2016

PFD Reports
Reports: 472 Areas: 69

65% response rate (above 63% average).

Clear 222 results
Mary Walker
All Responded
2016-0150 21 Apr 2016 Manchester West
Belong Village Care Quality Commission
Concerns summary (AI summary) Night-time patient checks lacked specific details on patient condition, and there was unclear guidance for care assistants on escalating health concerns. Both procedures require urgent review.
Action Taken (AI summary) Belong Wigan has provided refresher training to all staff on 'Safe Management of Records' policy and procedures, emphasizing accurate recording. All support workers have been reminded of procedures to escalate health concerns. The CQC undertook a comprehensive ratings inspection at Belong Wigan Care Village and found a flow chart for unexpected changes in health had been developed and given to every member of staff and was displayed within each household. Also, a night time record sheet had been introduced.
Angus West
All Responded
2016-0158 20 Apr 2016 Yorkshire West (Eastern)
York Teaching Hospitals NHS Foundation …
Concerns summary (AI summary) The placenta was not retained after a baby's death, impeding a comprehensive post-mortem examination to determine the cause, such as infection or cord issues.
Noted (AI summary) The Royal College of Midwives agrees with the coroner's recommendations to retain and safely store placentas for babies compromised in labour. They provide information regarding current practice, disposal and reasons to store placenta within the NHS. York Teaching Hospital is instituting a standard operating procedure in respect to retention of placenta following childbirth by September 2016. They have already established that all placentas are routinely inspected at all deliveries, and that all placentas from stillborn infants or intra partum deaths are sent for detailed histopathology examination.
Helen Patton
All Responded
2016-0152 20 Apr 2016 Newcastle Upon Tyne
Department of Health and Social Care
Concerns summary (AI summary) Mini Tracheostomy Procedures pose an ongoing mortality risk due to being frequently performed outside theatre and without ultrasound guidance. A critical lack of national guidelines exacerbates these risks.
Noted (AI summary) The Department of Health acknowledges concerns regarding mini tracheostomy procedures, and includes a joint response from the Faculty of Intensive Care Medicine (FICM) and the Royal College of Anaesthetists (RCOA). They confirm that routine use of ultrasound is not mandated and references various guidelines related to tracheostomy procedures. The Faculty of Intensive Care Medicine and Royal College of Anaesthetists reviewed information about a death following a minitracheostomy, but state the provided data is inadequate to answer questions definitively and note that routine ultrasound is not mandated prior to minitracheostomy.
Luke Ayres
All Responded
2016-0148 15 Apr 2016 Birmingham and Solihull
Birmingham and Solihull Mental Health N…
Concerns summary (AI summary) Delays in emergency response were caused by a cut-off 999 call, a staff member providing ambulance information from a distance without current patient status, and paramedics not being immediately escorted to the ward.
Action Planned (AI summary) The trust has improvement measures in place including implementation of a single anti barricade system, replacement of 70 observation panels and piloting of a new clinical handover tool. The trust will also implement a more robust approach to Environmental and ligature risk assessments and extend the simulation of medical emergencies on wards.
Adele Blakeman
All Responded
2016-0145-wp25219 15 Apr 2016 Manchester South
Greater Manchester Police
Concerns summary (AI summary) The antiquated GMP computer system hinders officers' access to critical information, preventing adequate situation assessment. Officers also failed to consistently record pertinent intelligence on individual profiles.
Action Planned (AI summary) • GMP is investing significantly in the replacement of technology through the IS Transformation Programme to replace existing separate command and control, custody, intelligence, work allocation, and property systems with one user experience and more intelligence information management process that enables partner agency information sharing (iOPS). • Mobile technology is distributed to operational staff which is already demonstrating through pilot site a significant forwards steps in information access, input, and decision-making. • GMP is undertaking comprehensive procurement, design and testing process before implementation which is currently scheduled for late 2017.
Hayley Clark
All Responded
2016-0143 12 Apr 2016 Yorkshire South (East District)
Rotherham Hospital NHS Foundation Trust
Concerns summary (AI summary) Staff failed to adjust the paracetamol dosage to reflect the patient's extremely low body weight, indicating a lack of appropriate medication management.
Action Planned (AI summary) An action plan is in place to ensure correct management of oral paracetamol for adult patients of extremely low body weight, including updating the drug chart, developing information for staff, and providing additional training. An audit of documentation of weights recorded in relevant nursing records and charts and on prescription charts will be undertaken.
Joyce Carney
All Responded
2016-0140 7 Apr 2016 Manchester West
Department of Health and Social Care Greater Manchester Police Home Office +2 more
Concerns summary (AI summary) Fragmented risk assessments and a lack of communication between police and hospital staff led to a misunderstanding of the ward layout, inadequate patient supervision, and a failure to assess risks to other patients and staff. There were no agreed protocols or senior oversight.
