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
Donald Martin
Partially Responded
2018-0166 28 Mar 2018 Derby and Derbyshire
RCN Legal Services New Lodge Nursing Home
Concerns summary (AI summary) A nurse lacked essential knowledge regarding appropriate CPR on flat surfaces and how to deflate patient mattresses during emergencies, posing a risk to patient safety.
Action Taken (AI summary) The RCN provides a reflective piece from Ms. Banjoko, detailing CPR processes and awareness of mattress deflation importance, and notes she has remediated her practice, completed basic life support training, and the NMC has closed its case with no further concerns.
Anthony Paine
Partially Responded
2018-0088 28 Mar 2018 Liverpool and Wirral
HM Prison and Probation Service Ministry of Justice The Chief Coroner of England and Wales
Concerns summary (AI summary) The provided text is a placeholder, stating that a brief summary of matters of concern will follow, but no specific concerns are detailed.
Action Planned (AI summary) NHS England details a service specification refresh completed in March 2018, with Spectrum benchmarking against these specifications, and revisions to approaches for secure hospital transfers, including a ten-point plan "Right Care, Right Place, Right Time", are being developed. HMPPS acknowledges concerns about healthcare provision at HMP Liverpool and highlights that responsibility for healthcare provision transferred to Spectrum Community Health CiC in partnership with Mersey Care NHS Foundation Trust on April 1, 2018, aiming for a consistent approach to care continuity.
John Wherlock
Historic (No Identified Response)
2018-0089 28 Mar 2018 Avon
Bristol NHS Trust
Concerns summary (AI summary) Simultaneous staff breaks led to insufficient ward cover and unsupervised patients, directly resulting in a fall; this unsafe staffing practice was still ongoing despite being criticised.
Matthew Gayle
Historic (No Identified Response)
2018-0092 27 Mar 2018 Staffordshire (South)
Department of Health and Social Care
Concerns summary (AI summary) Insufficient numbers of consultant histopathologists and a lack of compulsory training in coroner's autopsies risk incomplete death investigations, as exemplified by a missed histology opportunity.
Maureen Campbell-Scott
Partially Responded
2018-0090 27 Mar 2018 London (East)
North East London Trust Fullwell Cross Medical Centre
Concerns summary (AI summary) A referral was sent to the wrong team and then lost, causing a four-month delay in assessment. There were also delays in delivering clinic letters to the GP, and prescribing did not always follow the psychiatric team's directions.
Action Planned (AI summary) NELFT has been liaising with Fullwell Cross Medical Centre and Redbridge CCG and progress has been made to address concerns and they are reconvening a meeting with primary care colleagues to discuss prescribing of medication to shared patients.
Joan Osborne
All Responded
2018-0091 26 Mar 2018 Nottinghamshire
Adbolton Hall Nursing Home
Concerns summary (AI summary) Numerous failures in nursing home care included not seeking specialist advice, missing appointments, inadequate record-keeping, and poor recognition/response to deteriorating patient condition and insulin refusal.
Action Taken (AI summary) Adbolton Hall outlines several actions already implemented, including appointing a new Home Manager, providing diabetes awareness training to staff, purchasing new blood glucose monitoring machines, removing Lucozade from the premises, and ensuring nurse-led interventions for diabetic residents.
Kenneth Longley
Historic (No Identified Response)
2018-0086 22 Mar 2018 Manchester (South)
Graham Street, Beswick, Manchester Wythenshawe Hospital
Concerns summary (AI summary) A nearly three-month delay in sending crucial medical information to the patient's GP after an echocardiogram created a risk of future deaths due to delayed diagnosis and treatment.
Edward Lundy
Historic (No Identified Response)
2018-0087 21 Mar 2018 Somerset
South London and Maudsley NHS Trust
Concerns summary (AI summary) Poor continuity of care, inadequate family consultation on discharge risks, and lack of evidence for implementing recommended improvements in mental health risk management for GP trainees were identified.
Barbara Johnson
All Responded
2018-0084 21 Mar 2018 Manchester (South)
Pennine Acute NHS Trust
Concerns summary (AI summary) Junior doctors routinely ignored diagnostic printouts from ECG machines, which flagged abnormalities, raising concerns about the impact on clinical interpretation and judgment.
Noted (AI summary) GMMH will include the handover process and expectations in the local induction template and implement electronic handover sheets, aiming for full implementation by July 31, 2018. Northern Care Alliance NHS Group states that the junior doctors concerned were employed by Pennine Acute NHS Trust, but placed at Tameside General Hospital, so they are not responsible for implementing changes and suggest the report be amended and addressed to Tameside Hospital.
