2018

PFD Reports
Reports: 419 Areas: 64

69% response rate (above 63% average).

Response Status
Responded 289 Historic 130
AI Classification
Action Taken 43%
Action Planned 40%
Noted 17%
Disputed 1%
Based on 361 classified responses
Top Categories
Hospital Death (Clinical Procedure… (181) Community health care and emergenc… (52) Other related deaths (44) Care Home Health related deaths (34) Suicide (from 2015) (34)
419 results
Lucia Ciccioli
Partially Responded
2018-0148 16 May 2018 London Inner (West)
Transport for London Wandsworth, Merton, Richmond and Sutton…
Concerns summary (AI summary) Inadequate cycle lanes and protection at a junction, problematic road markings, and dangerous road conditions in an adjoining street compromise cyclist safety.
Action Planned (AI summary) TfL, working with LBW, proposes to complete a revised design of the junction and set out next steps by December 2019, with construction potentially beginning in 2020 subject to approvals and funding. They will also investigate relocating a loading bay or reducing its operating hours to improve cyclist safety.
Doris Ridgwell
Partially Responded
2018-0151 15 May 2018 Surrey
Care Quality Commission Epsom & St Helier University Hospital N…
Concerns summary (AI summary) A critical communication failure meant an abnormally high INR result for a Warfarin patient was not effectively relayed or acted upon before discharge, leading to fatal complications.
Action Taken (AI summary) The Trust has revised its Standard Operating Procedure for telephoning coagulation results to ensure urgent abnormal blood results are communicated effectively, including escalation to the Site Manager if necessary. It has also re-issued guidance to clinical staff clarifying their responsibility to communicate clinically urgent abnormal blood results to patients and take appropriate action, even after discharge.
Gladys Rich
Partially Responded
2018-0149 14 May 2018 Northamptonshire
Avenue House Nursing and Care Home Care Quality Commission Kettering General Hospital +1 more
Concerns summary (AI summary) The care home failed in fall risk assessment and action plan implementation, while the under-resourced Falls Prevention Service lacked proactive follow-up and discharge mechanisms.
Action Planned (AI summary) The care home will contact the Falls Team after sending referrals and action plans to confirm receipt and intended actions, recording all contact in residents' care plans.
Philip Ashton
Historic (No Identified Response)
2018-0146 14 May 2018 Milton Keynes
PJ Care
Concerns summary (AI summary) Medication errors occurred due to flawed procedures, staff were unprepared for emergencies, and vital medical history was inaccessible to ambulance crews.
Hans-Peter Schmidt
Historic (No Identified Response)
2018-0145 14 May 2018 Cornwall& the Isles of Scilly
Cornwall Council Heritage Attractions Ltd Lands End Resort
Concerns summary (AI summary) Lack of barrier maintenance, absent permanent barriers, inadequate international warning signs, and insufficient staff training at cliff hot spots create significant safety hazards.
Charles Grainger
Historic (No Identified Response)
2018-0353 12 May 2018 Derby and Derbyshire
Derbyshire County Council Milford House Care Home NHS Southern Derbyshire Clinical Commis…
Concerns summary (AI summary) Systemic barriers prevented social workers from sharing crucial falls history with multi-agencies, and investigations failed to adequately review past falls risk assessments, risking future deaths.
Thomas Ratchford
Historic (No Identified Response)
2018-0147 11 May 2018 Manchester (North)
Elizabeth House (Oldham) Limited
Concerns summary (AI summary) Carers improperly used a hoist for pressure relief without expert advice, highlighting insufficient training in moving/handling and pressure relief for staff and management.
Marcus Allen
All Responded
2018-0144 11 May 2018 West Yorkshire (East)
Radcliffe Investment Properties
Concerns summary (AI summary) Large lounge windows lacking restrictor devices open excessively, creating a fall hazard when residents must lean out to close them.
Action Taken (AI summary) Estates & Management has provided further training to its teams on handling correspondence. Restrictors will be installed where necessary and letters have been sent to every leaseholder to carry out a survey, and amendments made to Health and Safety Risk Assessments to undertake annual inspections of apartments to check the restrictors are functioning correctly.
Ahmed Tabeche
All Responded
2018-0143 11 May 2018 London (East)
Twinglobe Care Homes Limited
Concerns summary (AI summary) Care home staff lacked a complete understanding of choking risks, and current procedures for visitors providing food are insufficient, failing to adequately protect at-risk patients.
