2017
PFD Reports
Reports: 446
Areas: 66
65% response rate (above 63% average).
Thomas Unsworth
All Responded
2017-0039
1 Mar 2017
Manchester (West)
Bolton Council, Highways Division
Concerns summary (AI summary)
The junction's design creates a significant "blind spot" for turning drivers, severely limiting their view of pedestrians, raising safety concerns during crossings.
Action Planned
(AI summary)
Bolton Council will request that Transport for Greater Manchester review the pedestrian stage indicators at the junction of Bradshawgate and Great Moor Street, with a view to changing from far side to nearside indicators.
Colin Hodge
All Responded
2017-0042
28 Feb 2017
Dorset
Dorset Highways Departments
Concerns summary (AI summary)
A junction's poor state of repair and lack of clear pavement/roadway boundaries encourage pedestrians to cross unsafely and drivers to cut corners, posing significant collision risks.
Action Taken
(AI summary)
Dorset County Council installed kerb stones on 19 August 2016 to define the edge of the footway and address concerns with the footway surface; they will also erect a marker post (bollard) in the footway to prevent vehicles from overrunning the footway at Howard's Lane.
Paul Briggs
All Responded
2017-0040
28 Feb 2017
Liverpool and Wirral
Merseyside Passenger Transport Authority
Concerns summary (AI summary)
The absence of rumble strips on double white lines at a merging carriageway increases the risk of vehicles inadvertently straying into oncoming traffic, particularly where visibility is inhibited.
Action Planned
(AI summary)
Merseyside Passenger Transport Authority will engage a contractor to install rumble strips within the white lines in the area concerned, aiming to instruct the contractor by the end of the following week.
Rachel Edwards
All Responded
2024-0220
27 Feb 2017
Suffolk
Norfolk and Suffolk NHS Foundation Trust
Concerns summary (AI summary)
The report notes Rachel was informally admitted.
Action Planned
(AI summary)
The Trust will assess medications prescribed upon discharge, which will continue across the Trust. The Trust is planning the technical changes required to build electronic bridges between different elements of the health system, but there is no confirmed date for completion.
Doreen Stapleton
All Responded
2017-0043
24 Feb 2017
London Inner (North)
Whittington Hospital NHS Trust
Concerns summary (AI summary)
An obsolete email address caused a critical district nursing referral to fail upon discharge, compounded by inadequate, explicit communication to a vulnerable patient and family about the fatal risks of missed medication and follow-up contact.
Action Taken
(AI summary)
The organisation has written to doctors, nurses and pharmacists highlighting learning points. They raised the issues at the Medical Committee and reintroduced patient leaflets about pulmonary emboli on inpatient wards, with spot audits to ensure they are in place.
Grant Burns
All Responded
2017-0048
23 Feb 2017
Southampton and New Forest
Solent NHS Trust
Concerns summary (AI summary)
There was a significant lack of cooperative working and communication between mental health and substance misuse services, which impeded a complete root cause analysis.
Action Taken
(AI summary)
The trust has compiled a spreadsheet of clients identified as being worked with by Adult Mental Health and Substance Misuse Services, which is updated at the Southampton Alcohol Recovery Service Management meeting. They will identify if there is any involvement from mental health services with Change Grow Live Manager with the Solent NHS Trust Clinical Manager and contact the mental health treating team.
Luke Mumford
All Responded
2017-0047
23 Feb 2017
Mid Kent and Medway
Kent County Council
Concerns summary (AI summary)
The road's narrow, unlit, and unkerbed characteristics, bordered by hedgerows, make the 70 mph speed limit unsafe, with experts stating speeds above 50 mph pose significant risks.
Action Planned
(AI summary)
Kent County Council will program a scheme to reduce the speed limit of the road to 50mph and will investigate a Crash Remedial Measure to seek to improve the 'safety' of this dual carriageway.
