2017
PFD Reports
Reports: 446
Areas: 66
65% response rate (above 63% average).
Alaanuloluwa Joseph
Historic (No Identified Response)
2017-0189
14 Jun 2017
London (West)
Hillingdon Hospitals NHS Trust
Concerns summary (AI summary)
Inaccurate monitoring and recording of fluid intake and output, a critical aspect of sepsis management, was not undertaken.
Maurice Macdonnell
All Responded
2017-0188
14 Jun 2017
London Inner (South)
Medicines and Healthcare products Regul…
Concerns summary (AI summary)
A potential conflict of interest arose when a doctor, also a research investigator, administered a second drug dose despite adverse effects, raising concerns about patient safety safeguards in clinical trials.
Noted
(AI summary)
The MHRA reviewed the SUSAR report and determined that the symptoms were in line with the known safety profile for nivolumab, and no further action is required for participants in nivolumab clinical trials. They also stated that conflict of interest lies outside the remit of MHRA for clinical trials.
Ellie Chappell
All Responded
2017-0198
14 Jun 2017
South Yorkshire (East)
Doncaster County Council
Concerns summary (AI summary)
The absence of warning signs on a road stretch with a high incidence of accidents due to slippery conditions poses an ongoing risk to drivers.
Action Planned
(AI summary)
Warning signs will be installed to warn of potential slippery road conditions by the end of September 2017.
Craig Hamilton
All Responded
2017-0197
13 Jun 2017
South Yorkshire (East)
Manor Field Surgery
Concerns summary (AI summary)
A lack of clear procedures to manage patients routinely obtaining or exceeding prescribed medication dosages, or to discuss alternative pain management, poses significant risks.
Action Taken
(AI summary)
The practice identified patients prescribed tramadol and other medicines with the potential for self-harm and changed all electronic prescriptions to paper format for review. They have changed their policy for repeat prescribing of all medication and created an amended 'Repeat Prescribing Policy and Procedure' and 'Acute Prescribing Protocol'.
Russell Sherwood
All Responded
2017-0192
13 Jun 2017
South Wales Central
South Wales Fire and Rescue Service
Concerns summary (AI summary)
The Fire Service departed a dangerous flood scene without closing the road or leaving warning signs, as their protocols and equipment do not permit road closures, relying solely on other authorities.
Action Planned
(AI summary)
The recommendations are being considered as part of its overarching response to the Fire Rescue Services (Emergencies)(Wales)(Amendment) Order 2017, with the outcome of the review reported by the Service's Senior Management Team by 31 October 2017.
William Wilson
Historic (No Identified Response)
2017-0186
12 Jun 2017
Manchester (South)
Church Inn
Concerns summary (AI summary)
The establishment lacked a clear system for alerting the designated first aider, and staff who attended the deceased were unfamiliar with basic life-saving first aid techniques.
Callum Smith
Partially Responded
2017-0185
7 Jun 2017
Avon
Avon and Wiltshire Mental Health NHS Tr…
Bristol Community Health
HMP Bristol
Concerns summary (AI summary)
There was a conflict in risk assessment methods for suicide/self-harm between healthcare staff and ACCT policy for prisoners. Staff required clearer guidance and detailed training on the ACCT process's lower threshold.
Action Planned
(AI summary)
Following the inquest, all healthcare staff will revisit the Prison Service Instruction (PSI) through Suicide and Self Harm (SASH) training and local training/meetings to ensure staff are fully aware of their obligations when adhering to PSI 64/2011.
Dennis Teesdale
All Responded
2017-0202
7 Jun 2017
West Sussex
Care Quality Commission
Department of Health, NHS England
Queen Victoria NHS Trust
Concerns summary (AI summary)
The hospital lacked specialist facilities and clinicians for complex procedures like PEG insertion. Written guidance was not followed, and no risk assessment was conducted for the procedure or alternative feeding methods.
Noted
(AI summary)
The Department of Health acknowledges the concerns and outlines the actions taken by other bodies (NHS England, NHS Improvement, CQC) but does not commit to any specific actions by the Department itself, beyond requiring trusts to publish data on avoidable deaths. The hospital acknowledges the concerns and outlines several actions, including reviewing the previous non-compliance with internal guidelines, but no specific actions are identified as already completed. The CQC response notes that the trust has already included items on its action plan to improve multidisciplinary communication and documentation and will monitor progress. The trust has also put forward a business case for a CT scanner on site, which the CQC will monitor.
Joyce Rumming
All Responded
2017-0182
6 Jun 2017
Wiltshire and Swindon
Great Western Hospitals NHS Trust
Concerns summary (AI summary)
Poor communication between software packages meant an allergic marker for Amoxicillin was missed, leading to the patient being administered a drug they were allergic to.
Action Planned
(AI summary)
The trust is working to improve the handover process with ambulance services, including plans for a new clinical note system including patient allergies. They are also exploring the IT infrastructure to improve information sharing and migrating the Emergency Department to the same server as the rest of the Trust.
