2017
PFD Reports
Reports: 446
Areas: 66
65% response rate (above 63% average).
Michael Drewry
All Responded
2017-0386
28 Dec 2017
Nottinghamshire
Nottinghamshire Healthcare NHS Trust
Concerns summary (AI summary)
The Crisis Team failed to provide consistent care, maintain accurate records, or promptly escalate concerns, leading to delays in crucial decision-making regarding the patient's management and potential hospitalisation.
Action Planned
(AI summary)
The Trust is shortly to introduce the Modified Modified Continuity Index (MMCI) into its routine reporting systems, and staff have been reminded of the importance of timely input in team meetings and managerial supervision on a monthly basis.
Mark Welsh
All Responded
2017-0456
28 Dec 2017
London Inner (North)
Transport for London
Concerns summary (AI summary)
Transport for London displayed an inordinate delay in implementing pedestrian crossings at a dangerous junction, using flawed decision-making based on incomplete accident statistics that omitted overall incidents and near misses.
Action Planned
(AI summary)
Subject to Camden Council agreement, Transport for London intends to progress a banned turning movement in order to provide a signal controlled crossing on Dukes Road, to be implemented next year.
Russell Robb
All Responded
2017-0385
22 Dec 2017
Manchester (South)
Trafford Adult Safeguarding Board
Trafford Clinical Commissioning Group
Concerns summary (AI summary)
A lack of regular medication reviews and guidelines on drug quantities, coupled with limited information sharing between safeguarding bodies, meant significant police interactions with the deceased were missed, hindering appropriate strategic oversight.
Action Taken
(AI summary)
Greater Manchester Police (GMP) now record high volume callers more accurately, and the GMP function that prioritises and allocates cases now sits within the Partnership Office. A revised policy is attached.
Ronald Farrington
Partially Responded
2017-0494
22 Dec 2017
Surrey
Surrey First Community Health Care
Care Quality Commission
Saffronland Homes limited
+1 more
Concerns summary (AI summary)
The care centre failed to implement specialist nursing advice, kept inaccurate records, and didn't seek medical attention for infection, exacerbated by inadequate tissue viability nurse staffing and poor CQC oversight.
Action Taken
(AI summary)
Surrey County Council has improved systems to identify long running adult safeguarding enquiries and take actions to bring them to a satisfactory conclusion, and has reduced the percentage of enquiries in progress for over 12 months. The care home has implemented structures and processes to avoid similar situations, including computerized care plans for wound and tissue care, regular reviews, and updates based on professional visits, audited by staff and SMT.
Sheila Ross
Historic (No Identified Response)
2017-0384
21 Dec 2017
Brighton and Hove
Carlton House Rest Home
Compliance Manager
Concerns summary (AI summary)
The report is incomplete and does not contain any specific concerns from the coroner.
Margaret Postill
Partially Responded
2017-0382
21 Dec 2017
Manchester (South)
Sunnyside Care Centre
Tameside General Hospital
Concerns summary (AI summary)
There was a lack of patient evaluation and incomplete assessment sheets after the deceased's return to the care home, compounded by poor quality hospital documentation lacking detail on clinical decision-making.
Action Taken
(AI summary)
The home has established an internal falls team, which comprises all the Heads of Department in the home and are subject to audit every three months. Each accidentlincident record has @ 24 hour observation record and an additional clinical walk round.
Craig Royce
Partially Responded
2017-0379
20 Dec 2017
Essex
Bindmans Solicitors
Care UK
Essex Partnership NHS Trust
+2 more
Concerns summary (AI summary)
A lack of a formal, robust documentary system for referring prisoners to mental health services meant reliance on unreliable telephone conversations, risking delays in crucial assessments.
Action Taken
(AI summary)
Since taking over prison healthcare services in 2017, Essex Partnership University NHS Foundation Trust has implemented a robust documentary system for referral of prisoners to mental health care, including widening the availability of a referral form to all prison staff.
Scott Rayner
All Responded
2017-0345
20 Dec 2017
Hertfordshire
Network Rail
Concerns summary (AI summary)
Inadequate fencing adjacent to the railway track, specifically behind a scrap metal dealer, presented a significant risk of trespass onto a high-speed line for both adults and children.
Action Taken
(AI summary)
Following a post-incident report, Network Rail inspected boundary fencing around St Albans Road and Bedford Street, and completed enhancement work on 22 February 2018, including installing additional palisade fencing in the area.
Lindsey Parker
All Responded
2017-0378
19 Dec 2017
Manchester (North)
Salford Royal Hospital
Concerns summary (AI summary)
Multiple issues included a lack of continuity in medical care, significant gaps in basic nursing observations, failure to recognise patient deterioration, and concerns over 'Hospital at Night' co-ordinators' qualifications for medical prioritisation.
