2017

PFD Reports
Reports: 446 Areas: 66

65% response rate (above 63% average).

Clear 211 results
Howard Jeffers
All Responded
2017-0115 15 May 2017 London (North)
Pharmaceutical Chemistry, Drug Misuse a…
Concerns summary (AI summary) The inability to accurately analyze and detect novel psychoactive substances (NPS) through toxicological testing poses an ongoing risk of future deaths.
Noted (AI summary) Imperial College London's Toxicology Unit acknowledges the difficulties in accurately analyzing and detecting NPSs due to their changing nature, lack of standards and pharmacological data, and states that no action is proposed. Alere Forensics describes its ongoing efforts to improve the analysis and detection of new psychoactive substances (NPS), including developing novel screening techniques, working with universities to obtain reference materials, and providing training to stakeholders. The Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit at the University of Hertfordshire is engaged in research to identify NPS and provide updated clinical guidelines, including using computational models to identify potential compounds before they appear on the market.
Nasar Ahmed
All Responded
2023-0134 12 May 2017 Inner North London
Department of Health and Social Care, L…
Concerns summary (AI summary) A school nurse's inadequate medication review process included using an incorrect allergy action plan, not verifying medication in school, and failing to ensure updated, in-date medication.
Disputed (AI summary) Bow School is improving medication management systems, ensuring robust monitoring, and supporting staff to provide effective interventions; the school will brief staff on medical policies and procedures (repeated September 2017), place awareness posters throughout the school, annotate menus with allergens (September 2017), raise awareness of medical needs via Anaphylaxis Campaign and PSHE curriculum, and offer first aid training to pupils (Year 9 in July 2017, all pupils next year). The Department of Health will not pursue making generic adrenaline auto-injectors available in public places due to safety concerns raised by the MHRA, but they are amending regulations to allow schools to hold spare auto-injectors without a prescription for emergencies, effective from 1 October 2017, and are developing guidance for school staff on their use. Compass Wellbeing has undertaken an internal investigation, reinforced accurate record keeping, provided medico-legal training on documentation, reviewed and reran training on their Competency Framework, and is implementing an electronic diary system with reminders for follow-up actions. BSACI has produced national guidelines for managing various allergies, promotes written personalized emergency management plans, and has been part of a campaign to allow schools to hold spare adrenaline auto-injectors, with revised regulations coming into effect on 1 October 2017, and is developing a website to support school staff. The London Ambulance Service (LAS) disputes the coroner's concern, stating that the Clinical Hub paramedic did not advise against using the EpiPen and that the call was appropriately managed and the LAS will take no action. Barts Health NHS Trust will implement an action plan, work with partners on the Asthma Friendly Schools Project, promote the Healthy London Partnership Paediatric asthma toolkit, improve knowledge of long-term conditions in childhood, and standardize asthma management across Tower Hamlets in line with London Paediatric Asthma standards. The practice discussed the case as a team, reviewed individual consultations, contacted the pharmacy, and contacted the safeguarding team and hospital respiratory team for learning; the nursing team will now post/email a copy of the asthma action plan to the child’s school health team or give a copy to parents to hand in, starting July 2017; the nursing team will investigate anaphylaxis care plans in secondary care and incorporate them into care plans by September 2017.
Cedric Skyers
All Responded
2022-0305 10 May 2017 Inner South London
BUPA, Lewisham Adult Safeguarding Board…
Concerns summary (AI summary) The care home's smoking risk assessment for immobile residents fails to adequately address immobility risks, lacks clear guidance on safety equipment provision, and does not document refusal of professional advice.
Action Planned (AI summary) Lewisham Safeguarding Adults Board commissioned a Safeguarding Adult Review in April 2016 with revised terms of reference and an expected conclusion in July 2017; the Board's annual report for 2017/2018 will contain full details of lessons learned and an action plan, and learning seminars will be held. The CQC is assisting the Fire Authority with a joint investigation and is planning to undertake a further unannounced comprehensive inspection of Manley Court in July 2017 to review documentation and consider whether the steps taken by the provider further reduce the risk to people at the service. BUPA has revised its safe smoking assessment and smoking policy, including offering smoking aprons and pendant alarms to residents who smoke in the garden, and requiring supervision for those who decline to wear aprons or have fire-retardant clothing. The updated policy removes staff discretion in risk assessments and requires documentation of residents' choices against professional advice.
