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
Christina Witney
Historic (No Identified Response)
2017-0112 7 Apr 2017 Wiltshire and Swindon
Great Western Hospitals NHS Trust NHS England
Concerns summary (AI summary) Concerns include inaccurate patient record keeping, delayed patient reviews despite deteriorating conditions, outdated sepsis guidelines, and insufficient training for locum and temporary staff.
Theresa Thompson
Historic (No Identified Response)
2017-0110 7 Apr 2017 Cornwall and Isle of Scilly
Public Health England
Concerns summary (AI summary) A post-splenectomy patient died from Streptococcus pneumonia due to lack of lifelong antibiotic prophylaxis and vaccination. Mixed messages about antibiotic use may deter patients from accepting crucial preventative treatments.
Annette Krasinsky-Lloyd
Historic (No Identified Response)
2017-0109 7 Apr 2017 Surrey
Royal Surrey County Hospital NHS Trust
Concerns summary (AI summary) Inadequate A&E governance, including an unsupervised SHO and delayed consultant involvement, led to critical delays in patient assessment, test results, anti-coagulation reversal, transfusions, and caused poor intravenous access.
Raymond Berry
Historic (No Identified Response)
2017-0108 7 Apr 2017 Surrey
Department for Transport Driver and Vehicle Standards Agency Honda UK
Concerns summary (AI summary) The parameters for Supplementary Restraint System (airbag) deployment may be inadequate, failing to activate airbags in collisions where impact is absorbed by the crumple zone away from sensors, resulting in severe injury or death.
Steven Amos
Historic (No Identified Response)
2017-0117 6 Apr 2017 Gloucestershire
Gloucestershire Hospitals NHS Foundatio…
Concerns summary (AI summary) Concerns exist regarding the appropriate escalation of care for patients experiencing acute deterioration during night shifts over weekend periods.
John Haughey
Historic (No Identified Response)
2017-0116 6 Apr 2017 East Riding and Kingston -upon-Hull
NHS England
Concerns summary (AI summary) The widespread availability of alcohol-based hand washing gels poses a risk of consumption by confused patients, and there's inadequate dissemination of this hazard and the need for formal risk assessments across sectors.
Isabel Gentry
Historic (No Identified Response)
2017-0111 6 Apr 2017 Avon
Committee of Vaccination and Immunisati… Department of Health and Social Care John Ratcliffe Hospital +1 more
Concerns summary (AI summary) The deceased's death from meningitis B could have been prevented by vaccination, highlighting an ongoing risk if the teenage group, which is at increased risk, is not included in the vaccination program.
Ronald Bennett
All Responded
2017-0097 5 Apr 2017 Brighton and Hove
Brighton and Sussex University Hospital… SECAMB
Concerns summary (AI summary) There are serious delays in ambulances arriving at the scene of an incident.
Action Planned (AI summary) The Trust is implementing several measures to improve emergency care performance, including expanding the emergency floor with an Urgent Care Centre, reviewing service provision at Princess Royal Hospital, implementing the SAFER care bundle, and expanding discharge capacity. They have also agreed and implemented a new clinical handover protocol with SECAMB. A new joint Standard Operating Procedure was developed in partnership with BSUH in March 2017, providing more clarity around the handover process and responsibilities, including escalation triggers, leading to improved performance in handover delays.
Christina Smith
Historic (No Identified Response)
2017-0107 4 Apr 2017 Somerset
Bute House Surgery Yeovil District Hospital
Concerns summary (AI summary) Critical communication breakdown led to both the patient and her GP being unaware of a diagnosed thoracic aneurysm, which was also not placed under surveillance, unlike her abdominal aneurysm.
Arthur Morley
Historic (No Identified Response)
2017-0106 4 Apr 2017 Buckinghamshire
HMP Grendon
Concerns summary (AI summary) The report indicated concerns but did not provide specific details on what matters gave rise to them, making it impossible to identify key safety issues.
Kymberley Holden
Historic (No Identified Response)
2017-0105 4 Apr 2017 Nottinghamshire
Derbyshire Community Health Services Ivy Grove Surgery
Concerns summary (AI summary) Persistent unsafe prescribing of controlled drugs and inadequate understanding of reporting serious incidents, compounded by poorly coordinated management for neurological patients, pose ongoing risks.
Sean Salvin
Partially Responded
2017-0103 4 Apr 2017 South Yorkshire (West)
Amey PLC Sheffield Council South Yorkshire Police +1 more
Concerns summary (AI summary) Inadequate information sharing, inaccurate incident location, and deficient risk assessments for highway hazards (including flooding and tree growth impacting lighting) contributed to ongoing road safety concerns.
Action Taken (AI summary) The council, along with other agencies, has developed a new Highway Flooding Priority Rating System, operational by June 30th, 2017. They've also improved existing procedures and protocols for information sharing between agencies.
Robert Owens
Historic (No Identified Response)
2017-0102 4 Apr 2017 South Wales Central
CWM Taf University Health Board
Concerns summary (AI summary) Outdated guidelines and failure to follow national guidance for Naso Gastric tube insertion, including PH testing and X-rays, compromised patient safety, compounded by inconsistent practice and lack of specific ITU guidance.
