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
Terence Ryan
All Responded
2017-0225 8 Sep 2017 Manchester (West)
Grasmere Surgery Wrightington, Wigan and Leigh NHS Trust
Concerns summary (AI summary) The GP surgery failed to correctly add new anticoagulation medication to repeat prescriptions and lacked a formal protocol for discharge medications. The hospital also lacked a protocol for vulnerable patients who self-discharge, particularly regarding follow-up and essential medication.
Noted (AI summary) Wrightington, Wigan and Leigh NHS Trust has reviewed its self-discharge policy and is communicating its requirements to staff. They are developing auditing of the Hospital Information System to ensure timely provision of discharge summaries and monitoring actions via the Trust's Quality & Safety Committee. The organization provided a blank response.
Anne-Marie James
Historic (No Identified Response)
2017-0210 8 Sep 2017 Black Country
NHS Lothian Scotland
Concerns summary (AI summary) A missed opportunity in hospital-family communication meant clinicians were unaware of the patient's ongoing delusions, leading to discharge without formal mental health aftercare or family guidance on relapse signs.
Melvin James
Historic (No Identified Response)
2017-0210-wp25845 8 Sep 2017 Black Country
NHS Lothian Scotland
Concerns summary (AI summary) The hospital discharged a patient without adequate mental health assessment, failing to communicate with family about ongoing delusions or provide formal referral and aftercare to local mental health services.
Glenys Pollitt
All Responded
2017-0228 7 Sep 2017 Manchester (South)
Stepping Hill Hospital
Concerns summary (AI summary) Inconsistent use of high-resolution X-ray screens and clinician confirmation bias led to missed abnormalities. There were also unclear processes for reinforcing learning and escalating patient deterioration to consultants.
Action Planned (AI summary) Stockport NHS Trust acknowledges that high-resolution screens should ideally be used for viewing X-rays. They note that a NEWS implementation plan is being developed, independent of the delayed launch of the new electronic patient record (ePR).
David Sewell
All Responded
2017-0229 7 Sep 2017 South Wales Central
Cwm Taff University Hospital Health Boa…
Concerns summary (AI summary) There was a lack of a robust system to ensure mental health patients, especially those with psychotic episodes, were seen and re-engaged, leading to discharge without adequate follow-up after an initial appointment failure.
Action Planned (AI summary) The University Health Board has reviewed the case and circumstances. They will ensure reception staff are aware if an appointment is with the Mental Health Team and direct accordingly and have reviewed the Disengagement Policy for Mental Health.
Jeffery Matthews
All Responded
2017-0230 6 Sep 2017 Cumbria
Cumbria County Council
Concerns summary (AI summary) Inadequate warning signage and obstructed visibility at a hazardous crossroads, combined with a failure to implement previously recommended safety improvements due to resource issues, created a significant risk.
Action Planned (AI summary) Funding was allocated to implement recommendations from a 2016 road traffic collision study, including high friction surfacing, improved road marking and signage, which is currently out for consultation. The highways department immediately improved the white lining after a fatal collision in March 2017.
Brandon Singh Rayat
All Responded
2017-0231 6 Sep 2017 Leicester City and Leicestershire South
East Leicestershire and Rutland Clinica… Secretary of State for Health
Concerns summary (AI summary) There is a critical lack of long-term mental health care provision for children in Leicestershire who cannot attend hospital due to anxiety, with the crisis team unable to fill this gap.
Noted (AI summary) The CCG acknowledges the need to update the CAMHs outpatient and community service specification to reflect new services implemented, such as alignment of CAHMs to the liaison service and the Crisis and Home Treatment service, and this pathway and contract review has commenced. The Department acknowledges the concerns around mental health provision for children in Leicestershire and highlights ongoing national work to transform children and young people's mental health services, supported by additional investment. It notes that the CCG responded separately and that a Serious Incident investigation has been undertaken.
