2017
PFD Reports
Reports: 446
Areas: 66
65% response rate (above 63% average).
Dean Saunders
Partially Responded
2017-0056
17 Feb 2017
Essex
Care UK Clinical Services
National Offender Management Service
NHS England
+1 more
Concerns summary (AI summary)
Serious systemic issues include a rigid protocol preventing mentally disordered individuals' transfer from police custody, unclear hospital transfer processes, and inadequate staff training in the ACCT process, compounded by insufficient psychiatric cover in prisons.
Action Planned
(AI summary)
NHS England states that Care UK circulated a document with contact details of medical staff who can sign Mental Health Assessment documents, and a new provider will deliver healthcare at HMP Chelmsford from May 2017 with greater access to psychiatrists. Essex Partnership NHS Trust has submitted its admissions protocol for regional review by the Secure Services Catchment Group for East of England and will inform the coroner of the outcome; it has also referred the issue of best practice in relation to the forensic pathway to the same group. Care UK developed a new Mental Health Pathway, formally signed off on 28 March 2017, and is rolling it out across all Care UK sites via mental health workshops to examine processes and quality of care provided.
Milan Dokic
Historic (No Identified Response)
2017-0050
17 Feb 2017
London Inner (West)
TFL
Concerns summary (AI summary)
The Cycle Superhighway's road surface has reduced grip, creating a significant hazard that increases the likelihood of road users losing control, especially cyclists at junctions. An urgent review and replacement is needed.
Etheline De-Gale
All Responded
2017-0058
16 Feb 2017
Bedfordshire and Luton
Ambassador House Care Home
Concerns summary (AI summary)
Vague care plans and inadequate staff training on risk assessment led to carers misinterpreting assistance needs. Insufficient staffing levels also compromised resident safety and impacted decisions regarding hospital admissions.
Action Taken
(AI summary)
Ambassador House Home reports that the care plan will stipulate that residents must not be left unattended when bedrails are lowered, and staff will carry gloves in their pockets at all times.
Thomas Green
Partially Responded
2017-0057
16 Feb 2017
Manchester (South)
Churchgate Surgery
Pennine Care NHS Trust
Tameside and Glossop Clinical Commissio…
Concerns summary (AI summary)
A referral to Adult General Psychiatry for an inpatient was not considered or actioned, resulting in no psychiatric follow-up or treatment plan for complex PTSD upon discharge; a commissioning gap exists for complex PTSD services.
Action Planned
(AI summary)
Tameside and Glossop CCG will clarify the Individual Funding Request process by 1/6/17, review and establish clear pathways into MH support for people with complex needs within four months, and seek assurance from PCFT regarding this serious incident through contract monitoring meetings.
Wendy Telfer
All Responded
2017-0046
14 Feb 2017
Exeter and Greater Devon
Devon Partnership NHS Trust
NHS Northern, Eastern and Western Devon…
Royal Devon and Exeter NHS Foundation T…
Concerns summary (AI summary)
Inadequate training for physical healthcare staff on mental health needs and Mental Health Act application is a concern. A severe national shortage of psychiatric beds also caused critical delays in patient transfer, contributing to preventable deaths.
Disputed
(AI summary)
The CCG is monitoring timely discharge performance data, the DPT contract review meeting also monitors the rates of delayed discharges from mental health wards through data reported to NEW Devon CCG by DPT, The Northern and Eastern Devon A&E Delivery Board also has oversight of discharges and DPT has improvement plans which aim to reduce delayed discharges. The CCG is working to streamline current processes for panel approval and funding of s117 aftercare and working towards a joint aftercare funding agreement. The Trust describes mental health training delivered, including specific programmes with Devon Partnership Trust (DPT). It argues that in this case, staff sought and followed specialist advice from the DPT Liaison Team and therefore acted appropriately, and would be circumspect about any training which meant staff acted in direct contravention of expert advice. The Trust undertook a Root Cause Analysis investigation with the Royal Devon and Exeter NHS Foundation Trust (RD&E), the actions from which are completed and part of regular management supervision. The Liaison Psychiatry team formally trained at least 496 staff, having delivered 175 teaching sessions in 2016 and developed a full day package called 'Management of Challenging Behaviour Rapid Tranquilisation'. Training continues in 2017.
Derek Lee
Historic (No Identified Response)
2017-0045
14 Feb 2017
Brighton and Hove
Sussex Partnership NHS Trust
Concerns summary (AI summary)
No specific concerns regarding future deaths were detailed in the provided text, only contact information.
David Alexander
All Responded
2017-0044
14 Feb 2017
Exeter and Greater Devon
Health and Safety Executive
Concerns summary (AI summary)
Overturns in the industry are underreported and poorly understood, lacking investigation into causes like hydraulic ram bracket failures. There's inadequate industry guidance and a failure to routinely use inclinometers, despite known risks from slight gradients.
Action Taken
(AI summary)
HSE conducted a survey of Devon feed mills in 2017, finding awareness of vehicle overturn risks and industry guidance. Some businesses have moved to non-tipping vehicles or fitted tipping sensors; others have implemented driver systems or cameras. Advice was given on work at height, noise, and workplace transport issues.