Abigail Baynham
Historic (No Identified Response)
2017-0104 3 Apr 2017 Black Country
Black Country NHS New Cross Hospital
Concerns summary (AI summary) The report notes that when Ms Baynham left hospital, there was no referral made back to the Mental Health Liaison Service which may have triggered a further assessment.
Malcolm Langford
All Responded
2017-0099 31 Mar 2017 Berkshire
Transport Manager, Reading Borough Coun…
Concerns summary (AI summary) Severely restricted visibility at a road junction, caused by a fence and trees, makes safe exiting impossible for normal drivers, indicating a critical design flaw.
Disputed (AI summary) The Council acknowledges changes made at the junction over the years but believes the accident was due to the driver's failure to stop, and requests clarity on the circumstances of the collision to properly ensure they meet their duty as highway authority.
Ondrej Suha
Historic (No Identified Response)
2017-0098 30 Mar 2017 Staffordshire (South)
National Offender Management Service
Concerns summary (AI summary) Prison officers lacked specific training for night shifts and basic resuscitation, hindering their ability to respond effectively to emergencies.
John Jaundoo
Historic (No Identified Response)
2017-0100 29 Mar 2017 Liverpool and Wirral
Liverpool City Council National Offender Management Service
Concerns summary (AI summary) Probation failed to appropriately place high-risk offenders and maintain dynamic risk assessments, while Adult Social Services lacked oversight, leading to unsuitable placements and missed public protection opportunities.
Lyndsey Holt
Historic (No Identified Response)
2017-0096 29 Mar 2017 South Yorkshire (East)
Dinnington Group Practice Yorkshire Ambulance Service NHS Foundat…
Concerns summary (AI summary) Methadone was prescribed unsafely over the phone without a face-to-face consultation, leading to a lack of critical patient information and an inappropriate large supply for a methadone-naive individual.
Beryl Foster
Historic (No Identified Response)
2017-0095 29 Mar 2017 Portsmouth and South East Hampshire
Portsmouth Hospitals NHS Trust
Concerns summary (AI summary) The practice of posting endoscopy discharge summaries, instead of emailing them, critically delayed GP awareness of medication changes, risking patient safety.
John Williams
Partially Responded
2017-0094 28 Mar 2017 London Inner (North)
Care UK HMP Pentonville National Offender Management Service +1 more
Concerns summary (AI summary) Inaccuracies in self-harm recording by a reception nurse and a missed second reception screen indicate potential training deficiencies and a need for improved referral systems.
Action Taken (AI summary) Care UK has reminded the nurse involved about giving evidence at an inquest and provided further support. The First Reception Health Screen template has been changed to include a mandatory field for mental health referrals, with electronic referrals made directly to the mental health in-reach team.
Olive Daynes
All Responded
2017-0091 28 Mar 2017 Leicestershire (South)
United Lincolnshire Hospitals NHS Trust
Concerns summary (AI summary) A GP was unaware of hospital advice regarding a patient's medication change and increased INR levels, due to a delay in the hospital letter arriving at the surgery, and the patient's INR subsequently increased significantly before her death.
Action Taken (AI summary) The hospital sends discharge letters electronically to the GP surgery and uses electronic discharge summaries for inpatients. Consultant-to-consultant referrals should be made directly when a patient requires a specialist outside their own specialty.
Michael Brennan
All Responded
2017-0114 27 Mar 2017 London Inner (North)
University College London Hospitals NHS…
Concerns summary (AI summary) A critical backup plan for emergency patient transfer failed due to unavailability of a satellite hospital bed, highlighting a lack of real-time bed status information for clinicians across the Trust's multiple sites.
Action Planned (AI summary) UCLH will revise its bed management policy by the end of May 2017 to reflect twice-daily bed state updates from Westmoreland Street Hospital. It is also implementing an electronic coordination centre in November 2017 to improve bed capacity management.
Steven Fone
Historic (No Identified Response)
2017-0101 27 Mar 2017 Manchester (South)
Adams Pharmacy the relevant regulator of pharmacies
Concerns summary (AI summary) The practice of allowing interchangeable prescription collection by different customers without consent raises concerns about potential abuse, stock-piling, and increased risk of harm or death from medication misuse.
Antony Abbott
Historic (No Identified Response)
2017-0092 23 Mar 2017 Manchester (West)
Foreign, Commonwealth & Development Off…
Concerns summary (AI summary) Spanish Custody Officers, despite receiving first aid training for detainees, are not trained in Cardio Pulmonary Resuscitation (CPR), posing a risk in emergency situations.
Grant Richards
Historic (No Identified Response)
2017-0089 23 Mar 2017 London (East)
Wanstead Place Surgery
Concerns summary (AI summary) The GP surgery failed to act on A&E follow-up recommendations and mental health team faxed documents, revealing systemic management control issues and a lack of suitable procedures for processing critical patient information.