2018

PFD Reports
Reports: 419 Areas: 64

69% response rate (above 63% average).

419 results
Janice Davies
All Responded
2018-0409 31 Dec 2018 South Wales Central
Cwm Taf University Health Board
Concerns summary (AI summary) Missing documented observations and pain scores before discharge, alongside absent formal guidance for prescribing oramorph to discharging patients, led to inconsistent and potentially inappropriate medication.
Action Taken (AI summary) The Health Board has developed a corrective action plan and implemented actions including a registered nurse reflection, a standard operating procedure for oral opioid medication use, and RRAILS discussions and audits.
Joan Wright
All Responded
2018-0408 28 Dec 2018 Manchester (South)
Department of Health and Social Care
Concerns summary (AI summary) Issues included inconsistent opioid handling, unaddressed statutory oversight for drug responsibilities, police failure to recognise safeguarding risks in medication errors, and a lack of statutory definition for "regular" medication checks in care homes.
Noted (AI summary) The Department of Health outlines existing regulations and guidance regarding controlled drugs, referencing the Shipman Inquiry, the Controlled Drugs Regulations 2006, NICE guidelines and CQC guidance; the Department suggests taking up the concern about Greater Manchester Police's actions with the Home Secretary.
Gregory Rewkowski
All Responded
2018-0411 28 Dec 2018 Manchester (North)
Greater Manchester Police North West Ambulance Service Pennine Care NHS Trust
Concerns summary (AI summary) The coroner notes practical difficulties for nurses raising welfare concerns on an acute ward, unclear reasons for the clinical lead's inaction, failure to escalate to a senior manager, restrictions on ward telephones, limited NWAS investigation, and concerns about police handling of Section 136 cases.
Action Planned (AI summary) Pennine Care NHS Trust has increased staffing levels, issued a memo to staff for greater awareness of the requirement to seek support from On-Call managers, and are planning to update policies and practice on how to respond to information in the public domain in the most effective manner. Greater Manchester Police will participate in a task and finish group and is represented at senior level on the GM Health and Justice Operational Delivery Group and the Greater Manchester Health and Justice Board, with focus on reviewing multi-agency protocols, shared resources, and formal joint working action plans. The partnership has developed a pan-GM protocol for response to mental health crisis, aiming for a common understanding of roles and responsibilities, a shared view of risk, and improved communication.
David Stacey
Partially Responded
28 Dec 2018 Leicester City and Leicestershire South
East Leicestershire Clinical Commission… Heart of England NHS Foundation Trust Minister for Health
Concerns summary (AI summary) A statutory requirement to provide beds for mentally disordered patients in special urgency cases is being ignored, leading to a lack of identifiable beds for high-need individuals.
1 response from the Department of Health and Social Care
Kenneth Bardsley
Historic (No Identified Response)
2018-0407 27 Dec 2018 Manchester (South)
Care Quality Commission Department for Work and Pensions Health and Safety Executive +2 more
Concerns summary (AI summary) The coroner raises concerns regarding the lack of minimum qualification standards for lift engineers, the absence of an escalation process for regulatory lift examination results, a lack of clarity on engineers following up on requirements, CQC's failure to identify unaddressed faults, and a lack of systems to ensure lift examination details are read and acted upon.
Joyce Long
Historic (No Identified Response)
2018-0406 24 Dec 2018 Buckinghamshire
Buckinghamshire Healthcare NHS Trust South Central Ambulance Service
Concerns summary (AI summary) The provided text is incomplete and does not detail any specific concerns regarding future deaths related to patient deterioration.
[REDACTED]
All Responded
2018-0405 21 Dec 2018 Shropshire, Telford and Wrekin
Midlands Partnership NHS Foundation Tru…
Concerns summary (AI summary) Significant delays in IAPT counselling and an unclear, difficult-to-follow electronic record system with poorly defined risk assessment protocols raised concerns for patient safety.
Action Planned (AI summary) Midlands Partnership NHS Foundation Trust is redesigning counselling services to reduce waiting times, with completion planned within six months. The Trust is also further developing the Rio system to improve the clarity of electronic patient records, although clinical staff cannot overwrite or delete entries without the system recording it.