Action Taken
(AI summary)
Salford Royal NHS Foundation Trust has implemented changes, including ensuring all staff are aware of the procedure for requesting additional reviews, implementing a clear escalation process, and clarifying the role and qualifications of the 'Hospital at Night' site coordinators, who triage electronic referrals from a senior experienced registered nurse.
Naomi Sourbut
Historic (No Identified Response)
19 Dec 2017
Exeter and Greater Devon
Devon Partnership Trust
Concerns summary (AI summary)
Recommendations from a 2017 root cause analysis report regarding suicidal ideation and protective factors for individuals expressing intent to self-harm were not clearly implemented.
Anne Morris
Partially Responded
2017-0383
18 Dec 2017
London Inner (South)
Oxleas NHS Trust
Department of Health
The Care Quality Commission
+2 more
Concerns summary (AI summary)
Hospital staff did not contact friends and relatives after the patient consented, and there was no written plan identifying the responsible team for onward care in the community. The community team also did not proactively contact the hospital for a discharge plan.
Action Planned
(AI summary)
Priory Group has reviewed and re-launched its Admission, Transfer and Discharge Policy and plans a rolling programme of training webinars in 2018, where discharge planning and communication with family/friends will be highlighted. Oxleas Home Treatment Team now contacts the referring organisation to request discharge information within 24 hours if it's not received, and the 'Transfer of Care within Oxleas and externally' protocol has been reviewed to ensure standardisation across all Oxleas services.
Stephen Shaylor
Partially Responded
2017-0380
18 Dec 2017
Exeter and Greater Devon
Care UK
Dorset Health Care University
Home Office
Concerns summary (AI summary)
Prison healthcare for detox inmates was "not fit for purpose" due to insufficient stabilisation places and inadequate night welfare checks. Intermittent observations are insufficient to detect self-harm, requiring continuous monitoring.
Noted
(AI summary)
Care UK clarified that night welfare checks are conducted by HCAs, with a nurse available for assistance, and that the nurse from the Integrated Substance Misuse Service reviews the welfare check list daily; they reiterate that ACCT documentation is the responsibility of prison staff and the welfare checks don't replace it, and that the MPCCC clinic is held weekly.
Mark Doyle
Partially Responded
2017-0375
18 Dec 2017
London Inner (North)
Care UK
HMP Pentonville
HM Prisons and Probation Service
Concerns summary (AI summary)
Significant failings in ACCT case reviews, inadequate healthcare information sharing, and a lack of clear criteria for prisoner transfer decisions were identified. There is also no mandatory first aid training for existing prison officers.
Action Taken
(AI summary)
Care UK has reflected on the inquest and reviewed healthcare processes, embedding Local Operating Procedures (LOPs) with senior management audits, to ensure relevant risks and triggers are identified and shared with the prison; additionally, prisoners admitted to the Substance Misuse Unit will remain for a minimum of two weeks, with senior manager and clinical lead reviews before any moves.
Pamela Hands
Partially Responded
2017-0373
18 Dec 2017
Cornwall and the Isles of Scilly
Royal College of Emergency Medicine
Royal College of Surgeons
Concerns summary (AI summary)
A critical risk of respiratory depression in opioid-treated patients receiving nerve blocks was not widely recognised, and national monitoring guidelines were absent. This necessitates new guidelines and professional awareness.
Action Planned
(AI summary)
The British Orthopaedic Association (BOA) intends to update its BOAST (BOA Standards for Trauma) document that covers the management of hip fractures to reflect and emphasise the need for appropriate monitoring of all patients, particularly those in pain pre or post procedure, within the next 12 months.
Daniel Watson
Partially Responded
2017-0370
18 Dec 2017
North Wales (East and Central)
Betsi Cadwaladr University Health Board
Wrexham County Council
Ysbyty Gwynedd
Concerns summary (AI summary)
A root cause analysis identified numerous care and service delivery problems, missed opportunities, and a lack of staff understanding. Significant improvements are needed in mental health teams' risk assessment and escalation training.
Action Planned
(AI summary)
The University Health Board will provide further debriefing and supervision for the Community Psychiatric Nurse (CPN), hold a focused session for the wider team on empathy and transparency, continue to make available the WARRN Accredited Programme for Care Coordinators, and update the MHLD Supervision Guidance for Nurses and Support Workers Policy by the end of February 2018. Wrexham Adult Social Care will provide feedback and management supervision to the social worker involved, implement the Mental Health and Learning Disability Supervision Guidance for Nurses and Support Workers Policy, and include relevant staff in the Wales Applied Risk Research Network (WARRN) training and specific training on assessment of suicide.
