2017
PFD Reports
Reports: 446
Areas: 66
65% response rate (above 63% average).
Kevin Morgan
All Responded
2017-0165
22 May 2017
Milton Keynes
Milton Keynes Council
Concerns summary (AI summary)
There was no effective follow up by social services and the housing team, a safeguarding alert was not properly addressed, and a meeting of senior professionals was not called to consider the case; there was no Serious Incident Review after the death.
Action Planned
(AI summary)
The Milton Keynes Safeguarding Board will not conduct a Safeguarding Adult Review but will undertake a learning review to identify practice improvements related to concerns raised in the Regulation 28 report. The review will include analysis of case reports, consideration of areas for concern, and a Signs of Safety approach.
Kate Dolby
Historic (No Identified Response)
2017-0164
19 May 2017
Nottinghamshire
Nottingham Clinical Commissioning Group
Concerns summary (AI summary)
Chronic underfunding and staff shortages in mental health services, particularly for doctors in the EIP team, led to precarious patient care and significant delays in treatment.
Alice Gibson-Watt
All Responded
2017-0163
18 May 2017
London (West)
NHS England
Concerns summary (AI summary)
A recurring failure to identify and appropriately escalate acutely physically unwell patients in mental health settings, compounded by insufficient vital sign monitoring and inconsistent use of early warning systems.
Action Taken
(AI summary)
NHS England outlines existing initiatives to improve perinatal mental health and the care of acutely unwell patients in mental health settings. This includes expanding access to specialist perinatal mental health care, rolling out the Recognising and Managing Patients Psychiatric Settings (RAMMPS) course, and supporting the Physical Health SMI CQUIN.
William Wilkes
Partially Responded
2017-0161
17 May 2017
Milton Keynes
Clinical Commissioning Group for Milton…
Milton Keynes University Hospital
Concerns summary (AI summary)
Hospital discharge procedures are unacceptably slow, taking weeks rather than days, highlighting a need for a more efficient local protocol between the Hospital Trust and CCG.
Action Taken
(AI summary)
Milton Keynes University Hospital NHS Foundation Trust has implemented a new policy, 'Patient's Choices To Avoid Long Hospital Stays', and is tracking delayed discharges daily via the Discharge Team. They participate in system-wide teleconferences and weekly length of stay meetings.
Lilly Baxandall
Partially Responded
2017-0160
17 May 2017
North Wales (East and Central)
Betsi Cadwaladr University Health Board
Conway County Council
Denbighshire County Council
+4 more
Concerns summary (AI summary)
Persistent, unresolved systemic issues, including ambulance handover delays, emergency department overcrowding, and bed blocking, continue to recur despite previous warnings, placing patients' lives at risk.
Action Planned
(AI summary)
Betsi Cadwaladr University Health Board, Welsh Ambulance Services NHS Trust, and the four Local Authorities are collaborating on actions to improve patient flow, including Innovation Unblocked event programmes and SAFER patient flow bundles.
Ruth Milne
Partially Responded
2017-0156
16 May 2017
South Lincolnshire
Lincolnshire Community Health Service N…
Lincolnshire Register Office
Concerns summary (AI summary)
Concerns about the lack of continuity and appropriateness of GP medical staff, and whether vital recommendations from a 2015 safeguarding report have been fully implemented.
Action Taken
(AI summary)
Lincolnshire Community Health Services reports on actions taken following a safeguarding report, including establishing leg ulcer clinics, integrating specialist nurses, reviewing caseloads, and providing training on leg ulcer care and safeguarding. An action plan tracker has also been introduced.
Blaise Alvares
Historic (No Identified Response)
2017-0157
15 May 2017
Wiltshire and Swindon
Chief Fire Officer’s Association
Concerns summary (AI summary)
This was at least the second fatality attributable to a Bio Ethanol burner, with previous accidental injuries also reported.
Sharon Soares
Historic (No Identified Response)
2017-0157-wp25813
15 May 2017
Wiltshire and Swindon
Chief Fire Officer’s Association
Concerns summary (AI summary)
There have been multiple fatalities and numerous accidental injuries linked to Bio Ethanol burners, indicating an ongoing and significant product safety risk.
Stephen Leven
All Responded
2017-0158
15 May 2017
London (North)
Department of Health and Social Care
Concerns summary (AI summary)
The lack of access for secondary care to crucial GP patient information, specifically a haemophilia diagnosis, poses a significant risk of future preventable deaths.
Action Planned
(AI summary)
The response outlines the Summary Care Record (SCR) system and NHS England's plans to mandate SCR access for 111, 999 services, and hospital acute admission areas by March 2016, including end-of-life and advanced care plans. It also mentions the development of an enhanced summary care record with greater access to patient care plans, special patient notes, and mental health crisis notes.