John Davies
All Responded
2017-0138 26 Apr 2017 Manchester (South)
Stockport NHS Foundation Trust
Concerns summary (AI summary) There was no risk assessment plan when the resident's needs changed from care to nursing, the District Nursing Team was unaware of the change, and patient records lacked detail with little communication between the care home and the District Nursing Team.
Action Planned (AI summary) A multi-agency risk assessment has been developed to support residential home managers and will be launched in June 2017 for patients waiting to be transferred to a nursing home. A Consultant Psychiatric Doctor for Older People is planning educational events with District Nursing staff from July 2017.
Jamie Elliott
All Responded
2017-0135 25 Apr 2017 London Inner (North)
East London NHS Foundation Trust
Concerns summary (AI summary) Mental health clinicians failed to contact external providers when patients received treatment elsewhere. There was also a lack of timely, face-to-face consultant psychiatric assessments for patients with worsening conditions, despite identified concerns.
Action Taken (AI summary) The Trust distributed a memo to clinical staff in City and Hackney regarding contact with external providers. A policy has been updated to include referrals to the Home Treatment team where patients haven't been seen within 48 hours of referral, needing prioritization and potential consultant review.
Barry Hodges
All Responded
2017-0133 24 Apr 2017 South Yorkshire (East)
Yorkshire Ambulance Service NHS Trust
Concerns summary (AI summary) Ambulance dispatch protocols were not followed, leading to unused resources and breached timescales without escalation. There was also a lack of staff knowledge and a "safety net" system for monitoring dispatches.
Action Taken (AI summary) The ambulance service has implemented a "Call Alert" system to highlight unallocated incidents, reduced timeframes for resourcing amber calls, and introduced performance frameworks to audit staff. They review delayed response incidents and reminded staff of reporting processes.
Johan Pambou
All Responded
2017-0125 20 Apr 2017 Birmingham and Solihull
NHS England
Concerns summary (AI summary) The GP practice lacked an adequate system to action hospital letters, leading to missed vaccinations. Concerns were also raised about the availability of essential vaccines and GPs' knowledge of how to access them.
Action Planned (AI summary) NHS England has established a serious incident group to address issues at the GP practice, including systems for monitoring letters and vaccine availability. They are developing a letter to GPs reinforcing responsibilities, and a Performance Advisory Group will consider regulatory action for the GP.
Daniel Campbell
All Responded
2017-0122 13 Apr 2017 North Northumberland
Network Rail
Concerns summary (AI summary) Broken and disrepaired fencing separating a public footpath from the railway line created easy opportunities for impulsive trespass, increasing the risk of death.
Action Planned (AI summary) Network Rail has included fencing upgrades in their 2018 renewals plan for the section of track where the incident occurred. Further works will be planned to improve the robustness of the boundary.
Luke Moulding
All Responded
2017-0121 13 Apr 2017 Bedfordshire and Luton
East London NHS Trust
Concerns summary (AI summary) A critical "opt-in" follow-up letter was not sent after a psychiatric consultation, and the current system of typing letters rather than using pre-printed materials caused significant delays.
Action Taken (AI summary) The Trust has updated its Operational Policy for CMHT, now requiring opt-in letters to be sent within 5 working days, subject to local audit. This followed a serious incident review that identified delays in sending such letters.
Chadrack Mulo
All Responded
2017-0120 12 Apr 2017 London Inner (North)
Department for Education
Concerns summary (AI summary) School procedures for unexplained absences were inadequate, with limited emergency contacts and delayed responses to non-attendance, revealing a need for wider adoption of immediate welfare checks.
Action Planned (AI summary) The Department for Education will update the 'Keeping Children Safe in Education' and 'School Attendance' guidance to recommend schools hold multiple contact numbers and clarify the link between attendance and welfare issues. Changes will be made at the earliest opportunity, subject to formal consultation on the safeguarding guidance.
John Higgs
All Responded
2017-0113 10 Apr 2017 South Yorkshire (West)
Department of Health and Social Care
Concerns summary (AI summary) The system for communicating unexpected, non-cancerous radiological findings is flawed, relying solely on one doctor to notice and input information, with no "red flag" or specific protocol for critical non-cancerous results.
Action Taken (AI summary) The Trust will reissue existing Guidance on Communication of Critical or Urgent Radiological Findings to relevant clinical staff who joined after 2016 and disseminate it via a Patient Safety Bulletin. They are also working towards the RCR's Standards for communication of radiological reports.