Maxim Karpovich
All Responded
2017-0054
22 Feb 2017
West Yorkshire (East)
Royal College of Midwives
Royal College of Obstetricians and Gyna…
Concerns summary (AI summary)
Midwives and a junior obstetrician did not understand that the CTG trace was abnormal, and an obstetric registrar incorrectly classified the CTG as normal; the coroner noted that midwives and obstetricians lack the core skills to interpret CTG tracings for intrapartum care.
Noted
(AI summary)
The RCOG acknowledges the concerns and explains that CTG training is already part of the curriculum. They highlight existing e-learning resources and suggest a new proposal could be trialled at the RCOG. The RCM outlines the role of midwives and their responsibilities according to NMC guidelines. They reference existing resources and studies related to CTG interpretation.
Ashley Talbot
All Responded
2017-0051
22 Feb 2017
South Wales Central
Bridgend County Borough Council
Maesteg Comprehensive School
Concerns summary (AI summary)
Poor design of the school service road and bus bay, coupled with insufficient staff supervision, created a highly dangerous situation for children crossing the road, stemming from a lack of accountability in the school's construction.
Action Taken
(AI summary)
The bus bay has been extended to accommodate seven buses, and the school site is now subject to a lockdown, with no vehicles allowed to enter or move around the site until the children have boarded/alighted. A new drop-off area has been developed approximately 200m from the school gates. The bus bay has been extended, a school lockdown occurs during bus loading, staff supervision has increased, a speed limit is in place, and a vehicle drop-off point has been created.
Etheline De-Gale
All Responded
2017-0058
16 Feb 2017
Bedfordshire and Luton
Ambassador House Care Home
Concerns summary (AI summary)
Vague care plans and inadequate staff training on risk assessment led to carers misinterpreting assistance needs. Insufficient staffing levels also compromised resident safety and impacted decisions regarding hospital admissions.
Action Taken
(AI summary)
Ambassador House Home reports that the care plan will stipulate that residents must not be left unattended when bedrails are lowered, and staff will carry gloves in their pockets at all times.
Wendy Telfer
All Responded
2017-0046
14 Feb 2017
Exeter and Greater Devon
Devon Partnership NHS Trust
NHS Northern, Eastern and Western Devon…
Royal Devon and Exeter NHS Foundation T…
Concerns summary (AI summary)
Inadequate training for physical healthcare staff on mental health needs and Mental Health Act application is a concern. A severe national shortage of psychiatric beds also caused critical delays in patient transfer, contributing to preventable deaths.
Disputed
(AI summary)
The CCG is monitoring timely discharge performance data, the DPT contract review meeting also monitors the rates of delayed discharges from mental health wards through data reported to NEW Devon CCG by DPT, The Northern and Eastern Devon A&E Delivery Board also has oversight of discharges and DPT has improvement plans which aim to reduce delayed discharges. The CCG is working to streamline current processes for panel approval and funding of s117 aftercare and working towards a joint aftercare funding agreement. The Trust describes mental health training delivered, including specific programmes with Devon Partnership Trust (DPT). It argues that in this case, staff sought and followed specialist advice from the DPT Liaison Team and therefore acted appropriately, and would be circumspect about any training which meant staff acted in direct contravention of expert advice. The Trust undertook a Root Cause Analysis investigation with the Royal Devon and Exeter NHS Foundation Trust (RD&E), the actions from which are completed and part of regular management supervision. The Liaison Psychiatry team formally trained at least 496 staff, having delivered 175 teaching sessions in 2016 and developed a full day package called 'Management of Challenging Behaviour Rapid Tranquilisation'. Training continues in 2017.
David Alexander
All Responded
2017-0044
14 Feb 2017
Exeter and Greater Devon
Health and Safety Executive
Concerns summary (AI summary)
Overturns in the industry are underreported and poorly understood, lacking investigation into causes like hydraulic ram bracket failures. There's inadequate industry guidance and a failure to routinely use inclinometers, despite known risks from slight gradients.