Peter O’Donnell
All Responded
2018-0201 20 Mar 2018 Manchester (West)
Department of Health and Social Care
Concerns summary (AI summary) Private hospital care had no clear consultant review agreements, inadequate junior doctor oversight/training, absent patient transfer protocols, and failed to report nurse misconduct, creating systemic safety risks.
Noted (AI summary) The Department of Health acknowledges concerns regarding independent hospitals and refers to existing standards, CQC ratings, and quality monitoring data submissions, also noting the ongoing Paterson Inquiry looking into accountability and quality of care in the independent sector.
Kellie Taylor
All Responded
2018-0083 19 Mar 2018 East Riding and Kingston upon Hull
Humber Bridge Board
Concerns summary (AI summary) The poor resolution of the CCTV system hindered accurate monitoring of individuals and delayed timely intervention during potential emergencies at the bridge.
Action Taken (AI summary) The Humber Bridge Board has purchased two Impact Protection Vehicles, liaised with the Samaritans to place signs, implemented a specialist training programme for staff and Police, and trained Control Room staff to recognize signs of emotionally distressed individuals.
Sheila Ross
Historic (No Identified Response)
2018-0081 19 Mar 2018 Sunderland
Hylton View Care Home
Concerns summary (AI summary) The care home used an outdated falls risk assessment, had a limited buzzer system unable to provide timely assistance, and exhibited poor communication with the family.
Jean Griffiths
All Responded
2018-0080 15 Mar 2018 Manchester (West)
Department of Health and Social Care
Concerns summary (AI summary) A national audit revealed widespread poor oxygen prescribing practices in hospitals, with many patients lacking valid prescriptions, risking inappropriate oxygen levels and increased mortality.
Action Planned (AI summary) The Department of Health acknowledges concerns regarding oxygen prescribing practices. NICE is updating its guideline CG101 to tighten prescribing practice and the BTS and Royal Colleges will have opportunity to participate in the development and comment on the draft guidance.
Janet Hall
Historic (No Identified Response)
2018-0082 14 Mar 2018 Manchester (South)
Pennine Acute Hospitals NHS Trust
Concerns summary (AI summary) The Emergency Department system, relying on manual transcription of blood results by junior doctors, led to incorrect discharge letters and prevented GPs from effective trend analysis.
Peter Stojilkovic
Partially Responded
2018-0077 14 Mar 2018 Manchester (South)
Stockport Clinical Commissioning Group Department of Health Heaton Moor Medical Practice +2 more
Concerns summary (AI summary) Poor communication post-discharge about melatonin prescribing and a complex, inconsistent system of national and local drug blacklists forced patients to seek medication from unlicensed online sources.
Action Planned (AI summary) The Medical Director will review the case with the practice to identify any further learning and will discuss the provision of medication at discharge with Pennine Care to identify any improvements that need to make.
Freddie Dobinson-Evans
Partially Responded
2018-0078 14 Mar 2018 London Inner (North)
Great Ormond Street Hospital Royal London Hospital
Concerns summary (AI summary) A critical genetic test result, indicating a pathogenic mutation, was misread as normal, leading to a diagnostic error that could have significant consequences for other children.
Action Taken (AI summary) Following concerns about miscommunication of genetic test results, the organisation met with the genetics lab at Great Ormond Street Hospital, who have changed the results format to address future directions in case of any abnormality, effective from 01/05/2018.
Thomas Curtin
All Responded
2018-0076 14 Mar 2018 Cornwall and the Isles of Scilly
NHS England
Concerns summary (AI summary) Private mental health locked rehabilitation units lack a national framework for referral response times, potentially leaving patients on inappropriate wards and risking their safety.
Action Planned (AI summary) NHS England is working with other bodies to improve national-level understanding of CCG commissioned rehabilitation services and support local areas to plan and commission the rehabilitation pathway more effectively, following a CQC report on mental health rehabilitation inpatient services.
Catherine Kennedy
All Responded
2018-0075 13 Mar 2018 Manchester (South)
Pennine Care NHS Trust
Concerns summary (AI summary) Miscommunication between ward staff and an on-call doctor led to a significant delay in patient review after an overdose, highlighting the lack of a consistent communication paradigm.
Action Taken (AI summary) The Situation, Background, Assessment, Recommendation (Decision) tool is currently taught within several courses and the Organisation Learning and Development have been supplying learners with a copy of the A5 SBAR(D) telephone pads, to write on as handing over. The organisation has developed an action plan relating to the points raised during the inquest, which includes the re-design of Community Mental Health Services and an apology to Ms Kennedy's brother. The actions described in the letter are incorporated in an enclosed action plan.