Action Planned (AI summary) The Trust has been working with Greater Manchester Police to learn lessons and address concerns including the security of patients under arrest and the protection of other patients. A final draft of the 'Patient Under Escort Record' is to be agreed and training on its use will be rolled out. The Department of Health has shared a report with NHS Protect to support a joint DH Home Office initiative to develop protocols, policies and procedures, to provide a national framework for joint risk assessments between police and NHS staff for patients detained at a hospital under arrest. The Minister for Policing will write to the National Policing Lead for Custody, Chief Constable to raise the matter with Chief Constables across England and Wales. The College of Policing is leading a programme of work aiming to set a national framework clarifying the roles and responsibilities of health and policing partners to maintain safety in mental health settings.
Matthew Sargent
All Responded
2016-0138 7 Apr 2016 Worcestershire
Government Legal Department Worcestershire Health and Care NHS Trust
Concerns summary (AI summary) Critical information sharing failures occurred as historical prisoner data and ACCT histories were not consistently reviewed or shared with healthcare staff upon reception. Personal officers also lacked regular meetings, limiting their knowledge of individuals.
Noted (AI summary) Care UK notes the concerns raised but states that the role and responsibilities of Personal Officers fall within the remit of the Prison Service. They note that PSI 74/2011 sets out the mandatory requirements for prison staff and healthcare in respect of prisoner's ACCT status ACCT alerts and risk assessments. Following concerns regarding the Personal Officer scheme, the prison will ensure that all staff are reminded of the policy. In response to concerns about historical information, a process has been put in place to ensure that staff have access to historical information where this information is available.
Milly Zemmel
All Responded
2016-0139 6 Apr 2016 Manchester City
North Manchester General Hospital
Concerns summary (AI summary) There were gross failures in applying the falls risk policy, escalating clinical review, providing one-to-one supervision, and handing over critical patient information, leading to an unsupervised, vulnerable patient falling. The internal investigation was also inadequate.
Action Taken (AI summary) The Trust has revised its Incident Reporting and Investigation Policy, launched an Enhanced Patient Observation Policy, and will include failure to escalate lack of medical review in the Lessons Learned Bulletin. Staff will use the SBAR communication tool.
Kristian Jaworski
All Responded
2016-0125 4 Apr 2016 London (North)
Department of Health and Social Care
Concerns summary (AI summary) A presumption in favour of vaginal delivery, partly driven by cost, needs to be re-evaluated to ensure patient safety and appropriate medical decision-making.
Noted (AI summary) The Department refers to existing Royal College of Obstetricians and Gynaecologists (RCOG) guidelines on operative vaginal delivery and General Medical Council (GMC) guidance on record keeping, but does not commit to any specific new actions.
Arthur Mason
All Responded
2016-0128 1 Apr 2016 Norfolk
Maurice Mason Ltd
Concerns summary (AI summary) Staff lacked formal risk assessment training and failed to identify risks for farm tasks, compounded by the absence of a comprehensive emergency plan for hazardous areas.
Action Taken (AI summary) The company has ceased the practice of personnel entering grain bins for cleaning. They have also booked IOSH Directing Safely and Managing Safely courses for staff.
Lillian Hursell
All Responded
2016-0129 1 Apr 2016 Mid Kent and Medway
Ranc Care Home Ltd
Concerns summary (AI summary) Faulty bedrail mechanisms led to instability, and staff provided inappropriate first aid after a patient's fall by moving her without assessing potential head and neck injuries.
Action Taken (AI summary) The care home has commenced retraining in first aid, moving and handling, and health and safety. They have introduced bedrail audits, re-educated staff in bed rail use, and advised staff not to move a person following a fall until assessed.
Sheila Slater
All Responded
2016-0127 31 Mar 2016 South Lincolnshire
Department for Transport
Concerns summary (AI summary) The staggered junction of the A16 with the B1166 is part of the Crowland Bypass which was pened in 2010 and there have been 3 fatalities associated with this junction and 10 injury producing collisions.
Noted (AI summary) The Department refers to existing design standards and notes the local authority is responsible for road safety. Highways England has been undertaking a scoping study with a view to updating the design guidance.
John Watt
All Responded
2016-0124 31 Mar 2016 Surrey
Surrey Local Highways Services Group Ma…
Concerns summary (AI summary) The lack of a safe or controlled pedestrian crossing on the main A25 road in Abinger Hammer village poses a significant risk to locals and visitors, especially families.
Action Planned (AI summary) Surrey County Council will request funding for a feasibility study to determine if a pedestrian crossing facility is possible and safe, will inspect and recondition the existing Vehicle Activated Sign and investigate the provision of signs to warn drivers that pedestrians are crossing the A25.
David Curtis
All Responded
2016-0144 31 Mar 2016 Exeter and Greater Devon
Devon County Council Devon Highways
Concerns summary (AI summary) Inconsistent and inadequate road signage fails to warn motorists of a critical left-hand bend immediately beyond a hill crest, unlike the opposite direction which has appropriate warnings.
Action Planned (AI summary) Devon County Council will erect a left-hand bend warning sign in advance of the crest of the hill on the A3079; work is anticipated to be completed by 31st July 2016.
Steven Nicholson
All Responded
2016-0135 30 Mar 2016 Newcastle Upon Tyne
Durham County Council
Concerns summary (AI summary) The A1018 slip road lacks appropriate lighting to identify sudden hazards and crucial signage warning motorists of flooding risks.
