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
Patricia Mercieca
All Responded
2016-0260 19 Jul 2016 London Inner (West)
Tunstall Response
Concerns summary (AI summary) Call handlers required refresher training on contacting resident managers during emergencies and lacked a protocol for raising immediate concerns when unable to get a response from emergency call system users.
Noted (AI summary) The London Ambulance Service states that based on their understanding of the call records, no changes to the questions asked of 999 callers would have enabled them to triage the call differently, unless they had been informed that contact with the patient had been lost.
Rosemarie Dees
Historic (No Identified Response)
2016-0259 19 Jul 2016 London Inner (South)
Resuscitation Council (UK)
Concerns summary (AI summary) An undetected foreign body airway obstruction could inhibit the use of a supraglottic airway, suggesting laryngoscopy should be a prerequisite for SGA insertion.
Khazna Khalaf
Historic (No Identified Response)
2016-0489 18 Jul 2016 West Yorkshire (West)
St Marien Hospital Trust
Concerns summary (AI summary) Local protocols and hospital guidelines were ineffective in alerting clinicians to ecstasy toxicity risks and symptoms, lacking a clear clinical protocol for initial intervention decisions and monitoring.
Sidney Alexander
Historic (No Identified Response)
2016-0257 18 Jul 2016 Lincolnshire (South)
United Lincolnshire Hospitals NHS Trust
Concerns summary (AI summary) Biopsy reports lacked sufficient space for consultants to fully complete their findings, resulting in incomplete and potentially inadequate medical documentation.
Margaret Gleeson
All Responded
2016-0255 15 Jul 2016 Manchester (West)
Wrightington, Wigan and Leigh Teaching …
Concerns summary (AI summary) Hospital weekend staffing levels were inadequate, leading to poor patient care. The MEWS tool was inaccurately scored and poorly understood, indicating a need for refresher training.
Action Taken (AI summary) The Trust reviewed staffing levels, provided refresher training on the MEWS tool, and conducted sepsis training, including drop-in sessions and mandatory attendance at a Sepsis Study Day for nursing staff, and is monitoring these actions via the Quality and Safety Committee.
Sydney Neil
All Responded
2016-0256 15 Jul 2016 Birmingham and Solihull
Birmingham Cross City Clinical Commissi… NHS England Wychall Lane Surgery
Concerns summary (AI summary) After a patient collapsed in a GP surgery, there was inadequate ventilation, no suction, and no oxygen provided for 8 minutes, raising concerns about resuscitation expertise and equipment in GP practices.
Action Planned (AI summary) Following a SUDIC case discussion, the practice incorporated continuous oxygen saturation readings during nebulisation into their acute asthma management protocol and implemented outcomes from a serious case review into their emergency protocol. NHS England acknowledges the concern regarding suction equipment and oxygen at the GP surgery, and highlights ongoing work to improve asthma management in primary care by communicating updated guidelines to GP practices and CCGs. They have also requested that the CQC ensure primary care services carry the necessary equipment and skills to address respiratory emergencies. The CCG reviewed guidance on basic equipment requirements for GP practices, including CPR training and equipment such as AEDs and oxygen, and will ensure practices adhere to this guidance via contract visits and disseminate learning from this incident to other CCGs.
Leilani Chute
All Responded
2016-0251 15 Jul 2016 West Sussex
St Richard’s Hospital Western Sussex Hospital NHS Trust
Concerns summary (AI summary) Junior doctors used non-standard medical practice without consultant knowledge, and consent for women in labor was not truly informed. Crucially, these issues were not identified by the Trust's internal investigation.
Action Taken (AI summary) Western Sussex Hospitals NHS Trust has audited the practice of manually pushing back the cervix, provided feedback to staff involved, and is offering additional training on cardiotocograph (CTG) interpretation and consent; they are also reviewing processes for planning investigations when perinatal deaths have occurred.
James Kane
All Responded
2016-0253 15 Jul 2016 County Durham and Darlington
County Durham and Darlington NHS Trust Department of Health and Social Care
Concerns summary (AI summary) A patient died due to a drain, and a scan potentially could have reduced this risk, indicating a need for further consideration of policy changes regarding such procedures.