Roger Tombs
Partially Responded
2017-0027
13 Feb 2017
Birmingham and Solihull
Care Quality Commission
Solihull Falls Team
Sunrise Senior Living
Concerns summary (AI summary)
Fall sensor mats were improperly placed on crash mats, potentially reducing their effectiveness and increasing the risk of undetected falls, injury, and death for vulnerable residents.
Noted
(AI summary)
Sunrise Senior Living acknowledges the report but states it is leaving the Home's management and registration with CQC on 1 March 2017. It invites dialogue and can describe immediate actions taken after the inquest but not future measures. The Falls Team reviewed its practices after the PFD report and found them consistent and accurate. A guidance document outlining good practice in sensor mat use was developed and sent to the local council for circulation to care homes in the borough.
Raymond Edwards
All Responded
2017-0029
10 Feb 2017
North Wales (Eastern and Central)
Betsi Cadwaladr University Health Board
Concerns summary (AI summary)
A critical lack of a reliable system for disseminating histology results to named consultants meant crucial diagnostic information was not promptly reviewed, posing a significant risk of delayed diagnosis and treatment in future cases.
Action Taken
(AI summary)
The University Health Board developed BCUHB Procedure MD23 to mitigate risks due to failure to act on diagnostic results, based on NPSA 16 guidance, and approved at the end of 2016. An electronic reporting system (CHAI Ping app) is being developed to provide alerts to clinicians when histology reports are authorised for viewing.
Rachel Morgan
Historic (No Identified Response)
2017-0055
9 Feb 2017
Manchester (South)
Greater Manchester West Mental Health N…
Concerns summary (AI summary)
The mental health ward failed to review medication despite patient concerns and did not conduct full risk assessments after self-harm incidents. There was also an over-reliance on inpatient status as a protective factor and a lack of clarity in observation policies.
Warren Myers
All Responded
2017-0032
9 Feb 2017
County Durham and Darlington
Highways Department, County Durham Coun…
Concerns summary (AI summary)
Inadequate warning signage on the approach to the corner significantly contributed to the accident risk.
Action Taken
(AI summary)
Durham County Council increased the size of bend ahead warning signs and re-erected a chevron sign. They have an Accident Investigation and Prevention team that investigates every fatal accident.
Matthew Roberts
All Responded
2017-0028
9 Feb 2017
West Sussex
Sussex Partnership NHS Trust
Concerns summary (AI summary)
There was no policy to log and scrutinize faxes, leading to potential loss of information, and staff often delayed reading referral details, hindering timely risk assessment. The organization also failed to conduct a formal review of the death.
Action Taken
(AI summary)
Sussex Partnership NHS Foundation Trust supplemented Information Governance training for EIP staff with posters on fax receipt. The EIP service developed a transition proforma, a best-practice tool for use by EIP practitioners at the point of transitions into and out of EIP service. The Trust has developed a new Serious Incident Policy.
Rebecca Shaw
Historic (No Identified Response)
2017-0067
8 Feb 2017
West Yorkshire (West)
Phuket Highway District
Concerns summary (AI summary)
The road layout at the junction was unsafe, with obstructed views of oncoming traffic and an inadequate central reservation, increasing the risk of collisions.
Anna Phillips
All Responded
2017-0033
8 Feb 2017
Cornwall and Isles of Scilly
Home Office
Concerns summary (AI summary)
The deceased obtained a dangerous, unlicensed weight loss drug (2,4 Dinitrophenol) online, which is known to cause fatalities.
Action Taken
(AI summary)
The National Food Crime Unit (NFCU) continues to prioritise tackling the illegal sale of DNP, sharing intelligence with Border Force, Royal Mail, and Post Office Investigations, and monitoring the internet for illegal sales. This data sharing led to an Operational Instruction being issued to all Border Force Officers and assisted inquiries into a DNP supplier who is being prosecuted.
David Read
All Responded
2017-0031
8 Feb 2017
Norfolk
Norfolk and Suffolk NHS Trust
Concerns summary (AI summary)
After an initial urgent referral and a cancelled appointment, a new appointment for mental health services was scheduled after a delay of over 16 weeks, during which time the patient died.
Action Taken
(AI summary)
Norfolk and Suffolk NHS Trust has fully staffed its team and made amendments to practice. If a service user does not attend an appointment the team will have a phone call to rearrange an appointment instead of sending a letter. The clinical team leader monitors cases that have an appointment pending on a daily basis.
Sheila Bowling
All Responded
2017-0010
7 Feb 2017
South Yorkshire (West)
First Mainline
Concerns summary (AI summary)
A 'Drive Clean System' in the vehicle, which encourages smooth driving, may have discouraged the driver from making necessary evasive steering movements, potentially contributing to the fatality. The system's influence on driver response requires review.
Disputed
(AI summary)
First Bus refutes that the 'Drive Green' system has any adverse impact on safety, stating that collisions in South Yorkshire have reduced by 23.5% since its introduction in 2010. They describe driver training, a Driving Standards Manager, and a safe driving bonus scheme, but maintain that safety is the number one priority.