George Cheese
All Responded
2017-0179
6 Jun 2017
Berkshire
Woodley Centre Surgery
Concerns summary (AI summary)
A patient with known suicidal thoughts was prescribed a large quantity of antidepressant medication. There was no system or "flag" in their notes to limit repeat prescriptions in such circumstances.
Action Taken
(AI summary)
The surgery introduced a policy requiring GPs only to issue repeat prescriptions and conduct depression reviews. They will also discuss the role of clinicians at a clinical meeting and arranged for a consultant psychiatrist to talk about management of mental health disorders.
Jack Braniff
Partially Responded
2017-0183
5 Jun 2017
Manchester (North)
Highways England
Oldham Council
Concerns summary (AI summary)
The coroner raises concerns that the size and position of an illuminated advertising board obstructs views for pedestrians and drivers, and that overhanging tree canopies compounded visibility issues at the collision site.
Action Planned
(AI summary)
The council will ensure the tree pruning program continues as efficiently as possible and is committed to reviewing the process and will implement practical improvements where appropriate.
David Hamilton
All Responded
2017-0180
5 Jun 2017
Manchester (South)
Grosvenor Medical Centre Stalybridge
Pennine Care NHS Trust
Concerns summary (AI summary)
Healthy Minds lacked documentation for therapy selection, clarity on referral triggers, and a formal escalation process for concerns. Limited information sharing between health professionals meant an incomplete patient picture.
Action Planned
(AI summary)
The practice escalated concerns about mental health support to the Clinical Commissioning Group. They escalated the matter to the Mental Health Clinical Lead and Head of Mental Health regarding the referral pathway to psychiatrists and the lack of sleep clinics. Healthy Minds service provides treatment options and offers advice. A log is kept on the system and patients can be "stepped up" during therapy. GPs can request consideration for assessment by a psychiatrist.
Derrick Brocklehurst
All Responded
2017-0181
5 Jun 2017
Manchester (South)
Tameside General Hospital
Tameside Metropolitan Borough Council
Concerns summary (AI summary)
A lack of documentation for carer visits and no system for recovering care notes meant care provision issues could not be established. The GP also did not receive a hospital discharge summary.
Action Planned
(AI summary)
The council will confirm in writing to all providers their obligations regarding Care Record Books, and the Homecare Commissioning Team will run a weekly report to track recovery of these books. The matter will be discussed at contract performance meetings if providers cannot recover records. The Trust has taken action to improve the timely completion of discharge summaries, including bringing in extra resources to clear a backlog. A new process and supporting documentation has been produced and disseminated to staff within the District Nursing Service, with compliance being monitored by team leaders.
Terry Latimer
Historic (No Identified Response)
2017-0178
1 Jun 2017
North Lincolnshire and Grimsby
North Lincolnshire Council
Concerns summary (AI summary)
A safeguarding notice with a request for Mental Health Services referral was not actioned. There was a lack of clarity among staff on whether such notices required follow-up or were just for information.
Michael Halfpenny
All Responded
2017-0174
1 Jun 2017
Leicester City and Leicestershire South
East Leicestershire and Rutland Clinica…
The Glenfield Surgery
University Hospitals of Leicester NHS T…
Concerns summary (AI summary)
A GP referral for vascular screening was sent to the wrong department and refused, with no follow-up. Both GP practice and hospital screening teams lacked awareness and proper systems for managing screening referrals.
Noted
(AI summary)
The surgery will raise the case as a discussion point in a practice meeting, make all doctors aware of self-referrals, and produce posters to put up in the waiting room to encourage patients with a family history of AA to self-refer for screening, also mentioning this fact in their PPG newsletter. The Trust has reviewed the process for rejecting imaging referrals and is strengthening the relevant guideline to include a clear statement of why the rejection was made. A new system has been implemented for redirecting imaging referrals sent to the incorrect team, and communication has been sent to GPs informing them how to refer into the Screening Programme. The CCG has enclosed the signed final report regarding the Serious Incident investigation into this case and confirmed that they have contacted the family to share the report.
Jonathan Palmer
Partially Responded
2017-0173
31 May 2017
London Inner (West)
HMP Wandsworth
Home Office
Concerns summary (AI summary)
There was no effective system for families to provide crucial health information for prisoners, nor assurance of its dissemination. Ineffective control of contraband (Spice) inflow posed significant health risks within the prison.
Action Taken
(AI summary)
A Safer Custody Learning Bulletin has been issued regarding receiving emergency calls and sharing risk information from families, Samaritans, and others. HMP Wandsworth conducts searches of all visitors and prisoners after visits and uses various methods for prisoner searches, including a new body scanner. Mail and property are searched, and a policy on property was updated in 2016.
Sarah Poole
All Responded
2017-0176
30 May 2017
Black Country
Royal Wolverhampton NHS Trust
Concerns summary (AI summary)
There were failures to record the reviewing doctor for an ECG and to account for previous abnormal ECG results during patient handover from paramedics.
