2017
PFD Reports
Reports: 446
Areas: 66
65% response rate (above 63% average).
John Scallan
Historic (No Identified Response)
2017-0391
13 Nov 2017
Coventry
Coventry and Warwickshire NHS Trust
Concerns summary (AI summary)
Patient observations were inconsistent and inadequate, failing to detect deterioration in a sedated patient. Staff lacked understanding of observation policy and were reluctant to conduct proper in-room checks, relying instead on distant sightings.
Graeme Flatman
All Responded
2017-0393
10 Nov 2017
Newcastle Upon Tyne
Cumbria County Council
Concerns summary (AI summary)
The A593 lacked appropriate signage warning road users of severe gradients and visibility limitations. Concerns were also raised about the suitability of a 60 mph speed limit on this challenging single carriageway road.
Action Planned
(AI summary)
Cumbria County Council will review signage at the collision location with the police and install any measures before the end of March. They will also look at the appropriateness of the 60 mph speed limit, but any changes will require a consultation and legal process taking at least 6 months.
Darren Powney
All Responded
2017-0346
10 Nov 2017
Sunderland
North East Ambulance Service NHS Trust
Concerns summary (AI summary)
Emergency ambulance staff showed confusion and lack of awareness regarding critical dynamic risk assessment protocols, including a 2016 policy. There was no bespoke policy for a frequent caller, and escalation procedures for confusion were insufficiently rapid.
Action Taken
(AI summary)
The Ambulance Service has disseminated a briefing and memorandum to staff specifying procedures for warning markers on properties, is rolling out THRIVE training to Emergency Operations Centre staff, has provided dynamic risk assessment training and conflict resolution training to operational staff, and has developed dashboard stickers for police assistance. They are also auditing staff's knowledge of the JOP and have disseminated the Regulation 28 report to other Ambulance Trusts.
Timothy Atkins
All Responded
2017-0265
9 Nov 2017
Portsmouth and South East Hampshire
Portsmouth City Council
Concerns summary (AI summary)
A narrow, pinch-point corner on a shared cycle/pedestrian pavement posed a safety risk due to poor visibility and the absence of a safety barrier.
Action Planned
(AI summary)
Portsmouth City Council is working to improve transport routes and safety for cyclists on the Eastern Corridor, including widening and straightening the cycle path across the Burrfields Road junction, with work starting in early 2018. They have also obtained agreement to cut back a hedge along the cycle path.
Daisy French
All Responded
2017-0264
9 Nov 2017
South Yorkshire (West)
Department of Health and Social Care
Concerns summary (AI summary)
The report identifies concerns regarding communication and information sharing between CAMHS and Adult Services, the transition of care, and out-of-hours provision for 16 to 18 year olds, and the appropriateness of placing under 18s in adult crisis houses or supported living without staff.
Noted
(AI summary)
Sheffield Health and Social Care NHS Foundation Trust and Sheffield Children's NHS Foundation Trust are working jointly, updating team protocols to ensure young people returning home to independent or supported living receive contact within 24 hours of A&E discharge. They have also identified an Operational Director Lead and will participate in a city-wide review, expecting a report between March and May 2018. The Department of Health acknowledges the concerns and explains the national position on transitioning between children's and adult mental health services, referencing NICE guidelines and NHS England's financial incentives. They note that local NHS organisations are responsible for reviewing local health services and mention actions taken by the NHS in Sheffield, including training, a Section 136 suite, and a Mental Health Liaison Consultant. They also note a safeguarding review to be completed by April 2018.
Ryan Vout
All Responded
2017-0376
6 Nov 2017
Nottinghamshire
NHS England
Department for Health
Nottingham County Council
+5 more
Concerns summary (AI summary)
There was a lack of coordinated psychiatric discharge, failing to involve professionals and family. Also, ambulances could not be pre-arranged for Mental Health Act warrants, and pre-entry risk assessments lacked formality.
Noted
(AI summary)
Nottinghamshire County Council has developed a more robust process for communicating demographics and essential risk information in relation to s135(1) warrants between AMHPs and the Police, including a typewritten document sent electronically by the AMHP. They are also exploring a dedicated conveyance service for people detained under the Mental Health Act. EMAS acknowledges its responsibility to provide timely ambulance service for patients with mental health needs. EMAS plans to adapt its operating model with an urgent care tier, which will go live across all five counties on 2 April 2018. The Department of Health acknowledges the concerns raised, focusing on discharge planning and transport for patients sectioned under the Mental Health Act. They state that these matters are operational and for local NHS services to determine, referencing the Crisis Care Concordat.