Nuala Seddon
Historic (No Identified Response)
2017-0034
6 Feb 2017
London Inner (North)
Barts Health NHS Trust
University College Hospital NHS Trust
Concerns summary (AI summary)
The patient transfer decision may have been made by non-clinical staff and lacked documentation. Inadequate patient monitoring post-ITU discharge and a failure to properly investigate a patient arrest raised serious safety concerns.
Natalie Thornton
Partially Responded
2017-0030
6 Feb 2017
Manchester North
Department of Health and Social Care
Salford Royal NHS Trust
Concerns summary (AI summary)
Inadequate monitoring and analysis of blood sugar data from insulin pumps, coupled with a lack of formal pump agreements and variable national support, posed a risk to patient safety.
Action Planned
(AI summary)
NHS Improvement is appointing a Clinical Lead for diabetes inpatient care to review insulin pumps and current support for users, with the review expected to be completed in late 2018. The Department of Health is also working to reduce variation in diabetes management and care by 2020, with £40 million in additional funding.
Gerome Reyes
Historic (No Identified Response)
2017-0012
3 Feb 2017
Southampton and New Forest
Mirage Finance Incorporated
Primebulk Shipmanagement Limited
Concerns summary (AI summary)
There is no confirmation that recommended safety upgrades, such as installing door limit switches on goods lifts, have been implemented, posing a continued risk on this and potentially other ships.
Robert Entenman
Partially Responded
2017-0011
3 Feb 2017
London Inner (South)
Fisher and Paykel
HCA Health Care UK
London Bridge Hospital
+2 more
Concerns summary (AI summary)
Nurses failed to notice an essential humidifier was off, partly due to the machine lacking an alarm. Significant delays occurred in identifying and replacing a blocked endotracheal tube, compromising patient care.
Noted
(AI summary)
London Bridge Hospital implemented several changes including introduction of bedside monitoring and nursing observations policy, the use of SBAR and DOPES handover techniques, and Human Factors Training. They have also added the Cardiac Arrest Record Checklist. The NMC acknowledges the concerns and states that they are currently investigating the matter in accordance with their statutory functions and will provide a further update in due course. The CQC details findings from a 2013 inspection where the hospital met standards for staff training and incident reporting. The hospital introduced a critical care daily safety briefing sheet in November 2015 to address staff sickness, patient problems, admissions/discharges, and specific safety issues.
Gordon Arthur
All Responded
2017-0009
2 Feb 2017
Manchester (West)
Salford Royal Hospital
Concerns summary (AI summary)
The absence of clear policies for requesting and communicating results of investigative tests to consultants led to critical delays in diagnosing and treating a patient's infection, risking future harm.
Action Taken
(AI summary)
Salford Royal NHS Trust reviewed policies and confirmed existing protocols for rapid notification of unsuspected pathology. These protocols have been disseminated by email and discussed at the Orthopaedic clinical governance meeting on 29th March 2017.
James Fox
All Responded
2017-0014
2 Feb 2017
London (North)
Metropolitan Police Service
Concerns summary (AI summary)
Concerns were raised about the accuracy of close-range police firearms, lack of less-lethal options, inadequate contingency planning for volatile situations, and inconsistent national training for officers.
Disputed
(AI summary)
The Metropolitan Police defends its officers' actions and states that there is no indication of misconduct. The IPCC investigation reported no matters of organisational learning other than a positive comment with regard to the use of body worn video.
Daniel Bowen
All Responded
2024-0093
1 Feb 2017
West Sussex, Brighton and Hove
University of Sussex
Concerns summary (AI summary)
The university failed to effectively use academic advisors to support struggling students and displayed deeply flawed communication between its various departments, health clinic, counsellor, and the student's GP.
Action Planned
(AI summary)
The University of Sussex is implementing several initiatives including a review of the Academic Advisor role, enhanced training for staff, a 'Results Release' campaign, an 'Enlitened' pilot app, and an Imminent Risk Protocol.
Dipa Lad
All Responded
2017-0019
31 Jan 2017
Nottinghamshire
East Midlands Ambulance Service NHS Tru…
Concerns summary (AI summary)
The ambulance service deviated from national resuscitation guidance without providing clear staff guidance or training, leading to poor staff awareness of critical policy changes and inadequate resuscitation techniques.
Action Taken
(AI summary)
EMAS reviewed its procedures and provided guidance for clinicians dealing with cardiac arrest patients, including additional guidance around futility aligned with BMA, RCUK, and RCN guidance. All clinical staff receive annual refresher training including resuscitation assessments, and dynamic risk assessments are performed for CPR technique.
David Griffiths
All Responded
2017-0013
31 Jan 2017
South Wales Central
Cardiff and Vale University Health Board
Concerns summary (AI summary)
There were no local protocols or specific training for intercostal drain insertion, and recommended real-time ultrasound guidance was unavailable, raising significant safety concerns for patients.
Action Taken
(AI summary)
The University Health Board has discontinued the practice of inserting chest drains at a 'marked' point and has purchased equipment. A task and finish group will oversee implementation and assessment across the Health Board and will report to the Quality, Safety and Experience Committee.