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
Marian Dale
Historic (No Identified Response)
2017-0086 23 Mar 2017 Manchester (South)
Stockport NHS Trust
Concerns summary (AI summary) The District Nursing Team lacked a central, contemporaneous record-keeping system, storing all notes at the patient's home, and had no protocol for their retrieval after death.
Patricia Donovan
Historic (No Identified Response)
2017-0087 22 Mar 2017 South Wales Central
Aneurin Bevan University Health Board
Concerns summary (AI summary) Surgery for a neck of femur fracture was delayed beyond NICE guidelines due to theatre staff and resource availability issues, despite the recognised risk of serious complications from prolonged waiting.
Michael Uriely
Partially Responded
2017-0069 22 Mar 2017 London Inner (West)
National Institute for Health and Care … NHS England Health Education England
Concerns summary (AI summary) Inadequate chronic asthma management, lack of coordinated care, and poor inter-service communication led to a failure to follow guidelines and recognise deteriorating patient condition.
Noted (AI summary) NHS England will share learning and support tools developed by the Healthy London Partnership, communicate up-to-date asthma guidelines to CCGs and GPs, and explore commissioning mechanisms to incentivise improved commissioning of asthma care. NICE has produced a quality standard on asthma and is developing further guidelines on diagnosis, monitoring and management of asthma, to be published in October 2017, which will inform updates to the quality standard.
Ralph Brazier
All Responded
2017-0090 20 Mar 2017 Surrey
Surrey County Council
Concerns summary (AI summary) Insufficient consideration of increasing cyclist numbers on highways leads to inadequate defect categorisation, prioritising cycle lanes over highways where many cyclists also face significant risks.
Action Planned (AI summary) Surrey County Council is preparing additional training for highway inspectors in relation to risk assessment for vulnerable users, including cyclists, to be completed by the end of August 2017.
James Spencer
All Responded
2017-0072 20 Mar 2017 Exeter and Greater Devon
Stoneham Bass
Concerns summary (AI summary) Inadequate training for induction support officers regarding drug-related collapse and the heightened risks for recently released prisoners due to decreased drug tolerance.
Action Taken (AI summary) Drug awareness training is now mandatory for all new operational colleagues working on the BASS contract and has been rolled out as refresher training for existing colleagues.
Scott Hooper
Historic (No Identified Response)
2017-0068 20 Mar 2017 Portsmouth and South East Hampshire
Southampton General Hospital
Concerns summary (AI summary) Incorrect patient weight recording led to inaccurate anticoagulant dosage, and critical clinical decisions were unrecorded. Lessons from internal meetings were not effectively disseminated or applied to all high-risk patients.
Trevor Curry
Partially Responded
2024-0091 17 Mar 2017 West Sussex, Brighton and Hove
NHS England Department of Health Sussex Partnership NHS Foundation Trust
Concerns summary (AI summary) The psychiatric hospital failed to record the deceased's critical cardiac history provided by family and did not ascertain his full physical history promptly, compounded by poor information sharing between trusts.
Action Taken (AI summary) Sussex Partnership NHS Foundation Trust has drafted a briefing for staff highlighting the importance of good documentation, completes documentation audits, and has introduced a new protocol for managing primary care clinical information and guidance for staff regarding obtaining summary care records. Learning from the death has been included in the Trust's quarterly quality report.
Stephen McDermott
Historic (No Identified Response)
2017-0071 17 Mar 2017 Preston and West Lancashire
Lancashire Care Foundation Trust
Concerns summary (AI summary) Fragmented electronic record systems and poor record usage led to incomplete mental health assessments, missing critical patient history and suicide risk factors across different teams. Staff also lacked adequate training.
Terence White
Partially Responded
2017-0078 16 Mar 2017 Gloucestershire
DAC Beachcroft Claims Ltd Grange Care Centre
Concerns summary (AI summary) The care centre failed to adequately document pressure sore treatment measures, specifically lacking turning charts, which prevented proper monitoring of the condition.
Action Taken (AI summary) The Grange Care Centre has made changes to ensure more thorough record keeping for resident's care plans, with daily records kept in individual folders and signed off by the nurse responsible for the shift, and checked by management. It has also introduced "Skin Integrity Boards" and refresher training on skin integrity.
Derek Turnbull
Historic (No Identified Response)
2017-0076-wp25690 16 Mar 2017 Sunderland
Gateshead Health Foundation Trust
Concerns summary (AI summary) There was an hour-long delay in calling an ambulance for a patient with a head injury and known fall risk, despite clear need for immediate hospital transfer, indicating a failure in protocols for urgent escalation.
James Mallett
All Responded
2017-0075 16 Mar 2017 Norfolk
Queen Elizabeth Hospital NHS Trust
Concerns summary (AI summary) Nursing staff lacked the knowledge and experience to perform neurological observations and respond to serious injuries, leading to delayed medical attention, poor record-keeping, and an absence of falls prevention or care planning. The hospital lacked systems to address staff inexperience.
Action Taken (AI summary) The Queen Elizabeth Hospital King's Lynn NHS Trust has given a copy of the Regulation 28 notice to each nurse on Windsor ward, shared the RCA with senior nurses in A&E, launched a falls campaign, provided training on falls assessment, piloted a new bed rails assessment document, and set up a falls intranet site. It has also devised a training programme for Registered Nurses on the undertaking and interpretation of neurological observations and updated mandatory training days.
Clive Davies
Historic (No Identified Response)
2017-0074 16 Mar 2017 South Wales Central
Cwm Taf Morgannwg University Health Boa… The Chief Coroner Welsh Assembly Government
Concerns summary (AI summary) Failures in conducting routine neurological and NEWS observations, including missed checks and an incorrectly calculated score, resulted in the deceased not receiving a necessary medical review.
