2018
PFD Reports
Reports: 419
Areas: 64
69% response rate (above 63% average).
Katy Roberts
Partially Responded
2018-0136
27 Apr 2018
London Inner (South)
South London & Maudsley NHS Trust
Southwark Safeguarding Children Board
Steel & Shamash Solicitors
Concerns summary (AI summary)
There was a failure to communicate the Care Plan and changes to it in writing, as well as to provide a clear route or opportunity to challenge these changes.
Action Planned
(AI summary)
The trust will implement a Community Care Plan for CAMHS clients, to be completed with the young person and family, and develop an implementation plan for its introduction across community teams. They will also survey service users to ensure guidance on seeking help is available.
Yazin Elhjaje
Historic (No Identified Response)
2024-0601
26 Apr 2018
Avon
University Hospitals Bristol NHS Trust
Concerns summary (AI summary)
Safety-netting advice provided upon discharge focused solely on headaches, failing to include information about the differential diagnosis of meningitis, despite it being considered.
Novia Delima
Historic (No Identified Response)
2018-0112
20 Apr 2018
Manchester (South)
Department of Health and Social Care
Mayor of Greater Manchester
NHS England
Concerns summary (AI summary)
Emergency Department demand prevented meeting triage targets, early paediatrician involvement for very young children was not ensured, and on-call consultants were not called despite significant demand.
Amanda Spark
Historic (No Identified Response)
2018-0109
19 Apr 2018
Dorset
Dorset University NHS Trust
Concerns summary (AI summary)
Concerns arose regarding a patient's decision to change her medication regime while under crisis team care, implying potential issues with medication management and oversight.
Adrian Jennings
All Responded
2018-0111
19 Apr 2018
Manchester (South)
Pennine Care NHS Trust
NHS England
Tameside Clinical Commissioning Group
+2 more
Concerns summary (AI summary)
Disjointed IT systems, lack of joined-up discharge planning, uncommissioned support services, and limitations in a national IT system hindered effective information sharing and patient care.
Noted
(AI summary)
Tameside and Glossop CCG acknowledges the need to expand mental health support and is investing in additional services, but does not recognize a gap in provision for individuals with high levels of needs like Mr. Jennings as they consider them covered by existing secondary care services. They will follow up on the other concerns with Pennine Care Foundation Trust through quality and performance monitoring. The Department of Health acknowledges the concerns raised and refers to national policy expectations and guidance, including the Mental Health Act 1983 Code of Practice and the Global Digital Exemplar programme. It also mentions the Healthcare Safety Investigation Branch's investigation into care for patients with mental health problems in emergency departments. NHS England notes the concerns and describes actions taken to address disparate IT systems (Global Digital Exemplar programme), joined-up discharge plans (national framework), and capturing when police bring in individuals (updated Emergency Department module in Lorenzo with mandatory data collection fields).
Stanley Langdon
Partially Responded
2018-0110
19 Apr 2018
County Durham and Darlington
Durham County Council
Haven Day Care Centre
Concerns summary (AI summary)
A day care centre provided services without receiving or creating an adequate care plan based on a needs assessment or family discussion, risking future similar accidents.
Action Taken
(AI summary)
The Haven Day Centre implemented all suggested improvements from a County Durham Commissioning team report, including obtaining signatures on risk assessments, reviewing complaints policies, unifying transport policies, improving training records, and revising home assessment documents.
Harry Jellicoe
Historic (No Identified Response)
2018-0108
18 Apr 2018
Lincolnshire
Lincolnshire County Council
Concerns summary (AI summary)
The national speed limit is too high for a bridge with restricted visibility and a height limitation requiring high-sided vehicles to use the center, exacerbated by a lack of priority signage.
Matthew Wilmot
All Responded
2018-0107
17 Apr 2018
Bedfordshire and Luton
B & D Civil Engineering Limited
M & S Water Services
Concerns summary (AI summary)
Risk assessments for path closures are inadequate for unique routes without alternative access, leading pedestrians to disregard barriers and use hazardous excavations.
Action Taken
(AI summary)
B & D Civil Engineering reports that M&S will amend its team briefing to emphasize assessing suitability of alternative pedestrian routes and escalating concerns to supervisors. The revised briefing will be mandatory for new operatives and refreshed for existing operatives every six months. M&S Water Services has amended its team briefing to include a procedure for operatives to escalate concerns about "unique" locations to a supervisor, who will then decide on appropriate control measures. The briefing will be mandatory for new operatives and refreshed for existing operatives every six months.