Action Taken
(AI summary)
HSE conducted a survey of Devon feed mills in 2017, finding awareness of vehicle overturn risks and industry guidance. Some businesses have moved to non-tipping vehicles or fitted tipping sensors; others have implemented driver systems or cameras. Advice was given on work at height, noise, and workplace transport issues.
Raymond Edwards
All Responded
2017-0029
10 Feb 2017
North Wales (Eastern and Central)
Betsi Cadwaladr University Health Board
Concerns summary (AI summary)
A critical lack of a reliable system for disseminating histology results to named consultants meant crucial diagnostic information was not promptly reviewed, posing a significant risk of delayed diagnosis and treatment in future cases.
Action Taken
(AI summary)
The University Health Board developed BCUHB Procedure MD23 to mitigate risks due to failure to act on diagnostic results, based on NPSA 16 guidance, and approved at the end of 2016. An electronic reporting system (CHAI Ping app) is being developed to provide alerts to clinicians when histology reports are authorised for viewing.
Warren Myers
All Responded
2017-0032
9 Feb 2017
County Durham and Darlington
Highways Department, County Durham Coun…
Concerns summary (AI summary)
Inadequate warning signage on the approach to the corner significantly contributed to the accident risk.
Action Taken
(AI summary)
Durham County Council increased the size of bend ahead warning signs and re-erected a chevron sign. They have an Accident Investigation and Prevention team that investigates every fatal accident.
Matthew Roberts
All Responded
2017-0028
9 Feb 2017
West Sussex
Sussex Partnership NHS Trust
Concerns summary (AI summary)
There was no policy to log and scrutinize faxes, leading to potential loss of information, and staff often delayed reading referral details, hindering timely risk assessment. The organization also failed to conduct a formal review of the death.
Action Taken
(AI summary)
Sussex Partnership NHS Foundation Trust supplemented Information Governance training for EIP staff with posters on fax receipt. The EIP service developed a transition proforma, a best-practice tool for use by EIP practitioners at the point of transitions into and out of EIP service. The Trust has developed a new Serious Incident Policy.
Anna Phillips
All Responded
2017-0033
8 Feb 2017
Cornwall and Isles of Scilly
Home Office
Concerns summary (AI summary)
The deceased obtained a dangerous, unlicensed weight loss drug (2,4 Dinitrophenol) online, which is known to cause fatalities.
Action Taken
(AI summary)
The National Food Crime Unit (NFCU) continues to prioritise tackling the illegal sale of DNP, sharing intelligence with Border Force, Royal Mail, and Post Office Investigations, and monitoring the internet for illegal sales. This data sharing led to an Operational Instruction being issued to all Border Force Officers and assisted inquiries into a DNP supplier who is being prosecuted.
David Read
All Responded
2017-0031
8 Feb 2017
Norfolk
Norfolk and Suffolk NHS Trust
Concerns summary (AI summary)
After an initial urgent referral and a cancelled appointment, a new appointment for mental health services was scheduled after a delay of over 16 weeks, during which time the patient died.
Action Taken
(AI summary)
Norfolk and Suffolk NHS Trust has fully staffed its team and made amendments to practice. If a service user does not attend an appointment the team will have a phone call to rearrange an appointment instead of sending a letter. The clinical team leader monitors cases that have an appointment pending on a daily basis.
Sheila Bowling
All Responded
2017-0010
7 Feb 2017
South Yorkshire (West)
First Mainline
Concerns summary (AI summary)
A 'Drive Clean System' in the vehicle, which encourages smooth driving, may have discouraged the driver from making necessary evasive steering movements, potentially contributing to the fatality. The system's influence on driver response requires review.
Disputed
(AI summary)
First Bus refutes that the 'Drive Green' system has any adverse impact on safety, stating that collisions in South Yorkshire have reduced by 23.5% since its introduction in 2010. They describe driver training, a Driving Standards Manager, and a safe driving bonus scheme, but maintain that safety is the number one priority.
