2017
PFD Reports
Reports: 446
Areas: 66
65% response rate (above 63% average).
James Allbones
Historic (No Identified Response)
2017-0336
21 Jul 2017
Nottinghamshire
Bassetlaw Clinical Commissioning Group
Care Quality Commission
Doncaster and Bassetlaw Hospital NHS Tr…
Concerns summary (AI summary)
A lack of consultant paediatrician review, inadequate sepsis training, poor handover protocols, and insufficient paediatric staffing levels put sick children at serious risk.
Steffan Bonnot
Historic (No Identified Response)
2017-0450
14 Jul 2017
West Sussex
Ofsted
Concerns summary (AI summary)
Inadequate and undocumented disclosure of a child's background information to prospective foster carers caused anxiety and posed a risk to informed placement decisions.
Elaine Davison
Historic (No Identified Response)
2017-0444
12 Jul 2017
West Yorkshire (East)
National Tree Safety Group
Concerns summary (AI summary)
A diseased tree, despite prior examination, had a hidden severe fungal decay that was missed due to inadequate inspection and misidentification of the condition, leading to an underestimation of its felling urgency.
John Wilson
Historic (No Identified Response)
2017-0445
12 Jul 2017
Manchester (South)
Beko Plc
Concerns summary (AI summary)
The product recall process was inadequate, relying on unrecorded standard mail that failed to inform the deceased, and lacked further robust efforts like registered post or follow-up visits, despite known increasing fire risk with product age.
Mark Berry
Historic (No Identified Response)
2017-0232
11 Jul 2017
Hampshire (Central)
Royal Hampshire County Hospital
South Central Ambulance Service NHS Tru…
Concerns summary (AI summary)
Hospital staff delayed police notification of a suspicious death due to procedural confusion. Additionally, ambulance handover and private ambulance communication lacked critical patient location details, hindering investigation.
Margery Astill
Historic (No Identified Response)
2017-0440
11 Jul 2017
Leicester (City & South)
Leicestershire NHS Trust
Concerns summary (AI summary)
Ineffective diary systems led to failures in referrals, the system for updating incident reports was unclear, communication with family members was inadequate, and there was a delay in attending to the patient after a fall.
Hannah Barney
Historic (No Identified Response)
2017-0442
11 Jul 2017
London Inner (South)
Department of Health
Kings College Hospital
NHS England
Concerns summary (AI summary)
A regional trauma centre lacked a 24-hour consultant plastics surgical service, risking patient lives due to potential delays in urgent debridement for severe infections like necrotising fasciitis.
Catherine Roberts
Historic (No Identified Response)
2017-0076
7 Jul 2017
North Wales (East and Central)
Betsi Cadwaladr University Health Board
Concerns summary (AI summary)
Problems with admission to the Emergency Department, resource availability, and patient flow continue despite previous reports to the Health Board, placing patients' lives at risk.
Sousse (Tunisia)
Historic (No Identified Response)
2017-0206
7 Jul 2017
London (West)
ABTA
Civil Aviation Authority
Department for Transport
+1 more
Concerns summary (AI summary)
Travel companies lacked board-level security advisors and failed to prominently display government travel advice, leaving customers potentially uninformed about terrorism risks in destination countries.
John Ramsden
Historic (No Identified Response)
2017-0437
6 Jul 2017
Manchester (West)
Agrade Community Care Services
Concerns summary (AI summary)
Inadequate family consultation occurred, as only one of three daughters was involved in critical end-of-life care decisions, including hospital admission.
Roy Lynch
Historic (No Identified Response)
2017-0431
5 Jul 2017
Essex
Essex Highways
Concerns summary (AI summary)
The highway design lacked stopping restrictions at a dangerous location, despite a nearby safe parking area, creating an unacceptable risk for drivers encountering stationary vehicles at speed.
Patricia Norfolk
Historic (No Identified Response)
2017-0438
5 Jul 2017
Manchester (North)
Pennine Acute NHS Trust
Concerns summary (AI summary)
Patients lacked daily senior clinician reviews, raising concerns about the standard of care provided during the interim period before new staff can be recruited.
Sheila Hynes
Historic (No Identified Response)
2017-0448
3 Jul 2017
Newcastle Upon Tyne
Newcastle Upon Tyne NHS Trust
Concerns summary (AI summary)
A mechanical aortic valve was remounted against manufacturer instructions by an untrained scrub nurse, without recorded discussion or awareness of associated risks by the surgical team.
David Lee
Historic (No Identified Response)
2017-0432
28 Jun 2017
Manchester (North)
North West Ambulance Service
Concerns summary (AI summary)
The inappropriate termination of an emergency call, due to uncirculated guidance and lack of training, led to a missed opportunity to escalate the need for medical assistance.
Robert Cardwell
Historic (No Identified Response)
2017-0203
23 Jun 2017
Preston and East Lancashire
Lancashire Care NHS Foundation Trust
Concerns summary (AI summary)
Significant communication failures prevented crucial patient information from reaching the multi-disciplinary team, leading to inappropriate discharge and a lack of follow-up care due to disorganised meetings and poor record-keeping.
Lee Swain
Historic (No Identified Response)
2017-0196
16 Jun 2017
Liverpool and Wirral
Chester Hospital NHS Trust
Mersey Care NHS Trust
Cheshire Wirral Partnership
Concerns summary (AI summary)
A lack of coordinated procedures for transferring mental health patients between NHS Trusts, exacerbated by exiting a Care Programme Approach, resulted in delayed intervention and ineffective information exchange.
Aaron McCaffrey
Historic (No Identified Response)
2017-0195
16 Jun 2017
Manchester (South)
Medicines and Healthcare products Regul…
Concerns summary (AI summary)
The lack of purchase limits for loperamide medication at retail stores enables bulk buying, increasing the risk of addiction and overdose.
Alaanuloluwa Joseph
Historic (No Identified Response)
2017-0189
14 Jun 2017
London (West)
Hillingdon Hospitals NHS Trust
Concerns summary (AI summary)
Inaccurate monitoring and recording of fluid intake and output, a critical aspect of sepsis management, was not undertaken.
William Wilson
Historic (No Identified Response)
2017-0186
12 Jun 2017
Manchester (South)
Church Inn
Concerns summary (AI summary)
The establishment lacked a clear system for alerting the designated first aider, and staff who attended the deceased were unfamiliar with basic life-saving first aid techniques.
Terry Latimer
Historic (No Identified Response)
2017-0178
1 Jun 2017
North Lincolnshire and Grimsby
North Lincolnshire Council
Concerns summary (AI summary)
A safeguarding notice with a request for Mental Health Services referral was not actioned. There was a lack of clarity among staff on whether such notices required follow-up or were just for information.
Doreen Miller
Historic (No Identified Response)
2017-0169
26 May 2017
Wiltshire and Swindon
Chippenham Community Hospital
Great Western NHS Hospital Trust
Wiltshire Health & Care
+1 more
Concerns summary (AI summary)
A safeguarding referral was improperly signed off by Wiltshire Council without investigation, and crucial cognitive assessment information was missing from the hospital discharge summary upon patient transfer.
Lucy Goldstone
Historic (No Identified Response)
2017-0168
26 May 2017
Manchester (City)
Department for Transport
Department of Health and Social Care
Concerns summary (AI summary)
There are no Automated Electronic Defibrillators (AEDs) available on trams or at tram stops across the Metrolink network.
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.
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.