Paul Fairey
All Responded
2018-0399 21 Dec 2018 London Inner (South)
London Borough of Lewisham
Concerns summary (AI summary) Obscured street lighting, faded road markings, and an ineffective speed cushion created hazardous road conditions, compromising pedestrian and motorist safety.
Action Taken (AI summary) Lewisham Council arranged for the cutting back of tree foliage and remarked the northbound and southbound "SLOW" markings. The council proposed to reconstruct the speed cushions near pedestrian refuge crossing points by the end of April 2019.
Richard Whale
All Responded
2018-0404 21 Dec 2018 Manchester (South)
Department for Digital, Culture Media a… Manchester United Football Club Trafford Borough Council
Concerns summary (AI summary) Impeded exit routes and obstructed handrails due to steward placement, coupled with non-compliance with steward codes and lack of audits, compromised public safety at the football ground.
Action Planned (AI summary) Manchester United Football Club has further revised the match-day slips/trips/falls risk assessment, introduced more detailed pre-match briefings for stewards, and put in place an additional match-by-match system of proactively checking both stewards' positioning within vomitories and checking compliance by stewards with the Code of Conduct; it disputes findings of non-compliance with code of conduct. The SGSA is amending the Green Guide to include specific reference to access to handrails in the context of vomitories and the positioning of stewards and has been liaising with Trafford Metropolitan Borough Council and MUFC to ensure lessons are learned. Trafford Council has requested that the club responds to future recommendations within a specified timeframe and will include observations of the monitoring of stewarding behavior during match-day audits. The council is reviewing its policies and procedures, including an appraisal of the Coroner’s concerns.
Dorina Zangari
Historic (No Identified Response)
2018-0403 21 Dec 2018 London (East)
Local Government Association London Borough of Barking & Dagenham Co… London Councils +5 more
Concerns summary (AI summary) Undermined fire safety measures, absent functioning fire detection, and an inadequate alternative escape route in maisonettes place residents at significant risk of death or injury from fire.
Mihaela Lazar
Historic (No Identified Response)
2018-0403-wp26468 21 Dec 2018 London (East)
National Fire Chiefs
Concerns summary (AI summary) Inadequate fire detection and warning systems, including missing smoke alarms and kitchen doors, combined with unacceptable escape routes in older maisonettes, pose a significant fire risk in thousands of properties.
Cady Stewart
Historic (No Identified Response)
2018-0402 21 Dec 2018 Manchester (South)
Tameside Clinical Commissioning Group
Concerns summary (AI summary) Opiate medication from a deceased parent on palliative care was not removed by nursing staff, remaining accessible and subsequently used by the deceased to end her life after a previous suicide attempt.
Diane Greenslade
All Responded
2018-0401 21 Dec 2018 Gwent
Aneurin Bevan University Health Board Welsh Ambulance Services
Concerns summary (AI summary) Inadequate ambulance call categorisation without clinical assessment, failure to escalate after failed contact, and high demand compounded by hospital delays led to significant delays in medical intervention.
Action Planned (AI summary) The Health Board reports improvements in ambulance response times and highlights several initiatives to improve the timeliness of releasing crews at the hospital, including practitioners reviewing WAST calls and additional doctors in the Emergency Department. The Welsh Ambulance Services NHS Trust acknowledges concerns and has completed and continues to work on strategic and operational quality improvements in patient safety, including training of Clinical Contact Centre staff, recruitment of clinicians, and improvements to policies and collaborative working; the Trust will also undertake a concerns investigation to address whether the delay had any impact and would welcome an opportunity to meet with the family.
William Atherton
Historic (No Identified Response)
2018-0400 21 Dec 2018 Norfolk
Queen Elizabeth Hospital
Concerns summary (AI summary) Failure of medical review, unrecognised worsening condition, missing nursing observations, and incorrect, inconsistently applied Early Warning Scores prevented proper escalation of patient care.