Karen Edgar
Partially Responded
2018-0106
16 Apr 2018
Cumbria
Cumbria Partnership NHS Foundation Trust
Department of Health and Social Care
Morecambe Bay Clinical Commissioning Gr…
+1 more
Concerns summary (AI summary)
Critically underfunded child and adolescent mental health services in Cumbria result in long treatment delays, risking lives and causing lasting harm.
Noted
(AI summary)
The Department of Health acknowledges concerns and states that commissioning of mental health services is a matter for the local NHS. They note that local commissioners have made considerable investment to services to children and young people in the last eighteen months.
William Callis
Historic (No Identified Response)
2018-0105
12 Apr 2018
Northamptonshire
St Lukes Primary Care Centre
Concerns summary (AI summary)
A lack of clear, specific instructions for GP practices on how to refer to the Urgent Care and Assessment team was identified.
Patricia Heslop
All Responded
2018-0102
12 Apr 2018
Sunderland
Department of Health and Social Care
HC-One
Concerns summary (AI summary)
Failures in care home included unreported falls, poor record-keeping, un-updated care plans, and staff inadequately trained in recognising patient deterioration and dementia care.
Noted
(AI summary)
The Department of Health acknowledges the concerns and refers to existing statutory guidance, CQC investigations, and national resources like the 'Falls and Fracture Consensus Statement' and NICE guidelines. They also mention the 'Quality Matters' initiative and plans to reform the social care system. HC-One describes actions taken following the incident, including internal investigations, informing staff of clinical concerns identified during meetings and supervision, and additional internal scrutiny of Hebburn Court. They also refer to improvements noted in a recent CQC inspection report.
James Sheffield
All Responded
2018-0214
12 Apr 2018
Manchester (West)
Salford Royal NHS Trust
Concerns summary (AI summary)
Delays occurred in diagnosis and surgical intervention for a fracture, and a patient's essential CPAP machine went missing during hospital ward transfer.
Action Taken
(AI summary)
The Trust updated its electronic patient record system's ward-to-ward transfer document and circulated a safety alert to staff informing them of the changes. These changes have been fully implemented.
George Goldby
All Responded
2018-0104
11 Apr 2018
Nottinghamshire
HC-One
Concerns summary (AI summary)
Nursing home staff were unaware of and failed to adhere to SALT recommendations for supervision and diet, resulting in missed re-referral opportunities and inadequate choking risk assessments.
Action Taken
(AI summary)
HC One allocated an Operational Project Manager, reviewed care plans, allocated staff to supervise eating and drinking, completed swallowing risk assessments, referred residents to SALT, and increased senior management cover; CQC inspection evidenced significant improvements in the quality and safety of care.
Lea Hunsley
All Responded
2018-0101
10 Apr 2018
Manchester (North)
EAM Care Group
Concerns summary (AI summary)
The care facility lacked an SUI protocol, and staff demonstrated inadequate skills in identifying and escalating deteriorating patients, poor observation, and insufficient use of care records.
Action Taken
(AI summary)
EAM Care Group completed a root cause analysis with commissioners, will obtain post-operative care plans prior to admission, and introduced new handover procedures including lunchtime handovers and archiving of staff notes; they also completed an action plan following a CQC inspection.
Ellie Butler
Historic (No Identified Response)
2018-0421
10 Apr 2018
London (South)
Cafcass
Department for Housing, Communities and…
London Borough of Sutton
+4 more
Concerns summary (AI summary)
No specific concerns were detailed in the provided text, only a reference to appended concerns.
Andrew Reid
All Responded
10 Apr 2018
Manchester (West)
Trafford Clinical Commissioning Group
Greater Manchester
Concerns summary (AI summary)
Inconsistent mental health service commissioning in Greater Manchester means Trafford residents lack out-of-hours emergency GP referrals, forcing A&E attendance or police involvement.
2 responses
from Andrew REID, Andrew REID Response2
Naseeb Chuhan
All Responded
2018-0099
9 Apr 2018
West Yorkshire (East)
Financial Conduct Authority
Concerns summary (AI summary)
Payday loan companies contributed to the deceased's dependency by encouraging loans despite awareness, and their financial checks were inadequate.