Action Taken (AI summary) Twinglobe Care Homes has implemented changes across its group of homes, including a Choking Risk Assessment, Choking and Aspiration Care Plan, Aspiration Guidance, Nutrition and Fluid Chart, Nutritional Profile, leaflet for relatives/visitors, poster, Deprivation of Liberty Screening Checklist, Mental Capacity Assessment Record, Best Interests Decision Form, Visiting and Visitors Policy, Meal and Mealtimes in Care Homes Policy, and Food bought in by Visitors Policy.
Lewis Colgan
Historic (No Identified Response)
2018-0161 9 May 2018 Buckinghamshire
Oxford Health NHS Trust
Concerns summary (AI summary) Inadequate supervision of care coordinators, incompatible caseloads, and staff changes compromised mental health care continuity and engagement. Lack of robust processes for CPA meetings and an incomplete Root Cause Analysis further raised concerns.
Edward Joyce
Partially Responded
2018-0142 9 May 2018 London Inner (South)
Chelsea & Westminster Hospital Medical Protection Society
Concerns summary (AI summary) A child's critical high temperature following a burn was missed by the GP and not recorded or acted upon by hospital staff, highlighting inadequate awareness of burn complications and follow-up advice.
Noted (AI summary) The Trust states the evidence indicates a temperature spike was not mentioned during the phone call, and the national information leaflet contains accepted advice and correct symptoms for burns injuries. The Paediatric Burns Network has been alerted, and the burns unit can be contacted by telephone 24 hours every day.
Joan Hanratty
Historic (No Identified Response)
2018-0141 9 May 2018 Manchester (South)
Denton Medical Centre
Concerns summary (AI summary) The system for providing antibiotics and steroids to COPD patients on request lacks explicit advice for them to seek medical attention if their condition does not improve within a specified period.
Kirsty Tolley
All Responded
2018-0139 9 May 2018 Norfolk
Queens Elizabeth Hospital NHS Trust
Concerns summary (AI summary) Inconsistent blood test monitoring for anaemia and inadequate Early Warning Score (EWS) assessment and escalation to doctors led to missed opportunities for intervention and a lack of clear medical cause of death.
Action Planned (AI summary) The staff in the clinical area have received support to ensure they understand and use the current escalation system. The Trust will adopt the National Early Warning System (NEWS2) on November 1st 2018, including new documentation, training and escalation procedures.
Stephen Tidey
All Responded
2018-0140 8 May 2018 Surrey
Surrey & Borders Partnership NHS Trust Surrey County Council Surrey Police
Concerns summary (AI summary) Inadequate recording of changes in suicide risk assessments and significant delays by mental health services in acting on high-risk MASH referrals following a critical trigger event.
Noted (AI summary) Surrey Police explains how Multi Agency Safeguarding Hub (MASH) reports are processed upon receipt and graded for risk. They state that they do not monitor partner agency responses and suggest forwarding one question to SABP and Adult Social Care. The Trust has already implemented a standardised log for Single Combined Assessment of Risk Forms (SCARF) across Community Mental Health Recovery Service (CMHRS) teams. They have also devised a new checking system between the MASH and the CMHRS teams and set up an automated email reply from the Mental Health/Drug & Alcohol inbox within the MASH.
Darren Trewin
All Responded
2018-0138 8 May 2018 Exeter and Greater Devon
Devon Highways
Concerns summary (AI summary) A partially blocked road drain caused water to cascade across the carriageway, and inadequate safety barriers failed to prevent a vehicle from leaving the road where the ground dropped steeply.
Action Planned (AI summary) Highways England has flagged the location as a flooding 'hotspot' with weekly inspections. They are planning to install an additional gully, conduct a wider drainage study, and undertake a Road Restraint Risk Assessment Process (RRRAP) to inform the need for a vehicle restraint barrier.
William Dickens
Partially Responded
2018-0137 8 May 2018 London Inner (South)
South London & Maudsley NHS Trust The Care Quality Commission
Concerns summary (AI summary) Hospital observation protocols for high-risk patients were not followed, and observation logs were retrospectively falsified, compromising patient safety and preventing timely intervention.
Action Planned (AI summary) The Director of Nursing will issue a safety alert, and ward managers will hold learning conversations with nurses regarding observation practices. The Therapeutic Engagement and Observation Policy will be reviewed, and new nurses and nursing trainees will receive a "Learning the Lessons" presentation. Six-monthly audits will be commissioned to establish compliance, and a timeline is being developed for transforming observations into an e-observation framework.
Jonathan Earp
All Responded
2018-0135 8 May 2018 Gloucestershire
Gloucestershire Hospitals NHS Trust
Concerns summary (AI summary) Inadequate management of prescribed Fentanyl patches meant 'unspent' medication was not accounted for, and staff failed to consider the cumulative effect of Fentanyl and suspected illicit drug use.