Action Taken
(AI summary)
The Emergency Department has instigated a policy that all ECGs must be reviewed and signed off by a Senior Decision Maker. An algorithm for how to manage an abnormal ECG has been developed and will be in place for the next Junior Induction in August 2017. A way of summarizing ambulance handover information into 1-2 sheets has been introduced.
Kenneth Evans
All Responded
2017-0175
30 May 2017
Black Country
Dudley Group of Hospitals NHS Trust
Concerns summary (AI summary)
Thromboprophylaxis was not arranged, and an effective risk assessment for developing blood clots was not undertaken for the patient.
Action Taken
(AI summary)
Following the incident, it has been made clear to all staff that the Evergreen area is part of the Trust's services and subject to the VTE assessment policy. Awareness and the need for VTE assessments has been discussed with medical teams and will be raised again at the next mandatory Medicine Audit meeting. The Evergreen area is being reconfigured to re-designate the beds as acute.
Jamie Pashley
Partially Responded
2017-0172
28 May 2017
London Inner (South)
Department of Health and Social Care
Kings College Hospital
South London and Maudsley NHS Trust
Concerns summary (AI summary)
The system over-relied on individuals proactively managing their rehabilitation post-detoxification. Concerns included a lack of fixed appointments, follow-up calls, and limited availability of an alcohol liaison nurse post-discharge.
Action Planned
(AI summary)
The Trust acknowledges concerns about alcohol dependency patient follow-up. They are considering a business case to expand the Alcohol Liaison team to reduce ED attendances and admissions.
Doreen Miller
Historic (No Identified Response)
2017-0169
26 May 2017
Wiltshire and Swindon
Chippenham Community Hospital
Great Western NHS Hospital Trust
Wiltshire Health & Care
+1 more
Concerns summary (AI summary)
A safeguarding referral was improperly signed off by Wiltshire Council without investigation, and crucial cognitive assessment information was missing from the hospital discharge summary upon patient transfer.
Lucy Goldstone
Historic (No Identified Response)
2017-0168
26 May 2017
Manchester (City)
Department for Transport
Department of Health and Social Care
Concerns summary (AI summary)
There are no Automated Electronic Defibrillators (AEDs) available on trams or at tram stops across the Metrolink network.
Bonamie Armitage
Partially Responded
2017-0170
25 May 2017
Gloucestershire
Cotswold Hunt
Council of Hunting
the Masters of Foxhounds Association
Concerns summary (AI summary)
There are no mandatory requirements for child participants in a Hunt to wear protective equipment, demonstrate competence, or have adult supervision with a specified ratio.
Noted
(AI summary)
The Master of Foxhounds Association acknowledges the coroner's concerns but highlights its limited regulatory powers over hunts and participants. They will keep safety issues under review and note the Cotswold Hunt's approach to supervision of children.
Daphne Williams
Partially Responded
2017-0167
25 May 2017
North Wales (East and Central)
Betsi Cadwaladr University Health Board
HM Stanley Site
Welsh Ambulance Services NHS Trust
+1 more
Concerns summary (AI summary)
Persistent issues with ambulance delays, emergency department admissions, resource availability, and patient flow continue to place patients' lives at risk despite previous reports.
Action Planned
(AI summary)
The University Health Board and Welsh Ambulance Services NHS Trust are collaborating on several actions to improve patient flow, including implementing SAFER patient flow bundles, developing integrated discharge hubs, and working with local authorities to reduce delayed transfers of care.
Dominic White
Partially Responded
2017-0177
24 May 2017
London Inner (North)
Barnet, Enfield and Haringey Mental Hea…
Camden and Islington NHS Trust
Whittington Health NHS Trust
Concerns summary (AI summary)
A robust protocol is lacking to ensure all personnel are aware of patient observation levels. An approved mental health professional showed a lack of recognition regarding the absconding risk when allowing a detained patient leave.
Action Taken
(AI summary)
Whittington Health NHS Trust, Camden & Islington NHS Foundation Trust, and Barnet, Enfield and Haringey Mental Health NHS Trust have created a joint protocol to improve mental health observations in the Emergency Department, including daily safety huddles and escalation procedures. A learning event was held, and an independent review of serious incidents relating to mental health has been commissioned.
Robert Mullis
Partially Responded
2017-0166
23 May 2017
Kent (Central and South East)
Network Rail
South Eastern Railways
Concerns summary (AI summary)
A vulnerable, partially sighted patient with dementia was able to disembark a high-speed train unaccompanied and access railway tracks directly from the end of the platform.
Action Taken
(AI summary)
Network Rail has installed platform-end fencing and anti-trespass panels on platforms 2, 5, and 6 and the London end of platform 1 at Ashford International Station. Equivalent fencing will be installed at the country end of platform 1 by the end of July 2017.