Action Planned
(AI summary)
The FCA is inviting views on overdraft pricing and monitoring repeated overdraft use, aiming to consult on proposed rules by the end of 2018; they are also fostering growth of alternatives to high-cost credit and invited firms with innovative alternatives to trial their approaches.
Darryl Souza
All Responded
2018-0098
9 Apr 2018
Northamptonshire
Highways Agency
Northamptonshire County Council
Northamptonshire Highways
Concerns summary (AI summary)
Compromised visibility at a crossroads junction, despite existing signage, necessitates urgent improvements like renewed signs, rumble strips, and "Stop" signs, but these lack an implementation timeframe.
Action Planned
(AI summary)
Northamptonshire County Council will introduce 'rumble strips' in advance of the Clipston junction and convert the junction to a 'Stop' requirement, aiming to complete the work by the end of June 2018.
Miriam Roach
Historic (No Identified Response)
2018-0096
6 Apr 2018
Cornwall and the Isles of Scilly
NHS Kernov Clinical Commissioning Group
Concerns summary (AI summary)
There are concerns regarding the aftercare or transition arrangements for those discharged from hospital to home with a moderate to high risk of self-harm and/or suicide, and specifically the obligations for putting in place contact arrangements for such patients.
Barbara Haley
Historic (No Identified Response)
2018-0095
3 Apr 2018
Manchester (South)
Care Quality Commission
Harbour Health Care Limited
Hilltop Court
Concerns summary (AI summary)
Staff provided unsuitable food to a high-risk choking patient on a soft diet and left her unsupervised during meals, contrary to safety assessments.
Casper Blackburn
Partially Responded
2018-0094
3 Apr 2018
Manchester (South)
Canals and Waterways Agency
Peel Holdings
Trafford County Council
Concerns summary (AI summary)
Extremely poor lighting and lack of CCTV near the canal made it difficult to discern the water from the land at night, posing a significant safety risk.
Noted
(AI summary)
The Canal & River Trust states it has no jurisdiction or responsibilities regarding the Bridgewater Canal or the land at the location, which they believe is the responsibility of Peel Holdings.
Matthew Faulkner
All Responded
2018-0097
29 Mar 2018
Hertfordshire
East of England Ambulance Service
Lister Hospital
Luton and Dunstable Hospital
+1 more
Concerns summary (AI summary)
Emergency ambulance services face severe resource shortages, unsustainable demand, and significant hospital handover delays, reducing ambulance availability for emergency calls.
Action Planned
(AI summary)
Luton and Dunstable Hospital prioritise cubicle space for new patients from ambulances, transfer existing patients, open contingency areas, and transfer patients to wards where beds will shortly become available. The East of England Ambulance Service will increase frontline patient staff by 330 FTE by 2020/2021 and is planning to arrange a further briefing for HM coroners; other actions include reviewing PSIT and HALO functions, adding staff to the Emergency Operations Centre, and collaborating with CCGs to review inter-hospital transfers. Princess Alexandra Hospital NHS Trust refurbished the Emergency Department, introduced a Steaming Process and Rapid Assessment of patients (RAT), and has a clear escalation process for ambulance handover delays, supported by an allocated Paramedic. East North Hertfordshire NHS Trust reconfigured the ambulance handover process, removing non-essential tasks and reducing handover time; they are conducting a focus week in June 2018 to improve performance further, monitoring it weekly.
Ross Reeves
Partially Responded
2018-0093
29 Mar 2018
Brighton and Hove
Brighton and Hove Clinical Commission G…
British Medical Association
NHS England
Concerns summary (AI summary)
The patient's transfer to his new GP was identified as likely unsafe.
Action Planned
(AI summary)
The CCG acknowledges concerns around prescription medication and data transfer. They plan to disseminate learning throughout Primary Care via guidance and interactive sessions and ensure adequate specialist support is available to Primary care.
Margaret Spencer
All Responded
29 Mar 2018
Black Country
Walsall Healthcare NHS Trust (Manor Hos…
Concerns summary (AI summary)
Inadequate staff training for a new IT system resulted in premature closure of patient access plans and lack of reviews, placing multiple patients at risk.
1 response
from Margaret Spencer
Frank Hayward
Partially Responded
29 Mar 2018
Black Country
1. Chief Executive, Sandwell Hospital a…
Trust
Concerns summary (AI summary)
Emergency Department failures included incorrect injury assessment, missed specialist review opportunities, poor equipment provision systems, inadequate inter-departmental communication, and significant CT scan delays.
1 response
from Frank Hayward