Harminder Dhillon
All Responded
2017-0266
6 Nov 2017
Bedfordshire and Luton
Network Rail
Concerns summary (AI summary)
The level crossing lacked CCTV monitoring and was prone to misuse due to insufficient half-barriers. The coroner suggested full-length barriers to prevent future incidents.
Action Planned
(AI summary)
Network Rail is developing additional enhancements targeting accidental and deliberate misuse at Automatic Half Barrier Crossings (AHBCs). The Marston level crossing is scheduled to be replaced by a vehicular road bridge in 2019.
John Nichols
All Responded
2017-0344
2 Nov 2017
Norfolk
Eastgate Residential Care Homes
King's Lynn Residential Care Homes
Concerns summary (AI summary)
The fire drills policy lacked safeguards to adequately monitor residents, especially those with dementia, before, during, and after drills.
Action Taken
(AI summary)
Kings Lynn and Eastgate Residential Care Homes engaged a fire consultant to observe fire drills, amended the pre-assessment form to include questions on distress caused by fire alarms, and revised the PEEP form. They have also amended the Group's Fire Drill Procedure and implemented relevant training.
William Bergman
Historic (No Identified Response)
2017-0343
31 Oct 2017
London Inner (North)
Barts Hospital NHS Trust
Concerns summary (AI summary)
A staff nurse prematurely dismissed a head injury as minor, failing to conduct vital observations or seek medical review for an elderly patient. This raises concerns that other healthcare professionals may similarly underestimate the severity of head injuries.
Gordon Penistan
All Responded
2017-0313
31 Oct 2017
Hampshire (Central)
Adult Social Services
Concerns summary (AI summary)
Other local authority Adult Services could benefit from lessons learned and actions taken in this case to address shortcomings, suggesting the need to share this information widely.
Action Taken
(AI summary)
ADASS circulated a confidential briefing regarding the coroner's report to all 153 local authorities with responsibility for adult social care via their news bulletin.
Kate Pierce
All Responded
2017-0312
31 Oct 2017
North Wales (East & Central)
Betsi Cadwaladr University Health Board
Concerns summary (AI summary)
There is a lack of clarity on when a sick child needs senior paediatrician review before discharge, especially with parental concerns. Additionally, the system for identifying and acting on learning opportunities from readmissions lacks clear, consistently applied criteria.
Action Taken
(AI summary)
The University Health Board confirms that it has a formal policy about discharging children from the children's assessment unit, and has altered the parent discharge information to explicitly state parents may escalate their desire to have a second opinion.
Douglas McTavish
All Responded
2017-0311
31 Oct 2017
North Wales (East & Central)
Whirlpool (UK) Appliances
Concerns summary (AI summary)
Whirlpool's risk assessment processes may not fully appreciate the extent of fire risk with its appliances, and the company may be too reluctant to rely on 'soft data' such as reported fires. Additionally, public awareness of the risk of spontaneous combustion may be insufficient.
Action Taken
(AI summary)
Whirlpool will support initiatives to raise consumer awareness of risks such as spontaneous combustion and has added relevant usage instructions to the 'Register my appliance' website.
Bernard Hender
All Responded
2017-0311-wp25922
31 Oct 2017
North Wales (East & Central)
Whirlpool (UK) Appliances
Concerns summary (AI summary)
Whirlpool's risk assessments for appliance fires were inadequate, with a dismissive approach to field data like reported fires. This prevents timely learning and proactive measures to enhance product safety and save lives.
1 response
from Whirlpool UK Appliances Limited
Vilhelmas Borkertas
Historic (No Identified Response)
2017-0342
31 Oct 2017
London Inner (North)
HMP Pentonville
Concerns summary (AI summary)
A bisexual prisoner was improperly celled with a homophobic cellmate despite clear risk assessment information, raising concerns about placing inmates with conflicting profiles.
Stuart Campbell
All Responded
2017-0390
30 Oct 2017
Manchester (South)
ADS
Concerns summary (AI summary)
Inadequate guidance and clinical support for ADS workers, coupled with a failure to follow escalation protocols and properly document shared care discussions, contributed to unmet patient needs.
Action Planned
(AI summary)
ADS has re-negotiated with Pennine Care NHS Trust for clinical advice and supervision, and has commissioned Applied Suicide Intervention Skills Training (ASIST) for shared care staff.
Jane Powell
Partially Responded
2017-0310
30 Oct 2017
Manchester (North)
Department of Health and Social Care
Home Office
Concerns summary (AI summary)
The ease with which large quantities of prescription-only medication can be obtained over the internet poses a significant risk of future deaths.