Ernest Smith
All Responded
2017-0459
14 Dec 2017
Surrey
Surrey and Borders Partnership NHS Trust
Concerns summary (AI summary)
The system for managing GP correspondence and medication review requests remains flawed. There is also no clear system to update GPs when patients are not under the medical team, risking unrecognised disengagement.
Action Planned
(AI summary)
The Adult Mental Health Division has created an action plan to address the coroner's concerns, which will be monitored at monthly Quality Assurance Group meetings and shared with other service divisions.
Maurice Wrightson
All Responded
2017-0372
13 Dec 2017
Northumberland (North)
Volvo Group (UK) Limited
Concerns summary (AI summary)
Volvo vehicle manuals provide insufficient guidance on using automatic i-shift gears for long downhill descents, which could exacerbate brake fade. Manufacturers need to supply clear instructions for these technologies.
Disputed
(AI summary)
Volvo Group UK does not support the statement that using automatic gear mode exacerbates brake fade in long descents, arguing that the correct use of the retarder is more important than the gearbox mode.
Rebecca Romero
Historic (No Identified Response)
2017-0369
13 Dec 2017
Avon
Avon & Wiltshire Mental Health Partners…
Dorset Healthcare University NHS Trust
NHS England
Concerns summary (AI summary)
The patient was discharged into an inadequate community care package with insufficient post-discharge contact and delayed medical review. There was confusion over unit transfers and inconsistent risk assessment terminology among staff.
Joseph Dune
Historic (No Identified Response)
2017-0371
12 Dec 2017
Isle of Wight
Care Quality Commission
Isle of Wight NHS Trust
St Mary’s Hospital
Concerns summary (AI summary)
Significant breaches in Information Governance allow clinicians to alter patient records under incorrect logins, making these critical changes invisible to treating clinicians and compromising data integrity.
Francis Beech
Partially Responded
2017-0367
12 Dec 2017
Birmingham and Solihull
Heart of England NHS Trust
St Giles Care Home
Concerns summary (AI summary)
The hospital lacked clear guidelines for high-risk fracture management, leading to poor continuity of care and inadequate discharge planning. The nursing home also failed to implement cast care plans, monitor for infection, or train staff.
Action Taken
(AI summary)
The care home has implemented a care of plaster cast policy and procedure, a care of plaster cast care plan, supervision and training with staff, and the National Early Warning score.
Sidonio Teixeira
Historic (No Identified Response)
2017-0366
12 Dec 2017
Worcestershire
HMP Long Lartin
Concerns summary (AI summary)
The adequacy of prison intelligence processes, including reporting and analysis, was questioned. A critical internal report on these issues was not shared with relevant staff, indicating a failure to learn lessons.
Irene Baker
All Responded
2017-0363
11 Dec 2017
Avon
Rosewood Lodge Nursing Home
Concerns summary (AI summary)
The care home failed to revise mobility care plans despite documented deterioration and missed monthly reviews. They also failed to escalate concerns, like inability to weight-bear, to a GP or emergency services.
Action Taken
(AI summary)
Rosewood Lodge has overhauled care plans, improved the management team structure, provided further staff training, and implemented a new computerised care plan software system and CCTV in communal areas. They also use sensor mats for residents at high risk of falls.
Paul Gander
Historic (No Identified Response)
2024-0092
8 Dec 2017
West Sussex, Brighton and Hove
Brighton and Sussex University NHS Hosp…
Concerns summary (AI summary)
A consultant was unable to access crucial electronic patient records from other hospital departments out-of-hours. Full access for authorised personnel is imperative to prevent future deaths.
Roger Saxby
Partially Responded
2017-0365
8 Dec 2017
Brighton and Hove
Brighton and Sussex University Hospital…
St George’s University Hospitals NHS Tr…
Concerns summary (AI summary)
The provided text only states the coroner's statutory duty to report concerns without detailing specific issues identified.
Noted
(AI summary)
St George's argues that thrombolysis was commenced as soon as practically possible and that the transfer back to RSCH was done with the patient's full agreement; transfers will only take place in exceptional circumstances after due consideration.
Benjamin Goodrum
All Responded
2017-0362
8 Dec 2017
Norfolk
Norfolk and Suffolk NHS Trust
Concerns summary (AI summary)
Although there was evidence of good communication with Mr Goodrum, the coroner noted that no one person took overall responsibility for him after his allocated co-ordinator left.
Action Taken
(AI summary)
The Trust has implemented a new recruitment system (TRAC), engaged a partner organization to promote career opportunities through social media, and has action plans for 'hotspot' areas.