Liam Thomas
All Responded
2017-0347 4 Sep 2017 Oxfordshire
Oxford Health NHS Trust
Concerns summary (AI summary) The patient had access to restricted plastic bags, possibly due to inadequate environmental safety checks on the ward. Additionally, communication with the supportive family regarding the patient's elevated risk was insufficient.
Action Taken (AI summary) Following the death, guidance was issued to staff that plastic bags must be removed at reception, or staff must accompany the visitor/patient to the room, allow them to remove items, and remove the bag. An independent investigation was carried out and the recommendations have now been completed.
Francis Langley
All Responded
2017-0240 4 Sep 2017 Wiltshire and Swindon
Great Western Hospitals NHS Trust
Concerns summary (AI summary) Inconsistent and contradictory falls risk assessments, differing between hospital departments, failed to properly assess the patient's risk, leading to bed rails not being used despite immobility and involuntary movements.
Action Taken (AI summary) The Trust has implemented the nursing personalised care plan documentation used at GWH on Forest and Orchard wards (SWICC) from July 2017, which includes bed rails assessment, falls assessment and a care plan.
Anthony McCormack
Partially Responded
2017-0241 4 Sep 2017 Manchester (City)
Department of Health and Social Care DLA Piper Solicitors Emirates Airlines +2 more
Concerns summary (AI summary) Airline staff training in cardiac arrest recognition and CPR was inadequate, while ambulance services failed to meet response targets, exacerbated by only one paramedic on duty at the airport, preventing advanced life support.
Noted (AI summary) The Department explains that paramedic cover at Manchester International Airport is by commercial arrangement, notes that a review is underway to understand the impact of the airport expansion and highlights the implementation of an improved ambulance performance framework nationally. Emirates states that First Aid and CPR training is undertaken by all Emirates cabin crew both as part of their initial training and also on an annual basis and that the CPR training conducted by Emirates meets the rigorous standards set by leading international bodies. Emirates also monitors the latest research and developments in pre-hospital emergency care and resuscitation on an ongoing basis.
Mohammad Ashraf
All Responded
2017-0243 1 Sep 2017 Birmingham and Solihull
Al Hijrah School Birmingham City Council Birmingham Community Healthcare NHS Tru… +1 more
Concerns summary (AI summary) Inaccurate and delayed care plans, poor communication between the school and catering service, and a failure to disseminate critical safety recommendations by the local authority resulted in inadequate allergy management for pupils.
Noted (AI summary) The Trust confirms that it has worked with Al-Hijrah school to provide a full response, and that its comments have been incorporated into the school's letter. This response is not classifiable as it appears to be a scan of a coversheet only. The content is unreadable and does not contain any meaningful information about actions taken or planned.
Shaun Carter
Partially Responded
2017-0245 29 Aug 2017 Gloucestershire
Health and Safety Executive Tonic Construction Ltd
Concerns summary (AI summary) Dumper truck safety procedures were not followed, understood by all personnel, or audited. There was also a lack of industry standards for managing spoil heaps, increasing the risk of accidents.
Action Planned (AI summary) The HSE is participating in a construction industry working group to improve safety related to dumper trucks and spoil heaps, and a manufacturers' sub-group is considering potential dumper truck design improvements. Other improvements being considered include features to prevent driving without a seatbelt and audible warnings.
Beryl Goode
Historic (No Identified Response)
2017-0246 29 Aug 2017 Bedfordshire and Luton
Abbotsbury Elderly Persons Home
Concerns summary (AI summary) Care home night staff, lacking medical training, failed to consider a head injury as the cause of a resident's confusion after a fall, indicating a need for improved awareness and assessment training.
Sam Crick
All Responded
2017-0457 25 Aug 2017 Cambridgeshire and Peterborough
Barking, Havering and Redbridge NHS Tru… Care Quality Commission NHS England
Concerns summary (AI summary) Missed neuroradiological findings and a critical report's unavailability to the neurosurgeon led to undetected brain herniation and rising intracranial pressure. The absence of a Serious Incident Report further hindered learning from this preventable death.
