2017

PFD Reports
Reports: 446 Areas: 66

65% response rate (above 63% average).

Response Status
Responded 292 Historic 154
AI Classification
Action Taken 46%
Action Planned 35%
Noted 17%
Disputed 2%
Based on 399 classified responses
Top Categories
Hospital Death (Clinical Procedure… (236) Community health care and emergenc… (63) Road (Highways Safety) related dea… (41) Other related deaths (38) Care Home Health related deaths (29)
446 results
Anton Kusz
Partially Responded
2017-0140 27 Apr 2017 South Wales Central
ABMU Health Board Welsh Ambulance Trust
Concerns summary (AI summary) An eight-hour ambulance delay for a patient with a fractured hip was caused by insufficient clinician capacity for 999 calls and widespread ambulance unavailability due to extensive hospital handover delays.
Action Taken (AI summary) The University Health Board details multiple improvements to reduce waiting times in the ED, including an Unscheduled Care Plan, Ambulatory Care services, consultant triage, virtual assessment, multidisciplinary frailty assessment, and more. They have also implemented a system of regular checks for patients delayed in ambulances.
John Davies
All Responded
2017-0138 26 Apr 2017 Manchester (South)
Stockport NHS Foundation Trust
Concerns summary (AI summary) There was no risk assessment plan when the resident's needs changed from care to nursing, the District Nursing Team was unaware of the change, and patient records lacked detail with little communication between the care home and the District Nursing Team.
Action Planned (AI summary) A multi-agency risk assessment has been developed to support residential home managers and will be launched in June 2017 for patients waiting to be transferred to a nursing home. A Consultant Psychiatric Doctor for Older People is planning educational events with District Nursing staff from July 2017.
Linsay Bushell
Partially Responded
2017-0137 25 Apr 2017 Liverpool and Wirral
Department for Health NHS England
Concerns summary (AI summary) A significant lack of provision and priority for commissioning therapeutic psychological services for mentally disordered female patients with Emotionally Unstable Personality Disorder was identified.
Action Taken (AI summary) NHS England is investing in psychological therapies for people with personality disorders and developing guidance on high-quality services. Mersey Care NHS Foundation Trust has established a Personality Disorder Hub, devised Borderline Personality Disorder Guidelines, and provided nurse training, among other improvements.
Jamie Elliott
All Responded
2017-0135 25 Apr 2017 London Inner (North)
East London NHS Foundation Trust
Concerns summary (AI summary) Mental health clinicians failed to contact external providers when patients received treatment elsewhere. There was also a lack of timely, face-to-face consultant psychiatric assessments for patients with worsening conditions, despite identified concerns.
Action Taken (AI summary) The Trust distributed a memo to clinical staff in City and Hackney regarding contact with external providers. A policy has been updated to include referrals to the Home Treatment team where patients haven't been seen within 48 hours of referral, needing prioritization and potential consultant review.
Joleen Linton
Historic (No Identified Response)
2017-0136 25 Apr 2017 Coventry
Coventry & Warwickshire Partnership NHS…
Concerns summary (AI summary) Concerns about inadequate and unreliable hourly patient observations due to environmental factors, inaccurate record-keeping, undetected errors, staff reluctance to enter rooms, and a poorly defined observation policy.
Barry Hodges
All Responded
2017-0133 24 Apr 2017 South Yorkshire (East)
Yorkshire Ambulance Service NHS Trust
Concerns summary (AI summary) Ambulance dispatch protocols were not followed, leading to unused resources and breached timescales without escalation. There was also a lack of staff knowledge and a "safety net" system for monitoring dispatches.
Action Taken (AI summary) The ambulance service has implemented a "Call Alert" system to highlight unallocated incidents, reduced timeframes for resourcing amber calls, and introduced performance frameworks to audit staff. They review delayed response incidents and reminded staff of reporting processes.
Najeeb Katende
Historic (No Identified Response)
2017-0132 21 Apr 2017 London Inner (North)
London Ambulance Service NHS Trust
Concerns summary (AI summary) There were failures to actively cross-check for shockable rhythms and to routinely use defibrillators in AED mode during cardiac arrest incidents, highlighting a need for improved staff training.
Charlotte Agnew
Historic (No Identified Response)
2017-0141 20 Apr 2017 London (City)
North NHS Trust
Concerns summary (AI summary) The report describes failures in the transfer of care, suicide risk assessment, care planning, medication management, and response to a request for urgent assessment; the coroner remains concerned that these failings could recur.
David Evans
Historic (No Identified Response)
2017-0134 20 Apr 2017 South Wales Central
Cardiff and Vale University Health Board
Concerns summary (AI summary) An untrained doctor performed a FAST ultrasound without supervision, and records were not stored. There was also inadequate escalation of care for symptomatic patients with identified Abdominal Aortic Aneurysm.
Patricia Webb
Historic (No Identified Response)
2017-0130 20 Apr 2017 Brighton and Hove
Brighton and Sussex University Hospital…
Concerns summary (AI summary) Inadequate fall prevention measures included insufficient observations, failure to identify fall patterns, and a lack of recorded meaningful activities. Unsuitable non-slip footwear also posed a risk.
Sian Hollands
Historic (No Identified Response)
2017-0129 20 Apr 2017 North West Kent
Dartford and Gravesend NHS Trust
Concerns summary (AI summary) Concerns include inadequate training on patient scoring systems, a failure to provide doctors with nurses' medical notes, and doctors' failure to correctly diagnose pulmonary embolism.
Errol Mann
Historic (No Identified Response)
2017-0128 20 Apr 2017 London (East)
Barts Health NHS Trust
