2017
PFD Reports
Reports: 446
Areas: 66
65% response rate (above 63% average).
Pamela Craigie
Partially Responded
2017-0279
27 Sep 2017
London (West)
Advinia Healthcare Ltd
London Borough of Hounslow
Concerns summary (AI summary)
The care home lacks clear criteria and staff confidence for requesting urgent 1:1 care funding from the local authority. Delays in urgent assessments and unclear interim safety plans for high-risk residents pose a significant risk.
Action Taken
(AI summary)
The Company has reviewed its Falls Prevention Policy, clarifying the 1:1 care protocol and updating risk assessments. The revised policy was issued to all homes in October 2017.
Peter Kollar
All Responded
2017-0234
27 Sep 2017
London Inner (South)
Royal College of Emergency Medicine
Royal College of Paediatrics and Child …
Concerns summary (AI summary)
Jaundice in children beyond the neonatal period is under-recognised by doctors. Non-escalation to specialists can adversely affect care and be life-threatening, especially when organ transplantation may be critically needed.
Noted
(AI summary)
The Royal College of Emergency Medicine discussed the case and unanimously concluded that it would not be justifiable or effective to amend the Paediatric Emergency Warning Score to include jaundice.
Hedley Greenland
Partially Responded
2017-0235
26 Sep 2017
South Wales Central
ABMU Health Board
Tynant Nursing Home
Concerns summary (AI summary)
Nursing staff failed to use a fluid balance chart or monitor urine output, hindering detection of critical issues. A nurse was untrained in male catheterisation, and there was a general lack of understanding and training in managing long-term indwelling catheters.
Action Taken
(AI summary)
The Health Board has implemented a booking and attendance system for community training recorded in an electronic central booking diary and responsibility for catheterisation training is shared between community and secondary care. A catheter passport was introduced in hospital and community settings which will be extended to care homes.
Rodney Hampshire
All Responded
2017-0236
26 Sep 2017
Manchester (West)
Salford Royal Foundation Trust
Concerns summary (AI summary)
The surgical ward currently lacks monitored beds, which a review suggests could potentially save lives by improving patient surveillance.
Action Taken
(AI summary)
Salford Royal NHS Foundation Trust implemented an 8-bed H6 Monitored Unit in June 2017 and is planning an Extended Recovery Unit to optimize post-surgical patient care, reduce complications, and facilitate appropriate use of critical care beds.
Shahbaz Salim
All Responded
2017-0237
22 Sep 2017
Nottinghamshire
Highways England
Concerns summary (AI summary)
The collision scene is hazardous due to its tendency to accumulate standing water during rainfall and a gap in the vehicle restraint barrier, which allows unimpeded traffic access.
Action Planned
(AI summary)
Highways England plans to implement a drainage scheme starting in February 2018, including silt removal, pipe repairs, and additional drainage installation. They will also make alterations to the vehicle restraint barrier, pending agreement with a third party, aiming for completion by June 2018.
Derek Dudley
Historic (No Identified Response)
2017-0284
21 Sep 2017
Surrey
CSS Telecare Service
Elmbridge and Ewell Borough Council
Tandridge District Council
Concerns summary (AI summary)
A community alarm operator ended a call with an elderly man who had fallen before he could get up, without checking for emergency contacts. This raises concerns about fall response protocols and subsequent safety.
Margaret Pine
All Responded
2017-0239
21 Sep 2017
Exeter and Greater Devon
Highways Infrastructure Development and…
Concerns summary (AI summary)
The absence of "no through road" signs at the start and reflective warnings at the dead-end wall risks drivers reaching a sudden, unexpected obstruction.
Action Taken
(AI summary)
Devon County Council has erected a reflective bollard in front of a wall and an additional 'No Through Road' sign on a lighting column to reinforce existing signage.
Barbara Sturgess
Historic (No Identified Response)
2017-0209
21 Sep 2017
Derby and Derbyshire
Ashgate House Nursing Home
Chesterfield Royal Hospital
Concerns summary (AI summary)
The hospital failed to promptly and formally communicate a patient's cervical spinal fracture and necessary care measures to the nursing home and GP practice, potentially jeopardizing their well-being.
Peter Cotter
All Responded
2017-0388
20 Sep 2017
Milton Keynes
South Central Ambulance Service NHS Tru…
Concerns summary (AI summary)
Emergency service triage software failed to register a head injury in an anticoagulant patient after a fall, risking severe complications and highlighting the need for a review of head injury recognition protocols.