Noted (AI summary) The Department of Health consulted NICE and the Royal College of Radiologists and concluded that there is no case for the routine use of ultrasound prior to or during paracentesis, but highlighted the concerns to the NICE guideline surveillance team for consideration in future updates. County Durham and Darlington NHS Trust will provide all trainees with a copy of the guidance regarding large volume paracentesis, ensure a clear audit trail of patients undergoing paracentesis (including a proforma and database), and perform all procedures between 8am and 8pm; a patient information leaflet will also be available.
Fred Whittaker
Partially Responded
2016-0249 14 Jul 2016 Manchester (South)
Heaton Moor Medical Centre NHS England
Concerns summary (AI summary) A patient was erroneously re-prescribed medication due to the lack of a system for recording reasons for stopping drugs and poor prescription management, a risk potentially widespread in GP practices.
Action Planned (AI summary) NHS England has been assured that the practice involved undertook a review and will do a significant event analysis. NHS England will share learning and best practice with GPs and the Medical Director will write to all GPs in Greater Manchester to share learning and to medicine management teams to provide support to practices.
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.
Daniel Paylor
Historic (No Identified Response)
2016-0353 1 Jul 2016 Wiltshire and Swindon
Medicine and Health Care Products Regul… Home Secretary, Home Office Member of Parliament for Maidenhead, Ho…
Concerns summary (AI summary) Ambulance services exhibit inadequate regulatory control, safeguards, and auditing for drugs compared to hospitals, lacking sufficient peer supervision and requiring only single-person authority for drug access.
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.
Terence Stilges
Partially Responded
2016-0293 30 Jun 2016 Birmingham and Solihull
Heart of England NHS Foundation Trust NHS England
Concerns summary (AI summary) Repeated incorrect labelling of troponin blood samples resulted in unavailable critical diagnostic information, contributing to delayed diagnosis and patient discharge before subsequent readmission with an acute myocardial infarction.
Action Taken (AI summary) NHS England supports the Heart of England NHS Foundation Trust's actions to review electronic systems, ensure junior doctors are aware of the discharge process through training, have individual clinicians review the event in their annual appraisal, and include the event in their internal quality improvement process.
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.
Dominic Smith
Partially Responded
2016-0240 30 Jun 2016 Manchester (North)
Department of Health and Social Care N.I.C.E Pennine Acute Hospitals NHS Trust +2 more
Concerns summary (AI summary) Antenatal screening for Group B Streptococcus (GBS) was not routinely offered, and intrapartum antibiotics were not routinely offered to women testing positive, and communication, handover, and record keeping were inadequate.
Noted (AI summary) The RCPCH acknowledges the coroner's concerns regarding Group B Streptococcus (GBS) but states that they are not aware of any new evidence or guidance on GBS and refers to their May 2015 response, deferring to the RCOG guideline. They are unable to comment on specifics of the case and defer to the Pennine Acute Hospitals NHS Trust regarding local matters. The Pennine Acute Hospitals NHS Trust is undertaking a rolling audit program on communication and documentation, and commissioned an improvement program focusing on these three areas. The Preceptorship programme has been updated to provide a competency based framework and a practice development midwife has been recruited to support the preceptorship program.
John Betteridge
Historic (No Identified Response)
2016-0238 30 Jun 2016 County Durham and Darlington
G4S National Offender Management Service NHS England +1 more
Concerns summary (AI summary) Prison healthcare staff and a GP lacked or had insufficient ACCT training, resulting in non-adherence to mandatory ACCT procedures and indicating a clear, ongoing training need.
Peter Rowe
Historic (No Identified Response)
2016-0242 29 Jun 2016 Manchester (South)
Central Manchester University Hospitals…
Concerns summary (AI summary) A patient with severe memory loss was prescribed penicillin despite a documented allergy, which was later deleted. Allergy information was accepted uncritically from the patient and an uninformed spouse.
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.