Howard Jeffers
All Responded
2017-0115
15 May 2017
London (North)
Pharmaceutical Chemistry, Drug Misuse a…
Concerns summary (AI summary)
The inability to accurately analyze and detect novel psychoactive substances (NPS) through toxicological testing poses an ongoing risk of future deaths.
Noted
(AI summary)
Imperial College London's Toxicology Unit acknowledges the difficulties in accurately analyzing and detecting NPSs due to their changing nature, lack of standards and pharmacological data, and states that no action is proposed. Alere Forensics describes its ongoing efforts to improve the analysis and detection of new psychoactive substances (NPS), including developing novel screening techniques, working with universities to obtain reference materials, and providing training to stakeholders. The Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit at the University of Hertfordshire is engaged in research to identify NPS and provide updated clinical guidelines, including using computational models to identify potential compounds before they appear on the market.
Nasar Ahmed
All Responded
2023-0134
12 May 2017
Inner North London
Department of Health and Social Care, L…
Concerns summary (AI summary)
A school nurse's inadequate medication review process included using an incorrect allergy action plan, not verifying medication in school, and failing to ensure updated, in-date medication.
Disputed
(AI summary)
Bow School is improving medication management systems, ensuring robust monitoring, and supporting staff to provide effective interventions; the school will brief staff on medical policies and procedures (repeated September 2017), place awareness posters throughout the school, annotate menus with allergens (September 2017), raise awareness of medical needs via Anaphylaxis Campaign and PSHE curriculum, and offer first aid training to pupils (Year 9 in July 2017, all pupils next year). The Department of Health will not pursue making generic adrenaline auto-injectors available in public places due to safety concerns raised by the MHRA, but they are amending regulations to allow schools to hold spare auto-injectors without a prescription for emergencies, effective from 1 October 2017, and are developing guidance for school staff on their use. Compass Wellbeing has undertaken an internal investigation, reinforced accurate record keeping, provided medico-legal training on documentation, reviewed and reran training on their Competency Framework, and is implementing an electronic diary system with reminders for follow-up actions. The London Ambulance Service (LAS) disputes the coroner's concern, stating that the Clinical Hub paramedic did not advise against using the EpiPen and that the call was appropriately managed and the LAS will take no action. BSACI has produced national guidelines for managing various allergies, promotes written personalized emergency management plans, and has been part of a campaign to allow schools to hold spare adrenaline auto-injectors, with revised regulations coming into effect on 1 October 2017, and is developing a website to support school staff. Barts Health NHS Trust will implement an action plan, work with partners on the Asthma Friendly Schools Project, promote the Healthy London Partnership Paediatric asthma toolkit, improve knowledge of long-term conditions in childhood, and standardize asthma management across Tower Hamlets in line with London Paediatric Asthma standards. The practice discussed the case as a team, reviewed individual consultations, contacted the pharmacy, and contacted the safeguarding team and hospital respiratory team for learning; the nursing team will now post/email a copy of the asthma action plan to the child’s school health team or give a copy to parents to hand in, starting July 2017; the nursing team will investigate anaphylaxis care plans in secondary care and incorporate them into care plans by September 2017.
Cedric Skyers
All Responded
2022-0305
10 May 2017
Inner South London
BUPA, Lewisham Adult Safeguarding Board…
Concerns summary (AI summary)
The care home's smoking risk assessment for immobile residents fails to adequately address immobility risks, lacks clear guidance on safety equipment provision, and does not document refusal of professional advice.
Action Planned
(AI summary)
Lewisham Safeguarding Adults Board commissioned a Safeguarding Adult Review in April 2016 with revised terms of reference and an expected conclusion in July 2017; the Board's annual report for 2017/2018 will contain full details of lessons learned and an action plan, and learning seminars will be held. The CQC is assisting the Fire Authority with a joint investigation and is planning to undertake a further unannounced comprehensive inspection of Manley Court in July 2017 to review documentation and consider whether the steps taken by the provider further reduce the risk to people at the service. BUPA has revised its safe smoking assessment and smoking policy, including offering smoking aprons and pendant alarms to residents who smoke in the garden, and requiring supervision for those who decline to wear aprons or have fire-retardant clothing. The updated policy removes staff discretion in risk assessments and requires documentation of residents' choices against professional advice.
Peter Richardson
Partially Responded
2017-0162
10 May 2017
Surrey
Garage Equipment Association
Health and Safety Executive
HSB Engineering Insurance Services Limi…
+4 more
Concerns summary (AI summary)
A lack of formal guidance on safe tolerances for critical elements of two-post vehicle lifts and insufficient torque specifications from suppliers creates an ongoing safety risk.
