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
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.
Nicholas Sullivan
Historic (No Identified Response)
2016-wp25385 22 Aug 2016 Manchester City
Manchester Mental Health and Social Car… North Manchester General Hospital
Concerns summary (AI summary) Reception staff in the Emergency Department did not use a checklist to identify mental disorder/conditions and record important background issues, there was no clear system to trigger urgent triage and safeguarding steps, and no system to safeguard the patient pending a mental health assessment.
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
John Jones
Partially Responded
2016-wp25383 19 Aug 2016 London Inner (North)
Consultant Psychiatrist, Keats House, L… Nightingale Hospital
Concerns summary (AI summary) The hospital failed to ensure an unwell patient engaged with crucial group therapy, despite it being the reason for admission, leading to isolation and a suboptimal therapeutic environment.
1 response from Nightingale Hospital
Amanda Coppen
Partially Responded
2016-wp25382 19 Aug 2016 London Inner (South)
Lands, Estates and Property Housing and… Royal Borough of Greenwich Surface Transport, Transport for London
Concerns summary (AI summary) The layout of Pilot Busway and the neighbouring road (West Parkside) is unusual and could mislead road users, and a new school being built close to the junction may increase the numbers of pedestrians using the junction.
1 response from Transport for London
Margaret Richardson
Historic (No Identified Response)
2016-wp25380 19 Aug 2016 Essex
North Essex Mental Health Partnership T…
Concerns summary (AI summary) A robust, comprehensive Action Plan with timescales needs to be put in place, following the findings of the Serious Incident Investigation and the evidence heard during the inquest.
George Watson
Historic (No Identified Response)
2016-wp25378 19 Aug 2016 Coventry
University Hospital, Coventry University Hospitals Coventry and Warwi…
Concerns summary (AI summary) Concerns include an unsatisfactory discharge process with unclear medication protocols, inefficient staffing allocation, inadequate monitoring of night shift staff, and insufficient clarity on investigatory process improvements.
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.
Christine Dryden
Historic (No Identified Response)
2016-0490 17 Aug 2016 West Yorkshire (West)
Incommunities
Concerns summary (AI summary) The absence of regular checks on installed smoke and heat detectors in properties presents a safety risk, necessitating a review of maintenance arrangements.
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
Micael McMonigle
Historic (No Identified Response)
2016-0289 15 Aug 2016 County Durham and Darlington
Tees, Esk and Wear Valley NHS Trust
Concerns summary (AI summary) Staff showed a lack of knowledge and failure to follow policy regarding leave for informal patients, risk assessments were not updated, and the response to the patient's absence was delayed and did not conform with procedures; staff knowledge of leave policy was inadequate.
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.
Michael Blow
Historic (No Identified Response)
2016-wp25367 12 Aug 2016 Portsmouth and South East Hampshire
Portsmouth Hospitals NHS Trust
Concerns summary (AI summary) An INR test was not carried out, and warfarin was restarted based on an outdated INR reading, without considering the impact of other treatments; the coroner noted a need to clarify the relevant protocol for junior doctors and nurse practitioners.
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
Stephen St Clair
Historic (No Identified Response)
2016-wp25358 12 Aug 2016 Isle of Wight
Ministry of Justice National Offender Management Service
Concerns summary (AI summary) Prison guidance for suicide risk factors is inadequate, omitting irrational behaviour as a key indicator of psychosis, which led to insufficient monitoring and care for a prisoner at risk.
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.
Anthony Preston
Historic (No Identified Response)
2016-wp25351 11 Aug 2016 Rutland and North Leicestershire
Leicestershire Partnership NHS Trust Priory Hospital, Cheadle
Concerns summary (AI summary) The discharge system lacked robustness, with no documentary proof of a telephone call to the Crisis Team, and no immediate follow-up notification of discharge; the coroner noted this left a high-risk patient without support.
Thomas Jordan
Historic (No Identified Response)
10 Aug 2016 West Yorkshire (East)
Her Majesty's Prison, Leeds The Leeds Teaching Hospitals NHS Trust
Concerns summary (AI summary) Communication failures between the hospital and prison healthcare resulted in continued administration of a discontinued drug, as discharge information was not promptly reviewed by prison staff.
Thomas Jordan
Partially Responded
2016-0287 10 Aug 2016 Yorkshire West (East)
Head of Healthcare, HMP Leeds Medical Director, Leeds Teaching Hospit…
Concerns summary (AI summary) Communication breakdown and failure to review discharge correspondence at the prison led to continued, incorrect drug administration after hospital clinicians requested discontinuation. Electronic discharge summaries could prevent such errors.
Action Planned (AI summary) Leeds Teaching Hospital has agreed to issue an electronic summary with all patients who transfer back to HMP Leeds following discharge. IT personnel from both the Hospital and Care UK will create a pathway to ensure all summaries are appropriately shared, and written summaries are provided in sealed envelopes in the meantime.