Action Taken (AI summary) The Trust reviewed the circumstances of fentanyl administration, discussed the case with ward staff and presented it to the Senior Nurse and Midwifery Committee. An action plan confirms work undertaken and ongoing as a result of the death, with oversight from the Trust Quality Delivery Group.
Joanne Richardson
All Responded
2018-0134 8 May 2018 Dorset
Dorset Healthcare University Hospital N…
Concerns summary (AI summary) Critical communication failures between mental health services meant a high-risk assessment by one team was not shared with the Community Mental Health Team, compromising informed patient care.
Action Taken (AI summary) Administrators now check both electronic patient information systems for referrals, and read-only access is available to administrators and team leads. A new referral inbox is used to share urgent risk information. The need to act on information has been reinforced within the CMHT, and learning has been disseminated to all CMHTs.
Kenneth Horne
Partially Responded
2018-0131 3 May 2018 Stoke-on-Trent & North Staffordshire
Staffordshire & Stoke-on-Trent Partners… Leek Moorlands Hospital Royal Stoke University Hospital
Concerns summary (AI summary) Critical information about recent falls was omitted from discharge paperwork and not communicated during hospital transfer, potentially leading to an unsafe transfer and a subsequent serious fall.
Action Taken (AI summary) The Trust has instructed clinical leads to include significant events like patient falls in discharge summaries, ensure verbal handovers occur alongside paper versions, revamped the Transfer of Care Form, and reiterated the importance of accurate Datix reporting. An audit of discharge summaries is also planned.
Martin Baker
All Responded
2018-0130 3 May 2018 Plymouth, Torbay and South Devon
Livewell South West
Concerns summary (AI summary) Poor communication with the family and a shortage of care coordinators meant the patient lacked advocacy, and his family was unprepared for deterioration after psychiatric discharge.
Action Planned (AI summary) Bath and North East Somerset Council and Avon and Wiltshire Mental Health Partnership NHS Trust have developed a joint action plan to address concerns raised. The plan includes actions, responsible agencies, and timeframes, and incorporates additional learning and monitoring methods.
Christine Withers
All Responded
2018-0127 1 May 2018 Black Country
Dudley NHS Trust
Concerns summary (AI summary) Crucial repeat blood tests for potassium levels were not performed as recommended, and nursing staff failed to adequately communicate with family about the patient's deteriorating condition.
Action Taken (AI summary) The Dudley Group NHS Trust has revised guidelines for hypokalaemia management, publicised them on the intranet, and scheduled a presentation. Staff are working with a palliative care champion to complete in-house palliative care competencies covering communication with patients and families.
Matthew Fulleylove
Historic (No Identified Response)
2018-0128 30 Apr 2018 West Yorkshire (East)
Treanor Pujol Limited
Concerns summary (AI summary) Operatives have restricted space to work near metal support legs, creating a risk of fatal injuries from rotating industrial saws. Some safety measures recommended by an expert engineer have not been fully implemented for industrial machines passing on tracks 11 and 12.
Sara Moran
All Responded
2018-0133 28 Apr 2018 Blackpool & Fylde
Department of Health and Social Care
Concerns summary (AI summary) Excessive caseloads for mental health professionals risk individuals not receiving adequate attention, potentially leading to fatal outcomes for vulnerable service users.
Noted (AI summary) The Department of Health acknowledges concerns about capacity within mental health services, but emphasizes the responsibility of individual NHS Trusts for staffing levels and training. The response outlines existing CQC regulations, national guidance, and initiatives to improve access to psychological therapies and increase the mental health workforce.
Catherine Burns
All Responded
2018-0132 28 Apr 2018 Blackpool & Fylde
Blackpool Teaching Hospitals NHS Trust
Concerns summary (AI summary) Emergency Department staff were overwhelmed by excessive patient numbers, leading to delays in doctor assessment and undetected patient deterioration, creating a risk of future deaths.
Action Planned (AI summary) The Trust is reviewing nursing and medical staffing in the Emergency Department, and has submitted a paper to the Executive Team for consideration of an increase in establishment. They are also embedding the Safer Care Bundle and are using Improved Streaming to the Urgent Care Centre and fast initial assessment.
Paul James
Partially Responded
2018-0254 27 Apr 2018 Mid Kent & Medway
HMP Elmley THE SECRETARY OF STATE FOR JUSTICE
Concerns summary (AI summary) A prisoner with a serious self-harm history was permitted access to razor blades in a single cell, reflecting inadequate risk assessment and safety protocols for vulnerable individuals.
Action Planned (AI summary) HM Prison & Probation Service will issue a learning bulletin on managing razor blade risks, pilot a revised ACCT case management process prompting consideration of razor blade access, and consider broader options for managing the issue.