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
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.
Richard Breatnach
Partially Responded
2016-0330 15 Sep 2016 Brighton and Hove
H R Healthcare Limited NHS England
Concerns summary (AI summary) Online medication prescribing allowed applicants to provide false information without verification, leading to excessive and inappropriate prescription of an addictive drug without patient contact or correct guidance.
Action Planned (AI summary) NHS England will assimilate current regulatory and professional guidance into one place for online prescribing, and will use this learning to inform its Digital Strategy. They will also include advice to General Practitioners about Special Patient Notes.
Keith Ruston
Historic (No Identified Response)
2016-0483 13 Sep 2016 West Yorkshire (West)
West Yorkshire Ambulance Service NHS Tr… Department of Health and Social Care
Concerns On the 22/12/2016 opened an inquest into the death of Keith William Rushton who, at the date of his death was 78 years old. The inquest was resumed and concluded on 31/8/2016. Ifound that the cause...
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.
Lauris Kodors
Historic (No Identified Response)
2016-0357 13 Sep 2016 London (North)
RSSB
Concerns summary (AI summary) The RSSB Rule Book inadequately permits stopping trains only when a person threatens damage to the train, not when a person is in danger from an approaching train.
Roy Millar
Historic (No Identified Response)
13 Sep 2016 Plymouth Torbay and South Devon
CQC, Safeguarding team National Customer Service Centre Secretary of State for Health
Concerns summary (AI summary) Ward administrators in the Neurology Department were unaware of their responsibility to book follow-up appointments, leading to a large number of patients, including the deceased, not having appointments booked; a review revealed 146 patients did not have follow-up appointments booked.
Zane Gbangbola
Historic (No Identified Response)
2016-0328 13 Sep 2016 Surrey
Department for Work and Pensions HAE Ltd Health and Safety Executive
Concerns summary (AI summary) Inadequate and misleading safety guidance for internal combustion engine equipment used in confined spaces, coupled with the misleading use of the HSE logo, increases the risk of harm.
Beverley Upton
Historic (No Identified Response)
2016-0318 7 Sep 2016 Rutland and North Leicestershire
MAC Skip Hire Limited
Concerns summary (AI summary) Unsafe loading shovel work methods and a lack of clear guidance and enforcement for drivers to stay in cabs put workers at risk. Training for risk assessment and health and safety awareness was inadequate.
Glen Jordan
Partially Responded
2016-0329 7 Sep 2016 Black Country
Care Quality Commission Dudley and Walsall Mental Health NHS Tr…
Concerns summary (AI summary) Staff failed to remove a holdall bag with an attached strap, a ligature risk, from a patient's room, highlighting a lapse in safety checks.
Action Planned (AI summary) The Trust will include a statement in its search policy to enhance the definition of "belongings" to include items used to keep or transport belongings (e.g., bags). They have also commenced a process of implementation, including staff education and a clinical audit planned for April 2017 to evaluate effectiveness.
Edward Mallen
Historic (No Identified Response)
2016-0254 7 Sep 2016 Cambridgeshire and Peterborough
Cambridge and Peterborough NHS Trust Cambridgeshire and Peterborough Clinica… GP Practice Orchard Surgery +1 more
Concerns summary (AI summary) A GP prescribed medication based on advice from a non-prescribing nurse without adequately informing the patient about critical side effects or support contacts. GPs also lacked awareness of available psychiatrist consultation.
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.
Dildar Shariff
Partially Responded
2016-0321 7 Sep 2016 Manchester (North)
Department of Health and Social Care N.I.C.E Pennine Acute NHS Trust
Concerns summary (AI summary) There is a critical lack of national awareness and NICE guideline inclusion regarding the increased haemorrhage risk in haemodialysis or uremia patients, potentially leading to future deaths.
Noted (AI summary) The Department of Health acknowledges the coroner's report and notes NICE's decision not to update its guidelines at this time, but that the information will be looked at when the guidance is next updated in 2017. NICE acknowledges the coroner's concerns about awareness of haemorrhage risk in renal failure patients with head injuries. While they believe their existing guideline covers this adequately, they have logged the concerns for consideration during the next update in 2017.
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.
Warren Sampson
Partially Responded
2016-0320 6 Sep 2016 Essex
Care UK Family Solicitors HMP
Concerns summary (AI summary) Prison healthcare lacked consistent input in ACCT reviews and a follow-up process for missed screenings. Officers were also not adequately familiar with local directives.
Action Taken (AI summary) Discipline staff now email healthcare each day with the ACCT reviews they are intending to hold and invite the appropriate healthcare professional to input into the process. A Second Health Screen is undertaken within 72 hours of an inmate arriving to ensure matters such as consent for obtaining GP records has been sought.
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.
Benjamin Brown
Historic (No Identified Response)
2016-0326 5 Sep 2016 London (North)
Edgware Community Hospital
Concerns summary (AI summary) Concerns identified inadequate auditing of 15-minute observations and clozapine management, alongside insufficient staff training for patient resuscitation.
John Jones
Historic (No Identified Response)
2016-0327 5 Sep 2016 Avon
Avon and Wiltshire Mental Health Partne…
Concerns summary (AI summary) A significant delay in notifying the GP of patient discharge from the Crisis Team left the patient without community support. Crisis Team training lacked clear communication protocols for such handovers.
Imad Hassan
Partially Responded
2016-0315 5 Sep 2016 South Wales Central
ABMU Health Board Cardiff and Vale Health Board CWM Taff Health Board +2 more
Concerns summary (AI summary) There is no formal backup plan for PCI procedures when primary hospitals lack capacity, and no agreed pathways for accessing critical care beds outside Wales or for unconscious STEMI patients.
Action Planned (AI summary) Cwm Taf University Health Board has been working to develop an interim solution pending the completion of a comprehensive pathway in the summer of 2017. A local corrective Action Plan for improvement was developed and will be shared with clinical colleagues. The United Hospitals University Bristol Trust will accept patients if there is insufficient critical care capacity in South Wales, facilitated by the regional PPCI centre. Work is underway on an all Wales basis to agree a longer term strategy for these patients.
Catherine Dinnen
Historic (No Identified Response)
2016-0313 2 Sep 2016 London (East)
Royal London Hospital
Concerns summary (AI summary) Concerns include significant delays in medical reviews, particularly out-of-hours, due to inadequate medical staffing levels. Lost observation records further hindered investigation into patient care.
Peter Lawrence
Historic (No Identified Response)
2016-0314 30 Aug 2016 Cambridgeshire and Peterborough
National Offender Management Service
Concerns summary (AI summary) The initial screening process for new prisoners lacked a robust method to identify and comprehensively record less obvious risk factors, particularly with limited background information.
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.
Robert Dearing
Historic (No Identified Response)
2016-0311 30 Aug 2016 Lincolnshire (Central)
Department for Transport
Concerns summary (AI summary) Unregulated, non-standard anti-glare visors significantly obscured driver vision due to extremely low light transmission. A lack of legislation and British Standard certification for these devices poses a safety risk.
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.
Kyles Lowes
Partially Responded
2016-0307 26 Aug 2016 North Northumberland
NEAS NHS Trust NHS Northumberland Clinical Commissioni…
Concerns summary (AI summary) Long emergency care journey times and a single paramedic crew after 10 pm in a busy area create significant risk of delayed responses. The proposed solution relies on staff goodwill and doesn't fully mitigate risks.
Action Planned (AI summary) The CCG is working with various organisations to review services in Alnwick and Berwick, to share staff and skills, and NEAS will deploy an additional Rapid Response Paramedic in the north of the county from December 2016.