
Action Planned (AI summary) A 20mph speed limit at Lockeridge is due to be completed by the end of 2016, including the provision of warning signs.
Luisa Mendes
All Responded
2016-0243 30 Jun 2016 Warwickshire
Chief Constable of Warwickshire Police
Concerns summary (AI summary) Police call handlers inappropriately categorised violent incidents, and there were no formal handover procedures or training for shift changes. The STORM computer system also lacked alerts for unauthorised deferrals.
Action Taken (AI summary) Warwickshire Police have trained staff on threat, harm, risk, and vulnerability using the National Decision Making model and are seeking to introduce a system change to alert priority incidents out of time. They are also in the advanced stages of procuring a new Command and Control system to include changes required as a result of the inquest.
Lee Davies
All Responded
2016-0239 29 Jun 2016 South Wales Central
Wallich Centre
Concerns summary (AI summary) Hostel staff lacked specific training on monitoring and safeguarding residents found after illicit drug use, instead only focusing on overdose recognition, leaving at-risk individuals unmonitored.
Action Planned (AI summary) The Wallich will present a PowerPoint on 'Dealing with Drug Overdose' to staff by the end of August 2016, revise their policy to include Cymorth Cymru's guidance by August 2016, and revise their e-learning module by September 2016.
David Little
All Responded
2016-0237 28 Jun 2016 Manchester (South)
Tameside Hospital NHS Foundation Trust
Concerns summary (AI summary) Hospital staff failed to maintain clear radiology records, misidentified a patient, and lacked training to recognise blocked bowel symptoms. Poor inter-departmental communication and treating the least serious diagnosis first were also issues.
Action Taken (AI summary) Tameside Hospital NHS Trust has devised a small bowel obstruction surgical pathway which has been agreed by the surgical, nursing and clinical teams and will be ratified before being signed off at Trust level by the end of September. The Trust has also invited the family to discuss their concerns and involve them with ongoing learning.
Michael Younghusband
All Responded
2016-0235 23 Jun 2016 Exeter and Greater Devon
Great Western Railway
Concerns summary (AI summary) A railway crossing point was in a poor state, with a section standing proud of the track, presenting a significant tripping hazard for users.
Action Taken (AI summary) Network Rail completed ballast surface improvement works at the East Devon Way crossing point on 20 July 2016, and edges of any trip hazards have been clearly marked.
Malcolm Bennett
All Responded
2016-0232 22 Jun 2016 Manchester (South)
Borough Care Ltd
Concerns summary (AI summary) Staff at the care home delayed calling an ambulance for three hours after a significant injury, despite the care plan requiring immediate emergency department transfer, potentially contributing to the death.
Action Taken (AI summary) Borough Care has updated risk management plans for residents on Warfarin, placed anti-coagulant warnings on care plans and MAR sheets, discusses medication at handovers, reviewed medication training to include anticoagulant use, and will review the 'Falls Prevention' and medication audit procedures by the end of September 2016.
Michael Hutchence
All Responded
2016-0228 20 Jun 2016 Manchester (South)
Stockport NHS Foundation Trust
Concerns summary (AI summary) Concerns included frequent, unnecessary ward transfers, poor medical record-keeping, care by unqualified staff, and inaccurate anticoagulant dosing due to weight recording issues. Equipment shortages and non-sterile surgical kits also caused dangerous operational delays and increased DVT risk.
Noted (AI summary) The Trust provides context regarding patient transfers and staffing levels, but does not describe specific actions taken or planned in response to the coroner's concerns.
Valerie Ellis
All Responded
2016-0252 16 Jun 2016 West Sussex
IC24 SECAMB Western Sussex Hospital NHS Trust
Concerns summary (AI summary) Inadequate discharge counselling for a vulnerable patient on medication, coupled with concerns about 111 health advisor training and imprecise algorithms. A call-back was prematurely closed and a joint investigation has not occurred.
Disputed (AI summary) The Ambulance Service states it has met NHS Pathways training requirements and believes further algorithm concerns should be directed to the Department of Health. They are open to sharing their Serious Incident report with IC24. The Trust launched a NOAC alert card in October 2015 and introduced a Standard Operating Procedure for pharmacy staff. They will also place a NOAC card in the medication bag given to patients on discharge, document discussions with relatives, and are revising their anti-coagulants policy. IC24 has implemented new Failed Contact Guidance and software to prevent premature call closure. They have reviewed their induction training program and specifically included information on accessing NHS 111 reports and sent an alert to out of hours GPs reminding them about accessing this information.
Laura McRory
All Responded
2016-0223 13 Jun 2016 London (East)
North East London Foundation Trust
Concerns summary (AI summary) The Trust lacked a clear process for employees seeking mental health care, especially regarding confidentiality and external referrals. There was also an inadequate safety plan on discharge and deficiencies in the internal investigation.
Action Planned (AI summary) The Trust states it has carefully considered the report and is fully cognisant of the issues and committed to continuously review its service and has enclosed the Trust's action plan to prevent the reoccurrence of the shortcomings identified in your Regulation 28 report
Kevin Dermott
All Responded
2016-0220 13 Jun 2016 Cheshire
Department for Health NHS England
Concerns summary (AI summary) While at HMP Durham, the deceased was left in a urine soaked cell during a hypomanic episode and a psychiatric referral was never completed; inadequate mental health cover at HMP Haverigg and a lack of suitable psychiatric care facilities at HMP Kirkham contributed to a failure to recognise relapse into depression at HMP Risley.