Action Planned
(AI summary)
HSB issued a technical document instructing surveyors to record pad wear on reports for vehicle lifting tables. They are also working with SAFed to establish a common approach to torque settings assessment, who are liaising with the HSE. The HSE intends to issue additional guidance concerning the inspection of two post ramps by thorough examiners, highlighting the risks and checks needed for the locking mechanism and lateral movement.
Richard Bull
Historic (No Identified Response)
2017-0154
10 May 2017
London (West)
Apple
Concerns summary (AI summary)
There is insufficient public perception of the risk associated with phone chargers in contact with water, requiring urgent and prominent safety warnings.
Maud Patrick
Historic (No Identified Response)
2017-0151
8 May 2017
Manchester (City)
Care Quality Commission
Manchester Clinical Commissioning Group
University of South Manchester Hospital…
Concerns summary (AI summary)
Systemic hospital care failures included no mental capacity assessment, poor A&E handover, unprogressed investigations, inadequate patient observations, and insufficient staffing and senior nursing leadership.
Andrew Wilson
Historic (No Identified Response)
2017-0152
8 May 2017
North East Kent
East Kent Hospital Foundation Trust
Concerns summary (AI summary)
No arrangements existed to provide peritoneal dialysis at non-renal hospitals, and treating clinicians were unaware of this service gap or the unavailability of trained staff and equipment.
David Sheppard
Partially Responded
2017-0153
8 May 2017
Birmingham and Solihull
Boldmere Court Care Home
Care Quality Commission
Department of Health and Social Care
Concerns summary (AI summary)
Communication breakdowns due to poor English language skills among care staff, inadequate first aid training, poor record-keeping, and substandard post-event investigation hindered effective emergency response and learning.
Noted
(AI summary)
The Department of Health acknowledges the concerns and outlines the responsibilities of care providers and the CQC. They clarify the role of the NMC and the requirements for language testing for non-regulated workers, noting the Care Certificate covers communication.
Muriel Brett
Historic (No Identified Response)
2017-0150
4 May 2017
Plymouth Torbay and South Devon
MRHA
Concerns summary (AI summary)
There are conflicting expert opinions regarding a potentially defective cardiac valve, with the operating surgeon identifying a defect not confirmed by an independent review.
Reginald Lewis
Historic (No Identified Response)
2017-0149
4 May 2017
Black Country
NHS Foundation Trust
New Cross Hospital
Concerns summary (AI summary)
Inadequate patient supervision, staff unawareness of visitor departures, and overcrowded wards with pressured junior staff accepting high-needs patients created an unsafe care environment.
Beryl Varcoe
Historic (No Identified Response)
2017-0144
3 May 2017
Surrey
Elmbridge Borough Council
Concerns summary (AI summary)
Community alarm installation officers may not have thoroughly range-tested devices, risking alarms not functioning throughout clients' homes, affecting a significant number of existing users.
Margaret Conway
Historic (No Identified Response)
2017-0145
3 May 2017
West Yorkshire (East)
Mid Yorkshire NHS Trust
South West Yorkshire NHS Trust
Concerns summary (AI summary)
Systemic separation of mental and physical health services led to challenging patient transfers and fragmented care for individuals with co-occurring serious mental and physical health problems. Closer integration and shared resources are needed.
Rayan Ahmed
Historic (No Identified Response)
2017-0148
3 May 2017
Avon
North Bristol NHS Trust
Concerns summary (AI summary)
Inadequate handover procedures in the special care unit mean nurses may care for unfamiliar babies during breaks, highlighting a need for comprehensive handover covering all potential responsibilities.
Ida Toole
Historic (No Identified Response)
2017-0146
2 May 2017
Milton Keynes
Excel Care
Concerns summary (AI summary)
A high falls risk patient was denied a sensor mat based on mental capacity, demonstrating a policy requiring urgent review for potentially neglecting safety needs.
Daniel Dunkley
Historic (No Identified Response)
2017-0147
2 May 2017
Milton Keynes
HMP Woddhill
Concerns summary (AI summary)
The report notes that three referrals were made for Mr Dunkley to undergo a full mental health assessment before his death.
Ahsiyah Bibi
Historic (No Identified Response)
2017-0142
30 Apr 2017
Birmingham and Solihull
Heart of England NHS Trust
Concerns summary (AI summary)
Critical blood gas results were lost, delaying treatment. A significant insulin prescribing error occurred due to clinicians confusing doses, exacerbated by inadequate dose checking and lack of Trust-wide learning from errors.