Concerns summary (AI summary) The Intensive Care Unit experienced severe and persistent staffing shortages, including Clinical Fellows, which directly compromised patient care and diverted consultant time from clinical duties.
Harold Mullins
Historic (No Identified Response)
2017-0127 20 Apr 2017 South Wales Central
Cwm Taf Health Board
Concerns summary (AI summary) The surgical team was unaware of the patient's thrombosis history. Deteriorating NEWS scores did not trigger timely clinician review, highlighting a failure in information sharing and effective care escalation.
Thomas Whitfield
Historic (No Identified Response)
2017-0126 20 Apr 2017 County Durham and Darlington
Tees, Esk and Wear Valley NHS Trust
Concerns summary (AI summary) Family-reported suicide risks were not documented or acted upon by hospital staff. The absence of monitored or recorded patient telephone calls prevented verification of communications regarding risks and affected risk assessments.
Johan Pambou
All Responded
2017-0125 20 Apr 2017 Birmingham and Solihull
NHS England
Concerns summary (AI summary) The GP practice lacked an adequate system to action hospital letters, leading to missed vaccinations. Concerns were also raised about the availability of essential vaccines and GPs' knowledge of how to access them.
Action Planned (AI summary) NHS England has established a serious incident group to address issues at the GP practice, including systems for monitoring letters and vaccine availability. They are developing a letter to GPs reinforcing responsibilities, and a Performance Advisory Group will consider regulatory action for the GP.
Elaine Talbot
Historic (No Identified Response)
2017-0131 19 Apr 2017 Manchester (North)
Bury Clinical Commissioning Group
Concerns summary (AI summary) General practitioners lacked direct urgent access to CT scanning, unlike those in neighboring areas. This commissioning issue risks delaying diagnoses and potentially impacting patient outcomes.
David Birtwistle
Historic (No Identified Response)
2017-0139 18 Apr 2017 Avon
Brisdoc NHS, University Hospital Bristol NHS Tr…
Concerns summary (AI summary) A patient diverted from A&E meant crucial tests for pulmonary embolism were missed, compounded by unavailable 111 referral information at the emergency department.
Daniel Maher
Historic (No Identified Response)
2017-0124 18 Apr 2017 Surrey
Surrey and Borders Partnership NHS Trust West Sussex County Council
Concerns summary (AI summary) Critical information sharing failures exist between inter-county mental health services, with professionals unable to access out-of-county patient records or routinely share s.136 assessment paperwork, hindering timely, comprehensive care.
Michael Newell
Historic (No Identified Response)
2017-0123 13 Apr 2017 Preston and West Lancashire
Lancashire Teaching Hospitals NHS Trust
Concerns summary (AI summary) Junior medical staff lacked awareness of liver failure's impact and early hypovolaemia, delaying critical treatment and consultant input. Inadequate nursing procedures and ineffective mortality reviews further compromised patient safety.
Daniel Campbell
All Responded
2017-0122 13 Apr 2017 North Northumberland
Network Rail
Concerns summary (AI summary) Broken and disrepaired fencing separating a public footpath from the railway line created easy opportunities for impulsive trespass, increasing the risk of death.
Action Planned (AI summary) Network Rail has included fencing upgrades in their 2018 renewals plan for the section of track where the incident occurred. Further works will be planned to improve the robustness of the boundary.
Luke Moulding
All Responded
2017-0121 13 Apr 2017 Bedfordshire and Luton
East London NHS Trust
Concerns summary (AI summary) A critical "opt-in" follow-up letter was not sent after a psychiatric consultation, and the current system of typing letters rather than using pre-printed materials caused significant delays.
Action Taken (AI summary) The Trust has updated its Operational Policy for CMHT, now requiring opt-in letters to be sent within 5 working days, subject to local audit. This followed a serious incident review that identified delays in sending such letters.
Chadrack Mulo
All Responded
2017-0120 12 Apr 2017 London Inner (North)
Department for Education
Concerns summary (AI summary) School procedures for unexplained absences were inadequate, with limited emergency contacts and delayed responses to non-attendance, revealing a need for wider adoption of immediate welfare checks.
Action Planned (AI summary) The Department for Education will update the 'Keeping Children Safe in Education' and 'School Attendance' guidance to recommend schools hold multiple contact numbers and clarify the link between attendance and welfare issues. Changes will be made at the earliest opportunity, subject to formal consultation on the safeguarding guidance.
Jamie Fairclough
Historic (No Identified Response)
2017-0119 12 Apr 2017 Central and South East Kent
Kent and Medway NHS Trust
Concerns summary (AI summary) Excessively high caseloads for Care Co-ordinators, often exceeding 75-80 service-users, compromised the quality of patient care and staff's ability to manage their responsibilities.
Christiana Pelle
Historic (No Identified Response)
2017-0118 10 Apr 2017 London Inner (North)
East London NHS Trust Homerton University NHS Trust
Concerns summary (AI summary) The report identifies a lack of clear guidance for nurses on when to involve a patient’s GP, the absence of a system for sharing information between the Community District Nursing Team and other agencies, and a lack of a system for communicating concerns with the care provider agency.
John Higgs
All Responded
2017-0113 10 Apr 2017 South Yorkshire (West)
Department of Health and Social Care
Concerns summary (AI summary) The system for communicating unexpected, non-cancerous radiological findings is flawed, relying solely on one doctor to notice and input information, with no "red flag" or specific protocol for critical non-cancerous results.
Action Taken (AI summary) The Trust will reissue existing Guidance on Communication of Critical or Urgent Radiological Findings to relevant clinical staff who joined after 2016 and disseminate it via a Patient Safety Bulletin. They are also working towards the RCR's Standards for communication of radiological reports.