Action Planned (AI summary) The council is implementing a scheme to improve highway drainage by replacing side gullies with more effective open gullies, expecting completion by the end of July 2016. They have arranged for temporary flood warning signs to be deployed until the works are complete.
Mandeep Singh
All Responded
2016-0116 23 Mar 2016 Teesside
North East Ambulance Service NHS Founda…
Concerns summary (AI summary) Ambulance arrival was significantly delayed due to severe demand, staff shortages, and challenges presented by road closures and diversions.
Action Taken (AI summary) NEAS has improved its paramedic resource base, with improved attrition rates, and is working to educate the public about appropriate use of services. They work with other agencies for road closure information and include such closures in shift reports.
Alwyn Head
All Responded
2016-0115 23 Mar 2016 Mid Kent and Medway
Medway NHS Foundation Trust
Concerns summary (AI summary) Failures included not establishing MRSA history, withholding prophylactic antibiotics, lacking a post-operative wound care plan, and providing meaningless wound documentation, compromising patient safety.
Action Taken (AI summary) The Trust introduced new admission/transfer documentation for patient infection status, is providing staff training, and implemented ward-to-board rounds. A Deteriorating Patient Programme and a Sepsis Action Group are in place, and the Trust has provided feedback to the NICE consultation on the proposed new Sepsis Guidance.
Lincoln Brady
All Responded
2016-0118 23 Mar 2016 Teesside
South Tees Hospitals NHS Foundation Tru…
Concerns summary (AI summary) Conflicting examination results during labour were not adequately investigated, leading to an undiagnosed breach presentation and preventing appropriate planning for delivery.
Action Taken (AI summary) The Trust has implemented presentation scanning for women in labour, with a training and skills maintenance programme for midwives. The partogram will include a section for documenting scan results, and relevant guidelines and website information have been updated.
Jane Bell
All Responded
2016-0119 22 Mar 2016 Blackpool and Fylde
Dalmeny Hotal
Concerns summary (AI summary) Insufficient poolside supervision at the hotel due to infrequent patrols and reliance on CCTV monitored by reception staff who are also busy with other tasks, creating a risk of future deaths.
Action Taken (AI summary) The hotel has implemented constant poolside supervision, including patrolling staff and CCTV monitoring, with head counts recorded every 30 minutes. They have also hired a leisure club manager with extensive qualifications.
Jonathan Lander
All Responded
2016-0114 18 Mar 2016 Worcestershire
Worcestershire Health and Care NHS Trust
Concerns summary (AI summary) A critical policy for tracking patients discharged between services has not been implemented since 2015, despite being identified as necessary by a Root Cause Analysis, indicating a failure in governance.
Action Taken (AI summary) The Trust has implemented a Substance Misuse Information Sharing Protocol with Swanswell Worcestershire Recovery Partnership. Action Plans from Root Cause Analyses are now uploaded to an Embedded Lessons Database, monitored by the Governance Team.
Helen England
All Responded
2016-0141 16 Mar 2016 Manchester West
Department of Health and Social Care
Concerns summary (AI summary) No protocol or guidance exists for Mental Health Nurses regarding doctor referral decisions when discharging self-harm patients, particularly those on a Community Treatment Order, creating a significant risk.
Action Taken (AI summary) The Trust has amended its Community Treatment Order Procedure in light of the coroner's concerns and is communicating this to staff.
Anna Masson
All Responded
2016-0108 15 Mar 2016 Central Hampshire
Southern Health NHS Foundation Trust
Concerns summary (AI summary) A new mental health referral screening pathway, conducted by junior staff, may not be robust enough to identify urgent cases, and there is inconsistent practice across the Trust's mental health teams.
Action Planned (AI summary) The Trust is reviewing its CMHT Standard Operating Procedure (SOP) to standardize screening processes across all teams, ensuring appropriate staff expertise and multi-disciplinary team discussions. A randomised audit will be undertaken across CMHTs to ensure governance around the screening process, with completion expected in September 2016.
Margaret Metcalfe
All Responded
2016-0107 14 Mar 2016 Teesside
Rosedale Care Home
Concerns summary (AI summary) Both a patient's hand-held buzzer and specialist bed alarm failed to alert staff when she got out of bed, resulting in a fall that was only discovered by hearing a 'thud'.
Action Taken (AI summary) Rosedale Centre implemented a new policy regarding Care Assist pagers, including staff responsibilities for checking equipment, documenting its use, responding to alerts, and reporting problems, with monthly audits by the manager.
Jason Vaughan
All Responded
2016-0105 11 Mar 2016 South Yorkshire (East)
Rotherham, Doncaster and South Humber N…
Concerns summary (AI summary) The IAPT electronic patient record system has insufficient narrative detail, and its risk assessment tool cannot track minor patient deterioration. Practitioners may also lack awareness of increasing suicide rates in specific demographics.
Action Planned (AI summary) The Trust will reiterate the importance of recording all relevant data on the IAPT system through internal communications. The Trust is also part of a national 'Sign up to Safety' movement and is relaunching its campaign to reduce suicides.