Ronald Bennett
All Responded
2017-0097 5 Apr 2017 Brighton and Hove
Brighton and Sussex University Hospital… SECAMB
Concerns summary (AI summary) There are serious delays in ambulances arriving at the scene of an incident.
Action Planned (AI summary) The Trust is implementing several measures to improve emergency care performance, including expanding the emergency floor with an Urgent Care Centre, reviewing service provision at Princess Royal Hospital, implementing the SAFER care bundle, and expanding discharge capacity. They have also agreed and implemented a new clinical handover protocol with SECAMB. A new joint Standard Operating Procedure was developed in partnership with BSUH in March 2017, providing more clarity around the handover process and responsibilities, including escalation triggers, leading to improved performance in handover delays.
Malcolm Langford
All Responded
2017-0099 31 Mar 2017 Berkshire
Transport Manager, Reading Borough Coun…
Concerns summary (AI summary) Severely restricted visibility at a road junction, caused by a fence and trees, makes safe exiting impossible for normal drivers, indicating a critical design flaw.
Disputed (AI summary) The Council acknowledges changes made at the junction over the years but believes the accident was due to the driver's failure to stop, and requests clarity on the circumstances of the collision to properly ensure they meet their duty as highway authority.
Olive Daynes
All Responded
2017-0091 28 Mar 2017 Leicestershire (South)
United Lincolnshire Hospitals NHS Trust
Concerns summary (AI summary) A GP was unaware of hospital advice regarding a patient's medication change and increased INR levels, due to a delay in the hospital letter arriving at the surgery, and the patient's INR subsequently increased significantly before her death.
Action Taken (AI summary) The hospital sends discharge letters electronically to the GP surgery and uses electronic discharge summaries for inpatients. Consultant-to-consultant referrals should be made directly when a patient requires a specialist outside their own specialty.
Michael Brennan
All Responded
2017-0114 27 Mar 2017 London Inner (North)
University College London Hospitals NHS…
Concerns summary (AI summary) A critical backup plan for emergency patient transfer failed due to unavailability of a satellite hospital bed, highlighting a lack of real-time bed status information for clinicians across the Trust's multiple sites.
Action Planned (AI summary) UCLH will revise its bed management policy by the end of May 2017 to reflect twice-daily bed state updates from Westmoreland Street Hospital. It is also implementing an electronic coordination centre in November 2017 to improve bed capacity management.
Ralph Brazier
All Responded
2017-0090 20 Mar 2017 Surrey
Surrey County Council
Concerns summary (AI summary) Insufficient consideration of increasing cyclist numbers on highways leads to inadequate defect categorisation, prioritising cycle lanes over highways where many cyclists also face significant risks.
Action Planned (AI summary) Surrey County Council is preparing additional training for highway inspectors in relation to risk assessment for vulnerable users, including cyclists, to be completed by the end of August 2017.
James Spencer
All Responded
2017-0072 20 Mar 2017 Exeter and Greater Devon
Stoneham Bass
Concerns summary (AI summary) Inadequate training for induction support officers regarding drug-related collapse and the heightened risks for recently released prisoners due to decreased drug tolerance.
Action Taken (AI summary) Drug awareness training is now mandatory for all new operational colleagues working on the BASS contract and has been rolled out as refresher training for existing colleagues.
James Mallett
All Responded
2017-0075 16 Mar 2017 Norfolk
Queen Elizabeth Hospital NHS Trust
Concerns summary (AI summary) Nursing staff lacked the knowledge and experience to perform neurological observations and respond to serious injuries, leading to delayed medical attention, poor record-keeping, and an absence of falls prevention or care planning. The hospital lacked systems to address staff inexperience.
Action Taken (AI summary) The Queen Elizabeth Hospital King's Lynn NHS Trust has given a copy of the Regulation 28 notice to each nurse on Windsor ward, shared the RCA with senior nurses in A&E, launched a falls campaign, provided training on falls assessment, piloted a new bed rails assessment document, and set up a falls intranet site. It has also devised a training programme for Registered Nurses on the undertaking and interpretation of neurological observations and updated mandatory training days.
Mariana Pinto
All Responded
2017-0093 14 Mar 2017 London Inner (North)
East London NHS Trust
Concerns summary (AI summary) The emergency department failed to effectively communicate illness progression and crisis team limitations to the family. The crisis line nurse did not escalate an urgent situation or prompt emergency services involvement.