Noted
(AI summary)
NHS England (NHS Digital) acknowledges the coroner's concerns and states that NHS Pathways identifies and assesses head injuries, including whether patients are on anti-coagulant treatment. They assert that the triage in the specific case was appropriate and consistent with NICE guidelines. South Central Ambulance Service acknowledges the coroner's concerns regarding the NHS Pathways triage system but states they cannot make changes to the software. They have notified NHS Digital of the concerns and advise the coroner to redirect the report to them.
Dennis Oldland
Historic (No Identified Response)
2017-0211
18 Sep 2017
Blackpool and The Fylde
Safehands Ltd
Concerns summary (AI summary)
Care workers prematurely leaving visits based solely on task completion and apparent contentment risks overlooking potential welfare concerns due to insufficient interaction time with vulnerable service users.
Kathleen Holme
All Responded
2017-0212
18 Sep 2017
Cumbria
SC Johnson and Son
Concerns summary (AI summary)
The automatic air freshener lacked prominent warnings about fire risks near naked flames, with critical safety information being too small on packaging and absent from the device itself.
Noted
(AI summary)
SC Johnson states that their Glade Automatic Air Fresheners meet or exceed current regulatory requirements regarding labeling and classification, and therefore no action needs to be taken. They will keep the matter under review.
Reginald Dixon
All Responded
2017-0214
18 Sep 2017
Black Country
West Midlands Ambulance Service
Concerns summary (AI summary)
An emergency call was incorrectly triaged, leading to a delayed response, compounded by insufficient resources and consistently slow ambulance attendance times, posing significant patient risks.
Action Taken
(AI summary)
West Midlands Ambulance Service has provided further education and refresher training around head injuries during NHS Pathways updates. The Trusts Director of Clinical Commissioning and Service Development has also written to the Clinical Commissioning Group regarding resourcing provision, including the Preventing Future Death report.
Paul Maddox
All Responded
2017-0220
17 Sep 2017
Liverpool and Wirral
Wirral University Hospital Trust
Concerns summary (AI summary)
The hospital failed to implement identified strategies to address missed opportunities in acting on reducing haemoglobin trends, demonstrating a critical delay in adopting patient safety improvements post-Root Cause Analysis.
Action Taken
(AI summary)
Wirral University Teaching Hospitals NHS Foundation Trust has changed the lab IT system and issued an action notice to staff, changing the delta check value for Hb from 25% to 20% and the telephone criteria from less than 70g/l to less than 75g/l.
Marko Petrovic
Historic (No Identified Response)
2017-0354
15 Sep 2017
West Yorkshire (West)
Health and Safety Executive
Concerns summary (AI summary)
There are no written guidelines for dismantling cantilevered scaffolds, nor are specific Risk Assessment Method Statements (RAMS) required for this process, risking worker safety.
David Lindsey
Historic (No Identified Response)
2017-0213
14 Sep 2017
Essex
Basildon and Thurrock University Hospit…
Concerns summary (AI summary)
The family contended that the trust did not follow NICE guidelines for cancer screening, referrals, diagnosis and treatment, and that the trust did not follow its own policies and guidelines.
Bronwyn Williams
All Responded
2017-0215
13 Sep 2017
London Inner (North)
Homerton University Hospital NHS Trust
Kindandental
Concerns summary (AI summary)
An urgent dental referral was sent by slow postal service, and the subsequent maxillofacial appointment was significantly delayed for nearly seven weeks due to cancellation and rescheduling.
Action Planned
(AI summary)
Homerton University Hospital is implementing electronic referrals via e-RS for GPs by April 2018. They are taking actions to mitigate risks related to dentists not being able to use the system, as they cannot fix the issues locally. Kindandental has applied for an NHS net email address and plans to use it for electronic referrals within two weeks of access and training. They also plan to build functionality into their system to send referrals via other email services with patient consent, and reviewed/updated their referral pathways and associated checklist to ensure thorough referral processes, emphasizing verification of patient details.
Sam Molyneux
All Responded
2017-0340
13 Sep 2017
Liverpool & Wirral
HM Prison & Probation Service
Concerns summary (AI summary)
Old prison wings lacking anti-barricade doors delayed emergency access, and a prisoner with documented self-harm threats was not placed on an appropriate monitoring plan (ACCT).
Action Planned
(AI summary)
HM Prison & Probation Service will revise the ACCT form and PSI 64/2011 Safer Custody policy to direct staff to consider emergency access, including the presence of an anti-barricade door, when locating prisoners on ACCT. This will also be included in ACCT case manager training.