Action Planned (AI summary) The Trust will review externally reported deaths weekly as part of a Morbidity and Mortality session to identify lessons and feedback to referring hospitals, as part of the ongoing SIR investigation. They have developed a 'Learning from Deaths' policy to respond to and learn from deaths of patients under their management. The CQC has requested written confirmation and evidence from Barking, Havering and Redbridge University Hospital NHS Trust (BHRUT) regarding actions taken following the death and any additional actions they intend to take. They are planning to inspect specific core services at BHRUT in the first part of 2018, including a 3-day in-depth inspection of the leadership and governance of the trust. NHS England will work with the Society of British Neurological Surgeons (SBNS) and the Royal College of Emergency Medicine to produce and distribute a guidance statement nationally within the next 6 months, focusing on treating patients with raised intracranial pressure and urging extreme caution in relation to the use of opiates. NHS England will also seek assurances from the Trust that they have addressed the concerns raised and will suggest an independent review of the case management.
Jonathan Meaney
All Responded
2017-0244 24 Aug 2017 London Inner (North)
Camden and Islington NHS Trust Royal Free London NHS Trust
Concerns summary (AI summary) Prolonged waiting for a mental health bed and a flawed discharge assessment, where overdose intent was not adequately addressed, resulted in the patient's premature release without proper consultation or confirmed follow-up care.
Noted (AI summary) The Royal Free London NHS Foundation Trust notes that the concerns relate to Camden & Islington NHS Foundation Trust (CANDI)'s Mental Health Liaison service, and that CANDI is undertaking a Serious Incident investigation. They have asked to be provided with copies of CANDI's Serious Incident investigation report and response to the Prevention of Future Deaths Report. Camden and Islington NHS Foundation Trust outlines several actions taken and planned: Clinicians involved have been prevented from working at this level of expertise until the SIR review is complete. Any decision to change the original decision made by another full time clinician whereby they are de-escalating the outcome, must be discussed and agreed with a senior member of the team and this must be clearly recorded in the patients notes; All agency or bank staff who work regularly with the team will receive regular formal clinical supervision from the team manager in line with Trust employees and agency staff will receive the same access to Trust training as Trust staff. Referral letters to GPs will include an accompanying note to alert the GP to any specific action they need to carry out.
Joseph Tarnowski
All Responded
2017-0247 24 Aug 2017 Manchester (South)
Hillbrook Grange Residential Care Home
Concerns summary (AI summary) A resident was unable to effectively use a call-bell due to potential unawareness of its portability or mobility limitations, highlighting a lack of consideration for alternative wearable alarm systems.
Action Taken (AI summary) Following the inquest, Hillbrook Grange Residential Care Home immediately provided residents with call bells to be worn around their necks.
Roger Hamer
All Responded
2017-0259 21 Aug 2017 Manchester (North)
Bury Metropolitan Borough Council Department for Transport
Concerns summary (AI summary) Inadequate highway inspection practices failed to document carriageway deterioration, and a proposed new management procedure risks increasing deaths, particularly for cyclists, by raising the threshold for defect investigation and repair.
Noted (AI summary) Bury Council, as Highway Authority, states that all Highway Inspectors are scheduled to undergo specific training and competency checks to ensure they understand how to undertake their role under the new Code of Practice. There will be regular evidence based reviews of the new Code of Practice and monitoring. The Department for Transport acknowledges the concerns but notes that local highway authorities have a duty to maintain the highways network in their area and that Central Government has no powers to override local decisions in these matters. They endorse a code of practice, issued by the UK Roads Liaison Group, providing guidance to highway authorities on how to maintain and manage their highways.
Francesca Whyatt
Partially Responded
2017-0248 21 Aug 2017 London Inner (West)
MENTAL HEALTH NATIONAL PROGRAMMES OF CA… Care Quality Commission NHS +1 more
Concerns summary (AI summary) Key safety gaps include no risk assessment for ward configuration, inadequate guidance on agency staff observation competency, and the failure to automatically treat ligature incidents as Serious Untoward Incidents (SUIs), despite the rapid risk of death.