Maria Hryniw
All Responded
2018-0398 20 Dec 2018 Manchester (South)
Care Quality Commission Department of Health and Social Care
Concerns summary (AI summary) Lack of assessment for PEG feeding suitability/volume for an end-of-life patient, unaddressed family concerns, and poor understanding between healthcare teams regarding decision-making, created unsafe care practices.
Noted (AI summary) The CQC reviewed the facts and evidence in relation to the death and completed an inspection at the service. The nursing home was found to have achieved beacon status with the Gold Standard Framework for end of life care. The Department of Health and Social Care acknowledges the concerns raised regarding end-of-life care and outlines existing frameworks, guidance, and initiatives aimed at improving care and decision-making in this area. They expect the CQC to respond as regulator of health and adult social care.
Kirsty Walker
All Responded
2018-0396 19 Dec 2018 Surrey
Department of Health and Social Care NHS England
Concerns summary (AI summary) Prolonged delays (months) in transferring prisoners requiring secure hospital care under the Mental Health Act, far exceeding recommended timeframes, are caused by a severe shortage of available beds.
Action Planned (AI summary) NHS England is undertaking demand and capacity reviews for adult secure services, aiming to optimise capacity and throughput, with results expected in 2019/20. They are also revising prison transfer and remission guidance, and expect this to make the transfer/remission process more efficient. NHS England is undertaking service reviews across all adult high, medium and low secure services and reviewing the current prison transfer and remission guidance. A new service specification for an integrated mental health service for prisons in England is being implemented.
Michal Netyks
Partially Responded
2018-0393 19 Dec 2018 Liverpool & Wirral
Home Office MOJ
Concerns summary (AI summary) Prison Custody Officers lack training for delivering deportation papers, and foreign national prisoners have unequal access to legal advice. Mezzanine safety at HMP Altcourse and the Home Office's conduct during proceedings were also concerns.
Action Taken (AI summary) HMP Altcourse has updated NOMIS with a record of risk assessment conversations and issued a notice to staff reminding them to use the Big Word translation service. The MoJ Estates Directorate has agreed to carry out a review of balcony design, expected to be completed in the autumn.
Henry Curtis-Williams
All Responded
2018-0397 19 Dec 2018 London (West)
Norfolk and Suffolk NHS Trust
Concerns summary (AI summary) A culture of inadequate contemporaneous note-taking, especially regarding suicidal ideation, and informal, unrecorded staff communication led to critical information being lost. Junior doctors could discharge high-risk patients without senior review.
Action Planned (AI summary) The Trust will be using the case in learning via patient safety newsletter and practice education teams. The Trust issued an internal alert to inpatient wards directing reflection on processes where information is received from differing sources.
Kurt Cochran; Leslie Rhodes; Aysha Frade; Andreea Cristea; PC Keith Palmer.
All Responded
2018-0304 19 Dec 2018 London Inner (West)
Department for Transport Home Office Metropolitan Police +5 more
Concerns summary (AI summary) A Prevention of Future Deaths report was issued to multiple authorities following the Westminster terror attack to address systemic issues related to such events.
Noted (AI summary) The Parliamentary Authorities confirm that they already plan to consider the automation of Carriage Gates and their general ease of use as part of the ongoing renewal project; and external reviewers have already been extensively involved in the New Palace Yard project, and will continue to be involved. The MPS will revise Post Instructions to relevant groups by direct emails, in hard copy and/or via electronic devices; MPS is working with MO19 and the National Police Chief’s Council to provide additional training on de-escalation techniques; and the MPS will ensure that there is appropriate input from tactical advisers at challenge panels, and the newly appointed PaDP OFC Sergeant will ensure that AFOs fully understand not only relevant changes to post instructions but also the rationale behind the changes. The BVRLA has increased counter terrorism training and guidance made available to vehicle rental and leasing firms, and routinely shares data and intelligence with police and counter terrorist authorities. The Department for Transport launched its Rental Vehicle Security Scheme in December 2018. The MCA states sufficient guidance already exists in the public domain for operating commercial vessels and leisure boats on navigable rivers and canals, referring to existing codes and training courses. The London Ambulance Service states that the Chief Coroner found no matters of concern regarding their actions, so they will not be taking any further action. TfL implemented internal changes in October 2017 to improve communication of security advice. TfL is currently reviewing the height of all its bridge parapets to identify those that are below 1m high, with high priority bridges expected to be completed by April 2019. The Home Office states the government accepts the Chief Coroner's recommendations and has taken action. The Department for Transport (DfT) launched the Rental Vehicle Security Scheme (RVSS) on 6th December 2018, and an industry led Advisory Panel was launched in January to oversee the development of the scheme.