Frances Greenhalgh
Historic (No Identified Response)
2017-0221
12 Sep 2017
Manchester (West)
Heaton Medical Centre
Concerns summary (AI summary)
A GP surgery failed to properly record and integrate a crucial treatment plan notification from the RAID Team into the patient's medical records and computer system, leading to a lack of awareness and follow-up.
Geoffrey Taylor
Partially Responded
2017-0226
11 Sep 2017
Cornwall and the Isles of Scilly
Department for Transport
Driver and Vehicle Licensing Agency
Concerns summary (AI summary)
Limited DVLA mechanisms exist for medically reviewing elderly drivers with deteriorating health, and GPs face conflicts of interest in reporting, potentially leading to patients withholding crucial medical information to retain licenses.
Action Taken
(AI summary)
The Department for Transport highlights existing processes for medical assessments of drivers, including the legal requirement for drivers to report medical conditions, investigations by the DVLA, and guidance for medical professionals. They also point to an older driver website developed with Department funding.
Henry Prow
Partially Responded
2017-0227
11 Sep 2017
Cornwall and the Isles of Scilly
Department for Transport
Driver and Vehicle Licensing Agency
Concerns summary (AI summary)
Limited DVLA mechanisms exist for medically reviewing drivers with deteriorating health, and GPs face conflicts of interest in reporting, potentially leading to drivers withholding information. Vehicle modification relevance also goes unchecked.
Action Planned
(AI summary)
The Department for Transport notes the DVLA is reviewing how restrictions imposed on driving licences are communicated to drivers. They also highlight existing processes for medical assessments of drivers, including the legal requirement for drivers to report medical conditions and revised GMC guidance to doctors on reporting concerns.
Brian Betterton
All Responded
2017-0224
11 Sep 2017
Bedfordshire and Luton
Department for Business, Energy and Ind…
Concerns summary (AI summary)
Product recalls for items like fuse boxes are ineffective because end-users are often untraceable, as professional purchasers are not required to log installation locations or end-user details.
Action Taken
(AI summary)
The Department for Business, Energy & Industrial Strategy set up the Working Group on Product Recalls and Safety in October 2016, which published recommendations on improving recalls and reducing fires in white goods on 19 July. They have also supported the development of a new BSI code of practice on corrective action and recalls and commissioned research to understand how to increase the impact and effectiveness of product safety messages.
Janet Williams
Historic (No Identified Response)
2017-0218
11 Sep 2017
London Inner (North)
East London NHS Trust
Concerns summary (AI summary)
The patient's care plan was not on the computer system, leading to missed reviews and alerts. The care co-ordinator dismissed family concerns, cancelled vital appointments, and made un-noted retrospective entries after the patient's death.
John Griffiths
Partially Responded
2017-0222
11 Sep 2017
Manchester (City)
Comish Way Group Practise
UHSM
Concerns summary (AI summary)
The Emergency Department lacked a system to check patients' recent attendances or access previous medical records and investigation results, leading to missed opportunities for comprehensive care.
Action Planned
(AI summary)
UHSM acknowledges concerns regarding checking for recent patient presentations in the emergency department. They state the ED system alerts clinicians to previous attendances and that the Electronic Patient Record System (EPR), to be phased in later in the year, will enhance this.
Brian MaClean
Partially Responded
2017-0223
11 Sep 2017
Manchester (City)
Great Places Housing Association
Director of Housing
Department for Adult Social Services
+1 more
Concerns summary (AI summary)
Social Services and housing providers failed to proactively assess fire risks, make referrals to fire services, or install automatic water suppression systems and appropriate alarms for high-risk individuals.
Action Planned
(AI summary)
In response to concerns, Manchester City Council has reviewed closed contacts, is undertaking an audit of 'No Further Action' cases, will provide further training for Contact Centre staff, will have the Quality Assurance Team undertake regular audits, is exploring increasing social work supervision of Contact Centre officers, will continue to raise awareness of GMFRS services among adult social care staff, and will refer the matter to the Manchester Safeguarding Adults Board.
Patricia Forshaw
All Responded
2017-0262
8 Sep 2017
Manchester (West)
Wrightington, Wigan and Leigh NHS Trust
Concerns summary (AI summary)
The hospital discharge card provided ambiguous contact information, leading to incorrect telephone advice being given and unrecorded critical observations by staff. Despite 'gross miscommunication,' a Serious Incident Review was not undertaken.
Action Taken
(AI summary)
Wrightington, Wigan and Leigh NHS Trust has notified emergency care staff that calls should not be put through to minors or majors, that treatment advice should not be given, and is reminding nursing staff of the requirement to document relevant care. The Accident & Emergency weekly mortality review will now include a review of any hospital attendances in the last four weeks.