Noted (AI summary) NHS England is working with other organisations to address the lack of secure psychiatric beds. Updated guidelines for transferring prisoners to secure mental health hospitals are due for final consultation in autumn 2016. HMP Risley has increased the level and depth of management checks on ACCT documents, will issue a Governor's Order clarifying staff responsibilities, and has informed staff to contact the Safer Custody department for immediate ACCT reviews. Changes are planned for implementation by the end of September 2016. The Department of Health acknowledges the concerns, highlights its commitment to working with NOMS and NHS England, and notes that NHS England and NOMS will be responding separately.
Anthony Fraser
All Responded
2016-0225 8 Jun 2016 South Yorkshire (East)
HMP Lindholme
Concerns summary (AI summary) Summary medical information was not conveyed to the receiving A&E department upon transfer, and there is no system for ensuring such information is sent; a system needs to be implemented to convey such information for every inmate transferred with an acute illness.
Action Taken (AI summary) Following concerns raised, the Trust co-authored a procedure with HMP Lindholme to convey summary medical information to A&E departments during inmate transfers, and the procedure has been issued to staff and is now in operation; a review of compliance will be undertaken.
Stephen Hunt
All Responded
2016-0216 8 Jun 2016 Manchester (City)
Chief Fire and Rescue Services Home Office
Concerns summary (AI summary) Fire and Rescue Services lacked adequate measures for managing heat stress in hot environments, had poor communication protocols, and insufficient training/SOPs for incident role handover, hazard recording, and thermal imaging camera use.
Noted (AI summary) DSFRS provides responses to the coroner's questions, but does not describe any specific actions taken or planned by their own service. The Ministry of Justice acknowledges the coroner's concerns regarding legal aid funding but states that funding decisions are made independently and there are no plans to change the current scheme.
Ezharul Islam
All Responded
2016-0214 6 Jun 2016 London (North)
Transport for London
Concerns summary (AI summary) There is no system in place to alert bus passengers when the vehicle is about to move, unlike previous methods which involved verbal warnings and a bell.
Action Planned (AI summary) Transport for London will consider the coroner's recommendations about passenger alerts as part of the Bus Safety Standard for London to find the most appropriate solution.
Jessica Birkhead
All Responded
2016-0208 2 Jun 2016 Exeter and Greater Devon
Northern, Eastern and Western Devon Cli… Seaton and Colyton Medical Practice
Concerns summary (AI summary) Mainstream adult support services were ill-equipped to provide appropriate care for individuals with intellectual disabilities, suggesting a need for a specific pathway review.
Action Planned (AI summary) The CCG will assess with provider organizations whether the "Green Light" audit tool can be applied to community services to review access of mental health services to individuals with learning disabilities and identify needed adjustments; assessment and agreement will be completed in 2016/17 to inform quality improvement initiatives in 2017/18. The Seaton & Colyton Medical Practice will hold a formal Significant Event Audit Meeting to discuss the case and consider appropriate pathways for others in similar situations.
Clarice Hilton
All Responded
2016-0207 2 Jun 2016 Manchester (West)
5 Borough Partnership NHS Trust
Concerns summary (AI summary) Psychiatric units lack a policy or guidance for staff on how to manage patients who refuse physical health observations, leading to critical delays in medical assessment.
Action Taken (AI summary) The Trust has reviewed and revised its Modified Early Warning Scores (MEWS) operational guidance to include instruction for staff on assessing those who refuse to engage with MEWS monitoring, including conducting general assessments using the A(airway) B (breathing) C (circulation) D (disability) E (exposure) approach; the revised guidance is currently in draft form and will be issued once ratified.
Danielle Robinson
All Responded
2016-0205 31 May 2016 North Wales (East and Central)
Betsi Cadwaladr University Health Board
Concerns summary (AI summary) Staff are not rigorously following the Therapeutic Engagement and Observation Policy, leading to missed opportunities for escalating patient observation levels during critical risk periods.
Action Taken (AI summary) The University Health Board has reviewed and updated its Therapeutic Engagement and Observation Policy to include the automatic escalation of observations following a serious attempt of self-harm until a full multi-disciplinary team review can take place; the policy will be formally re-launched at a learning event planned for September 2016.
Keenan Walsh
All Responded
2016-0202 27 May 2016 Exeter and Greater Devon
Devon County Council North Devon Council
Concerns summary (AI summary) Unregulated private holiday swimming pools, non-standard pool design, and inadequate adult supervision ratios created significant safety hazards for children.
Noted (AI summary) Devon County Council acknowledges the coroner's concerns, notes that responsibility lies with District Councils, and will raise the issue with the 'Visit Devon Community Interest Company'. North Devon Council is seeking counsel's opinion on the scope of S3(2) Health and Safety at Work etc Act 1974 and will share this with other local enforcing authorities in Devon to inform the development of intervention plans; the tourist industry in the county will be advised accordingly.
Christopher Sears
All Responded
2016-0212 25 May 2016 Surrey
Department for Education Department for Transport Greenshades Coach Travel Ltd +2 more
Concerns summary (AI summary) Bus drivers transporting students are not required to have Basic Life Support training or emergency protocols, and BLS is not routinely taught in secondary education.
Action Planned (AI summary) The DfE intends to consult on a revised version of guidance on school transport in the autumn and will consider whether they should further clarify the description of the training that drivers and escorts should receive. The DfT will reinforce the importance of basic life support training for drivers through targeted communications and social media, and raise the profile of the issue with bus industry and local authority stakeholders.