Ruth Edwards
All Responded
2018-0395 18 Dec 2018 SouthWales Central
Cardiff and Vale University Health Board West Quay Surgery
Concerns summary (AI summary) Patient discharge after an overdose failed to include psychiatric liaison assessment, passing critical responsibility to the family. Inadequate history-taking led to underestimated risk, and insufficient GP medication reviews created an overdose risk.
Action Taken (AI summary) The practice has taken on a full-time Clinical Pharmacist to oversee repeat and acute prescribing, and patient monitoring. They achieved an NHS award for quality improvement in this area. The University Health Board conducted an internal review and will remind staff of the importance of full and diligent information taking. The matter of medication reviews has been raised with the Primary Community and Intermediate Care Clinical Board as a practice issue.
Susan Longden
All Responded
2018-0394 18 Dec 2018 Avon
NHS Digital
Concerns summary (AI summary) The NHS Pathways algorithm fails to prompt questions about recent surgery for severe abdominal pain, and NHS 111 advisors don't adequately prioritise speaking to patients directly. These systemic issues have been repeatedly raised.
Action Planned (AI summary) NHS Digital acknowledges that the question about a recent surgical procedure or operation is not specifically asked in a sub-section of their abdominal pain pathways and are reviewing how this might be included as part of a larger clinical review, which is due for completion later this year; and they do currently require that all users of NHS Pathways seek to talk directly with the patient where possible.
Natalie Hunter
Historic (No Identified Response)
2018-0392 18 Dec 2018 Isle of Wight
St Mary’s Hospital NHS Trust
Concerns summary (AI summary) The Isle of Wight NHS Trust frequently fails to provide timely discharge summaries to GPs, hindering continuous patient care, especially for mental health needs. Additionally, underfunding has led to inadequate out-of-hours mental health staffing.
Jacqueline Valvona
All Responded
2018-0391 18 Dec 2018 Isle of Wight
Island Roads Isle of Wight Council
Concerns summary (AI summary) A lack of safe pedestrian crossing on a busy road near a popular pub, especially for elderly residents with mobility issues, may lead to future deaths.
Action Planned (AI summary) The Isle of Wight Council instructed Island Roads to undertake a feasibility study and design for a pedestrian controlled crossing and will undertake a further assessment in the summer to determine whether a new crossing should be considered. Island Roads will undertake a further pedestrian survey in the summer months to determine vehicle and pedestrian numbers during peak tourist season, and then assess the suitability of a new controlled crossing.
John Duckenfield
All Responded
2018-0389 18 Dec 2018 South Yorkshire (West)
Brancaster Care
Concerns summary (AI summary) Care home staff dishonesty regarding patient observations and GP calls, coupled with inaccurate records, indicated serious failures. Management surprisingly deemed the care reasonable despite these issues.
Action Taken (AI summary) The care home revised its policy on observations and record keeping, trained all registered nurses in January 2019, issued them with the new procedure, and implemented monthly audit checks on care records. Nurse Bogdan completed an observations training module on National Early Warning Score (NEWS2) on 17 January 2019.
John Delahaye
Partially Responded
2018-0388 18 Dec 2018 Birmingham and Solihull
Birmingham and Solihull Mental Health N… Birmingham Community NHS Trust G4S +2 more
Concerns summary (AI summary) National risk assessment templates are unclear on medication, and unreliable electronic records impede identifying past medical conditions. Healthcare staff are also inconsistently present or informed of crucial ACCT reviews.
Action Planned (AI summary) NHS Digital began rolling out a new mandated coding system called SNOMED CT coding from April 2018 to replace all other coding systems; and SNOMED CT has been introduced as an alternative coding system into the prison general practice electronic medical records; SystmOne since 14 January 2019.