Leah Ratheram
Historic (No Identified Response)
2017-0081 15 Mar 2017 Birmingham and Solihull
Birmingham and Solihull Mental Health T… Birmingham Children’s Hospital NHS Trust Birmingham City Council +2 more
Concerns summary (AI summary) Fragmented mental health services for young adults, with separate organizations and incompatible record systems, led to uncoordinated care, poor information sharing, and unclear responsibility during patient transfers in crisis.
Michael Mahon
Historic (No Identified Response)
2017-0073 15 Mar 2017 Manchester (South)
Pennine Care NHS Foundation Trust
Concerns summary (AI summary) The crucial annual clozapine test was missed, and there was no system in place to identify this omission, allowing symptoms undetectable by monthly checks to go unnoticed.
Mariana Pinto
All Responded
2017-0093 14 Mar 2017 London Inner (North)
East London NHS Trust
Concerns summary (AI summary) The emergency department failed to effectively communicate illness progression and crisis team limitations to the family. The crisis line nurse did not escalate an urgent situation or prompt emergency services involvement.
Action Planned (AI summary) East London NHS Foundation Trust is developing a written discharge care plan to clarify the limitations of the Home Treatment Team, and will increase flexibility to bring forward visits for service users experiencing deterioration in their mental health between scheduled visits from October 2017. From October 2017, the service will be reconfigured to provide the availability for 24 hour face to face contact if required and an enhanced urgent response service. Following a serious incident review, the Trust updated its Operational Policy for CMHT, mandating that opt-in letters be sent within 5 working days, and will conduct local audits to ensure compliance.
Jack Sheldon
Historic (No Identified Response)
2017-0088 14 Mar 2017 South Yorkshire (East)
Chief Fire Officer
Concerns summary (AI summary) The emergency services lacked an effective system for managing multiple calls, prioritising resources, and mobilising appropriate appliances, compounded by inadequate staff training and difficult-to-use systems.
Rebecca Evans
Partially Responded
2017-0077 14 Mar 2017 North Wales (East and Central)
BCUHB HM Stanley Site Welsh Ambulance NHS Trust +1 more
Concerns summary (AI summary) Significant and recurring delays in patient handover at Emergency Departments led to late hospital admission and delayed medical treatment, tying up ambulance resources and risking future deaths.
Action Taken (AI summary) The University Health Board details a series of actions already taken, including improvements in performance indicators for ambulance handovers and emergency department waiting times, and implementation of patient navigators at YGC Emergency Department. They also mention an unscheduled care plan.
George Dicker
Historic (No Identified Response)
2017-0083 13 Mar 2017 London (North)
RSSB
Concerns summary (AI summary) There is no alarm or warning system to alert railway signallers when a person accesses the tracks via a gate at the end of a platform.
James O’Brien
All Responded
2017-0082 13 Mar 2017 London Inner (South)
Cambian Group
Concerns summary (AI summary) Critical delays in emergency response, including resuscitation and defibrillator deployment, were compounded by inadequate staff training, poor induction for agency nurses, and insufficient information provided to ambulance services.
Action Taken (AI summary) Cambian Group sold Cambian Healthcare Limited in December 2016, so the response was forwarded to Cygnet Healthcare Limited. RadcliffesLeBrasseur, acting for Cambian Adult Services, outlines existing practices including staff tours for familiarity, prioritising internal/bank staff over agency, and an agency nurse induction protocol. The NEWS system has also been introduced at the hospital with staff training.
Daphne Cherry
All Responded
2017-0080 13 Mar 2017 Gloucestershire
Care UK
Concerns summary (AI summary) Concerns exist regarding care home staff's ability to identify and appropriately escalate medical concerns, including when a medical review is needed.
Action Taken (AI summary) Care UK has taken actions including training the home manager, deputy, and unit leaders in early recognition of deteriorating patients, delivering training to all staff, introducing daily meetings and walkarounds to discuss residents, and CQC has acknowledged the implemented changes.
Andrew Lownes
Historic (No Identified Response)
2017-0070 13 Mar 2017 London Inner (West)
Glass and Glazing Federation
Concerns summary (AI summary) The absence of clear, written unloading instructions for heavy, unstable industrial units led to confusion regarding complex banding, creating a risk of accidental dislodgement and serious injury to workers.
Lester Stacey
Historic (No Identified Response)
2017-0084 10 Mar 2017 Staffordshire (South)
South Staffordshire and Shropshire NHS …
Concerns summary (AI summary) A patient with complex physical and mental health issues disengaged from community mental health services post-discharge following medication changes, contributing to low moods and his subsequent death.
Anna Walker
Historic (No Identified Response)
2017-0079 10 Mar 2017 London (East)
Barking, Havering and Redbridge Univers…
Concerns summary (AI summary) Post-operative checks were not compliant with protocol, leading to delayed detection of a bleed, due to failures in portering, ward nurse responsibilities, and unclear clinical accountability. The incident was also inappropriately downgraded.
Carol Harvey
Partially Responded
2017-0059 10 Mar 2017 North Wales (East and Central)
Betsi Cadwaladr University Health Board Ysbyty Gwynedd
Concerns summary (AI summary) There is no procedure to confirm district nurse referral receipt and action, and significant delays exist in developing and implementing a safe patient discharge procedure from acute hospitals.
Action Planned (AI summary) The University Health Board has provided a working action plan relating to the case which will be monitored at the Secondary Care QSE meeting in July 2017.
Peter Norton
Historic (No Identified Response)
2017-0251 9 Mar 2017 Cornwall and the Isles of Scilly
Halfords Group PLC
Concerns summary (AI summary) The store lacked guidance, policies, and risk assessments for cycling indoors, including a safe designated area and helmet use, creating an unsafe environment.