Gordon Arthur
All Responded
2017-0009
2 Feb 2017
Manchester (West)
Salford Royal Hospital
Concerns summary (AI summary)
The absence of clear policies for requesting and communicating results of investigative tests to consultants led to critical delays in diagnosing and treating a patient's infection, risking future harm.
Action Taken
(AI summary)
Salford Royal NHS Trust reviewed policies and confirmed existing protocols for rapid notification of unsuspected pathology. These protocols have been disseminated by email and discussed at the Orthopaedic clinical governance meeting on 29th March 2017.
James Fox
All Responded
2017-0014
2 Feb 2017
London (North)
Metropolitan Police Service
Concerns summary (AI summary)
Concerns were raised about the accuracy of close-range police firearms, lack of less-lethal options, inadequate contingency planning for volatile situations, and inconsistent national training for officers.
Disputed
(AI summary)
The Metropolitan Police defends its officers' actions and states that there is no indication of misconduct. The IPCC investigation reported no matters of organisational learning other than a positive comment with regard to the use of body worn video.
Daniel Bowen
All Responded
2024-0093
1 Feb 2017
West Sussex, Brighton and Hove
University of Sussex
Concerns summary (AI summary)
The university failed to effectively use academic advisors to support struggling students and displayed deeply flawed communication between its various departments, health clinic, counsellor, and the student's GP.
Action Planned
(AI summary)
The University of Sussex is implementing several initiatives including a review of the Academic Advisor role, enhanced training for staff, a 'Results Release' campaign, an 'Enlitened' pilot app, and an Imminent Risk Protocol.
Dipa Lad
All Responded
2017-0019
31 Jan 2017
Nottinghamshire
East Midlands Ambulance Service NHS Tru…
Concerns summary (AI summary)
The ambulance service deviated from national resuscitation guidance without providing clear staff guidance or training, leading to poor staff awareness of critical policy changes and inadequate resuscitation techniques.
Action Taken
(AI summary)
EMAS reviewed its procedures and provided guidance for clinicians dealing with cardiac arrest patients, including additional guidance around futility aligned with BMA, RCUK, and RCN guidance. All clinical staff receive annual refresher training including resuscitation assessments, and dynamic risk assessments are performed for CPR technique.
David Griffiths
All Responded
2017-0013
31 Jan 2017
South Wales Central
Cardiff and Vale University Health Board
Concerns summary (AI summary)
There were no local protocols or specific training for intercostal drain insertion, and recommended real-time ultrasound guidance was unavailable, raising significant safety concerns for patients.
Action Taken
(AI summary)
The University Health Board has discontinued the practice of inserting chest drains at a 'marked' point and has purchased equipment. A task and finish group will oversee implementation and assessment across the Health Board and will report to the Quality, Safety and Experience Committee.
David Holman
All Responded
2017-0018
30 Jan 2017
Cheshire
Cheshire East Council, Highway Departme…
Concerns summary (AI summary)
A lack of dedicated cycle lanes on a busy road, coupled with an obstructed footpath and a hazardous kerb dip, created an unsafe environment for cyclists.
Action Planned
(AI summary)
Cheshire East Council has programmed works to remove and relocate a road sign situated in the footway and re-kerb a length of the road to provide a higher consistent kerb height. The Road Safety Team will also conduct a complete Safety Assessment of the carriageway regarding the provision of a cycleway.
Frederick Chisnall
All Responded
2017-0017
30 Jan 2017
Cheshire
Halton Clinical Commissioning Group
St Helens Clinical Commissioning Group
Concerns summary (AI summary)
Agency staff lacked adequate training in proper documentation, monitoring clinical condition changes, and urgently obtaining medical assistance, raising concerns about patient safety.
Action Taken
(AI summary)
Following a safeguarding investigation, Reflex Agency provided further training to its staff, and disciplinary action was taken against a nurse by St Mary's Nursing Home, who also assured they would no longer use Reflex Agency for non-registered staff. The Team Manager for St Helens Contracts and Quality Monitoring service liaised with the agencies for assurance of actions taken.