Leigh Wilde
Historic (No Identified Response)
2018-0085 12 Mar 2018 Manchester (South)
IMI (Institute of the Motor Industry) LTE Group
Concerns summary (AI summary) The company lacked documented rationale for employee suspension, failed to consider risk factors or offer support services, and kept inadequate meeting records, raising concerns about employee welfare.
Martin Tilley
Historic (No Identified Response)
2018-0071 12 Mar 2018 Gloucestershire
Gloucestershire Care Services NHS Trust
Concerns summary (AI summary) A psychiatric patient with severe suicidal ideation and hallucinations was not followed up by the Homeless Healthcare Team after missing an appointment, and no emergency assessment referral was made.
David Sketchley
Partially Responded
2018-0069 9 Mar 2018 Gloucestershire
BUPA UK CARE QUALITY COMMISSION Medicines and Healthcare Products Regul… +1 more
Concerns summary (AI summary) The investigation into a patient's death was inadequate, failing to determine supervision levels, collaborate with manufacturers, identify incident cause, or properly assess equipment suitability.
Noted (AI summary) The CQC is gathering evidence into this matter with a view to deciding whether there has been a failure by BUPA and/or the Registered Manager to comply with the Health and Social Care Act 2008 and will contact BUPA to request a copy of their response to the prevention future death report.
Bernard Gerrard
Partially Responded
2018-0070 8 Mar 2018 Derby and Derbyshire
East Midlands Ambulance Service NHS Tru… NHS Hardwick Clinical Commissioning Gro…
Concerns summary (AI summary) Emergency ambulance services are experiencing unacceptable delays in vehicle response times, even for urgent calls, due to insufficient funding and overwhelming demand.
Action Planned (AI summary) EMAS is negotiating with its Coordinating Commissioner regarding the contract settlement for 2018/19 and 2019/20, and anticipates recruiting and training additional frontline operational staff and staff within the Emergency Operations Centre. They have already established an Urgent Care Transport Service (UCTS) which went live on Tuesday 3 April.
Elizabeth Griffin
Partially Responded
2018-0072 7 Mar 2018 London Inner (West)
Chartered Trading Standards Institute Wandsworth Watch Alarm Office for Product Safety and Standards +2 more
Concerns summary (AI summary) No specific concerns for future deaths were detailed in the provided text.
Noted (AI summary) The Department highlights the launch of a new Code of Practice on product recalls (PAS 7100) and the development of a comprehensive digital service for consumer product safety information. They also support the 'Register My Appliance' site and are meeting with Whirlpool UK regarding their recall processes. Whirlpool outlines its product safety processes, including senior leadership oversight, and highlights the existence of a freephone number and prominent stickers on new products encouraging registration. They are also leading discussions within the industry on improving consumer awareness of the 'Register My Appliance' site. The CTSI states it is a professional body without powers to investigate and the matter is for local authority trading standards departments. They also highlight a workforce survey showing cuts to trading standards services.
Venkata Kagga
Partially Responded
2018-0068 7 Mar 2018 Manchester (South)
The Royal Society for Prevention of Acc… Healthcare Safety Investigation Branch Department of Health and Social Care +2 more
Concerns summary (AI summary) Critical safety features for button batteries in household devices are lacking, and national safety alerts are not effectively sustained. Hospital policies for paediatric assessment and compliance were not followed, exacerbated by poor information sharing across services.
Action Planned (AI summary) HSIB has launched a scoping exercise, including collecting further details about the incident and conducting a short literature review, to examine whether the case meets their criteria for investigation.
Ivanika Olivari
Partially Responded
2018-0073 7 Mar 2018 London Inner (West)
Department of Health and Social Care General Medical Council St Georges Hospital
Concerns summary (AI summary) Hospital guidelines and staff training are inadequate regarding urgent patient contact, specifically for leaving messages and utilising all contact numbers, risking delays in life-critical situations. National guidance needs clarification.
Action Planned (AI summary) The Trust has amended Appendix 1 of the Confidentiality Code of Conduct policy to enable staff to leave telephone messages for patients in urgent and emergency situations, has disseminated the learning from this case throughout Cardiology services, and will report to the next Patient Safety and Quality Committee meeting. The GMC is considering how best to use communication channels to remind doctors of their duty to take prompt action if they think that a patient's safety, dignity or comfort may be seriously compromised, will alert the Information Governance Alliance to the absence of guidance for NHS staff on the use of voicemail, and is working on extra resources to expand its ethical guidance hub.