Action Planned (AI summary) East London NHS Foundation Trust is developing a written discharge care plan to clarify the limitations of the Home Treatment Team, and will increase flexibility to bring forward visits for service users experiencing deterioration in their mental health between scheduled visits from October 2017. From October 2017, the service will be reconfigured to provide the availability for 24 hour face to face contact if required and an enhanced urgent response service. Following a serious incident review, the Trust updated its Operational Policy for CMHT, mandating that opt-in letters be sent within 5 working days, and will conduct local audits to ensure compliance.
James O’Brien
All Responded
2017-0082 13 Mar 2017 London Inner (South)
Cambian Group
Concerns summary (AI summary) Critical delays in emergency response, including resuscitation and defibrillator deployment, were compounded by inadequate staff training, poor induction for agency nurses, and insufficient information provided to ambulance services.
Action Taken (AI summary) Cambian Group sold Cambian Healthcare Limited in December 2016, so the response was forwarded to Cygnet Healthcare Limited. RadcliffesLeBrasseur, acting for Cambian Adult Services, outlines existing practices including staff tours for familiarity, prioritising internal/bank staff over agency, and an agency nurse induction protocol. The NEWS system has also been introduced at the hospital with staff training.
Daphne Cherry
All Responded
2017-0080 13 Mar 2017 Gloucestershire
Care UK
Concerns summary (AI summary) Concerns exist regarding care home staff's ability to identify and appropriately escalate medical concerns, including when a medical review is needed.
Action Taken (AI summary) Care UK has taken actions including training the home manager, deputy, and unit leaders in early recognition of deteriorating patients, delivering training to all staff, introducing daily meetings and walkarounds to discuss residents, and CQC has acknowledged the implemented changes.
Billy Wilson
All Responded
2017-0061 9 Mar 2017 West Yorkshire (East)
Nursing and Midwifery Council
Concerns summary (AI summary) Critical gaps exist in mandatory and assessed training for CTG tracing interpretation for both student and practicing midwives, leading to proficiency issues upon hospital recruitment.
Noted (AI summary) The Royal College of Obstetricians & Gynaecologists acknowledges the concerns regarding CTG training. They note CTG training is part of the current curriculum and offer support for further proposal.
Paul Barber
All Responded
2017-0184 2 Mar 2017 Brighton and Hove
Brighton and Sussex University Hospital…
Concerns summary (AI summary) The report indicates a risk of future deaths unless action is taken, but no specific concerns were detailed in the provided text.
Action Taken (AI summary) Brighton and Sussex University Hospitals NHS Trust has circulated a message to staff about correct containers for sterile body fluids, altered the lab SOP to include an educational message when the wrong container is received, and discussed the case at a clinical governance meeting to improve prioritization of urgent follow-ups.
Terence Millington
All Responded
2017-0035 2 Mar 2017 South Yorkshire(West)
Sheffield Hospitals NHS Trust
Concerns summary (AI summary) Inadequate arrangements for on-call doctors, including a senior doctor's failure to ensure availability and a consultant's distant location, delayed prompt emergency care and a blood product request was incorrectly met.
Action Taken (AI summary) Sheffield Teaching Hospital NHS Trust has discussed the incident with the doctor concerned and included reference to on-call responsibilities in the local induction program. An emergency epistaxis bag is now available and monitored on ward I1, and the incident will be presented at the Trust's Safety and Risk Management Board meeting.
Ceriann Richards
All Responded
2017-0041 1 Mar 2017 South Wales Central
Neville Hall Hospital Royal Gwent Hospital Welsh Ambulance Service NHS Trust +1 more
Concerns summary (AI summary) Significant and prolonged handover delays between ambulance crews and hospital staff led to critical delays in ambulance dispatch and availability, worsening since new guidance.
Action Taken (AI summary) Aneurin Bevan University Health Board describes steps taken to address ambulance handover issues, including establishing an Urgent Care Board, implementing a Standard Operating Procedure for bed management, and introducing 'Breaking the Cycle' to improve patient flow, implementing transfer teams and discharge facilitators. The Welsh Government acknowledges concerns about handover delays and outlines existing initiatives by the Welsh Ambulance Services NHS Trust to limit conveyance rates, including an enhanced clinical desk, alternative pathways, and a frequent callers project.