Action Taken (AI summary) The Priory Hospital Roehampton details environmental and health and safety risk assessments undertaken and coordinated with Policy H43 Observation and Engagement throughout the ward. The Incident Management; Reporting and Investigation Policy (OP4) has been updated to include a requirement that serious self-harm incidents will require an SBAR notification to be made and further investigation will be commissioned.
Jac Davies
All Responded
2017-0250 21 Aug 2017 Swansea Neath and Port Talbot
Welsh Assembly Government
Concerns summary (AI summary) Landlords in Wales are under no legal obligation to install smoke alarms in rented properties, contrasting with England's regulations, and current "best practice" recommendations carry no enforcement.
Action Planned (AI summary) The Welsh Government is drafting regulations under the Renting Homes (Wales) Act 2016 that will place a legal duty on both social and private landlords to fit smoke and carbon monoxide alarms, with a consultation on the draft regulations underway.
Christopher Fairhurst
Historic (No Identified Response)
2017-0277 16 Aug 2017 Manchester (North)
Department of Health and Social Care
Concerns summary (AI summary) Systemic GP shortages, reliance on locums, and insufficient training are causing reduced patient access, poor continuity of care, and insufficient consultation times. Struggling specialist mental health services are also unsafely raising referral thresholds.
Spencer Hurst
Partially Responded
2017-0275 16 Aug 2017 Black Country
Parkhill Group of Companies Walsall Metropolitan Borough
Concerns summary (AI summary) The coroner notes that another young male had died in similar circumstances at the same location in 2007, but there were no adequate notices warning of the risks of swimming, nor fencing or measures to mitigate the risks.
Action Planned (AI summary) Parkhill Estates plans to erect a sandstone memorial with safety warnings and four signs at entrances to the Mere, with completion expected by Spring 2018. They will also implement a 6-monthly inspection regime of the signage.
Dorothy Webb
All Responded
2017-0273 16 Aug 2017 Black Country
Walsall Manor Hospital Trust
Concerns summary (AI summary) A radiologist failed to assess a "mass" on a scan and note a fracture on an x-ray, missing critical opportunities for further investigation and timely diagnosis.
Action Taken (AI summary) The Trust has amended the Serious Incident investigation process to complete reports before future inquests. They have also provided additional training to radiologists, provided feedback to colleagues regarding the red flag system, and produced a lessons learned bulletin.
Frederick Dudley
Historic (No Identified Response)
2017-0272 16 Aug 2017 Staffordshire (South)
Highways England
Concerns summary (AI summary) A dangerous, uncontrolled pedestrian crossing on a busy dual carriageway is obscured by a wall, located on a bend, and near a speed limit change, creating significant visibility and safety risks for pedestrians.
Helen Cannon
Partially Responded
2017-0260 16 Aug 2017 Manchester (City)
Care Quality Commission Department for Community and Local Gove… Department of Health and Social Care +2 more
Concerns summary (AI summary) Emergency responders failed to seek medical assistance for a patient with internal hemorrhage after a fall, misinterpreting her symptoms. A subsequent flawed investigation failed to identify critical inaccuracies in risk assessment completion and staff understanding.
Noted (AI summary) Illegible response.
Isabella Pritchard
All Responded
2017-0261 16 Aug 2017 Berkshire
Department of Business, Energy and Indu… Department of Communities and Local Gov…
Concerns summary (AI summary) The unregulated fireplace industry lacks safety standards, leading to inherently dangerous designs and vague installation instructions. Absence of building control for installation significantly increases the risk of serious incidents.
Action Planned (AI summary) The department will ask the Building Regulations Advisory Committee to reconsider regulating stone fire surrounds and will alert registered installers to good practice guidance. Officials will also continue working with other agencies to keep guidance up to date.