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 165 results
Elvis Snelson
Historic (No Identified Response)
2016-0042 21 Jan 2016 Manchester City
Department of Health and Social Care
Concerns summary (AI summary) The "legal high" acetylfentanyl, a highly potent opioid, poses significant risks due to users being unaware of its opioid nature, leading to dangerous sedation and respiratory depression.
Leslie Murray
Historic (No Identified Response)
2016-0016 21 Jan 2016 London Inner (West)
St George’s Hospital
Concerns summary (AI summary) Insufficient staffing on hospital wards prevents essential one-to-one patient care, leading to preventable falls and other critical care deficiencies that may contribute to patient deaths.
Alice Dickenson
Historic (No Identified Response)
2016-0021 21 Jan 2016 Central and South East Kent
Kent and Medway Cancer Collaborative
Concerns summary (AI summary) The GP referral form for rapid access endoscopy is limited, potentially leading to the omission of critical past medical history that would assist endoscopists.
Leslie Summerfield
Historic (No Identified Response)
2016-0019 20 Jan 2016 Manchester (South)
Central Manchester NHS Trust
Concerns summary (AI summary) The withdrawal of urgent endoscopy services at a hospital, despite available resources, forces critically ill patients to be transported, causing unnecessary discomfort and potentially aggravating their conditions.
Lee Rushton
Historic (No Identified Response)
19 Jan 2016 Liverpool and Wirral
102 Petty France SW1H 9AJ The Secretary of State for Justice
Concerns summary (AI summary) There is a lack of clear policy and training regarding how ACCT care plans and mandatory reviews should integrate with Cell Sharing Risk Assessments requiring single cell occupancy for prisoner protection.
Lee Rigby
Historic (No Identified Response)
2016-0011 14 Jan 2016 Manchester (West)
United Response
Concerns summary (AI summary) The report identifies potential risks in resident care, including support workers not having keys for timely access, adequacy of staffing levels, review of risk procedures and staff training.
Anne Scott
Historic (No Identified Response)
2016-0024 12 Jan 2016 Cornwall
Cornwall and Isles of Scilly Safeguardi…
Concerns summary (AI summary) Community care providers lacked training to correctly interpret and act upon data from health monitoring devices, and county-wide safeguarding recommendations for such training remain unconfirmed.
Colin Williams
Historic (No Identified Response)
2016-0008 11 Jan 2016 Cornwall
Cornwall Council Local Adult Safeguardi…
Concerns summary (AI summary) A client with complex health and social needs, exacerbated by alcoholism, experienced "agency blindness" and lacked consistent support due to fragmented services, funding changes, and administrative difficulties.
Nicholas Milligan
Historic (No Identified Response)
2016-0007 11 Jan 2016 Cornwall
British Maritime Federation Royal Yachting Association
Concerns summary (AI summary) The increasing speed and power of power boat leisure craft creates additional risks that users should be aware of to prevent accidents.
Emily Milligan
Historic (No Identified Response)
2016-0007-wp25057 11 Jan 2016 Cornwall
British Maritime Federation Royal Yachting Association
Concerns summary (AI summary) The increased speed and power of modern power boat leisure craft introduce additional risks, requiring greater awareness from users to prevent accidents.
Robin Brett
Historic (No Identified Response)
2016-0013 11 Jan 2016 Wiltshire and Swindon
Great Western Hospital NHS Foundation T…
Concerns summary (AI summary) A missed steroid dose went unnoticed due to a lack of system alerts on both paper and electronic drug charts for patients on long-term steroid therapy.
Norman Dorn
Historic (No Identified Response)
2016-0006 8 Jan 2016 Cornwall
Care Quality Commission Cornwall and Isles of Scilly Safeguardi…
Concerns summary (AI summary) Cornwall care homes may lack adequate or updated policies for recognising and confirming death and for resuscitation, with staff often lacking awareness and proper training.
Joanne French
Historic (No Identified Response)
2016-0004 7 Jan 2016 West Sussex
Sussex Partnership NHS Trust
Concerns summary (AI summary) Early patient discharge was hampered by unclear assessment requirements, a failure to include family input in decision-making, and inaccurate or incomplete discharge assessment notes.
Mark Holdsworth
Historic (No Identified Response)
2016-0003 4 Jan 2016 Central Lincolnshire
Lincolnshire Police
Concerns summary (AI summary) Police failed to communicate critical information about the deceased's recent suicide threat to arresting officers and custody staff, resulting in an incomplete risk assessment upon release.
Gary Peel
Historic (No Identified Response)
4 Jan 2016 West Yorkshire (West)
SUSTRANS
Concerns summary (AI summary) The need for deterrent measures on viaduct walls should be reviewed to prevent future deaths from individuals jumping.