Noted
(AI summary)
The Department of Health provides background on regulations and describes Operation Pangea and the FakeMeds campaign; MHRA will investigate further once it receives information from Greater Manchester Police.
Michael Giles
All Responded
2017-0309
30 Oct 2017
Worcestershire
Worcestershire Acute Hospital Trust
Concerns summary (AI summary)
Inconsistent handover processes, lack of senior weekend patient reviews, absence of leadership during crises, and poor medical record-keeping created risks in patient care.
Action Planned
(AI summary)
The Trust has undertaken an audit of record keeping, is developing a clinical records keeping video, and is providing human factors training; it will continue to audit patients unexpectedly brought to intensive care.
Stephen Coulson
Partially Responded
2017-0307
27 Oct 2017
Manchester (City)
Care Quality Commission
Central Manchester University Hospitals
NHS England
Concerns summary (AI summary)
Inadequate systems for controlled drug management and patient observation policies, coupled with a failure to learn from investigations, posed risks to patient safety.
Action Taken
(AI summary)
The Trust has updated its Controlled Drug Policy, updated the Opiate Patch Monitoring Form, amended nursing admission documentation, developed education around delirium and neurological assessment, implemented a new electronic neurological observation chart, and educated doctors on fentanyl patch prescribing. The CDAO reports incidents into a reporting system to share lessons learned. CQC obtained and reviewed the Trust's revised action plan and will monitor its implementation during quarterly engagement meetings and future inspections. They also considered whether further regulatory action was needed but found no evidence of a systemic issue.
David Jackson
Partially Responded
2017-0308
24 Oct 2017
West Sussex
Fitzalan Medical Group
West Sussex Clinical Commissioning Group
Concerns summary (AI summary)
Lack of intervention for an immobile patient who deteriorated over two weeks at home due to refusal of medical assistance, exposing risks in community health care for vulnerable individuals.
Action Planned
(AI summary)
NHS England will refer concerns about guidelines for issuing Controlled Drugs prescriptions to its national prescribing team and will decide whether the guidance needs amendment; a decision is expected by the end of summer 2018.
Sian Witheridge
Partially Responded
2017-0305
23 Oct 2017
London Inner (North)
Camden & Islington NHS Trust
One Housing Group
Concerns summary (AI summary)
Mental health records were unavailable or unread, risk assessments were inadequate and unenforceable, and there was a misunderstanding of suicide risk coupled with disjointed care between services.
Action Planned
(AI summary)
The organisation plans to provide Highbury Grove Crisis House staff with access to their IT system in early 2018, following training and checks. It has also agreed to jointly investigate all deaths connected to the Crisis House.
Liam Oldsworth
Historic (No Identified Response)
2017-0301
20 Oct 2017
Lincolnshire
United Lincolnshire Hospital
Concerns summary (AI summary)
The serious incident analysis report was significantly delayed in being received by the coroner's office, hindering timely review and learning.
Ronald Brewer
All Responded
2017-0306
19 Oct 2017
Gloucestershire
Barchester Homes
Concerns summary (AI summary)
Inadequate administration, documentation, and dispensation processes for medications, especially palliative ones, posed risks in the care home.
Action Taken
(AI summary)
A Deputy Manager with palliative care experience was appointed to support training and practice, staff undertook competency assessments, further training was provided, medication fridges were replaced, and policies/procedures were updated. The facts of the case will form a case study for staff training.
June Evans
Historic (No Identified Response)
2017-0302
19 Oct 2017
Surrey
St Peter’s Hospital
Concerns summary (AI summary)
Agency staff unfamiliarity led to unreferred pressure sores, clinicians were unaware of patient deterioration, nutritional advice was ignored, and understaffing compromised care.
Jakub Moczyk
All Responded
2017-0300
19 Oct 2017
Norfolk
Lifeshield Medical Services Limited
Concerns summary (AI summary)
Inadequate pre-fight medical checks for boxers and medics failing to assess a boxer's fitness to continue after vomiting, relying instead on a non-medically qualified referee/trainer.
Noted
(AI summary)
The organisation claims they informed the referee and promoter about incomplete medicals and states that new policies are in place for boxing events including drug testing and head scanning, leading most promotors to no longer want them to cover events. They state that they have no power to enforce rules.
Wycliffe Matthews
Historic (No Identified Response)
2017-0299
18 Oct 2017
Manchester (West)
Grange Care Home
Concerns summary (AI summary)
Care home staff lacked adequate training on hoist use and failed to maintain proper records of critical events.