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
Ellie Clark
Partially Responded
2018-0066 6 Mar 2018 Gwent
Aneurin University Health Board Grange Clinic
Concerns summary (AI summary) Failures in care planning, clinical oversight, and triage systems led to delayed and inadequate care. Critical medical information was not prominent, and staff felt unable to challenge decisions, impacting patient safety.
Action Taken (AI summary) The Health Board conducted a formal review of the action plan implemented in 2015 and shared lessons learned following the case with GP practices and paediatric consultants. Respiratory pharmacists developed a community pharmacy service to identify patients with outstanding reviews or overusing reliever medication and the ABUHB Medical Director issued further correspondence to all GP practices and paediatric consultants to ensure that lessons learned following this sad case are acknowledged and shared by the GP community
Rastislav Petrisko
Historic (No Identified Response)
2018-0067 6 Mar 2018 London Inner (South)
Oxleas Mental Health Trust
Concerns summary (AI summary) Inconsistent risk assessment and classification of a patient, combined with a delayed police notification policy for absconding low-risk patients, led to an unacceptable delay in emergency response.
Georgia Polydorou
Partially Responded
2018-0079 6 Mar 2018 London Inner (North)
Homerton University Hospital N.I.C.E
Concerns summary (AI summary) Elderly patients on blood thinners are at risk due to delayed CT scans after falls, as deterioration signs can be delayed. Communication failures, including language barriers and inadequate information sharing with family, further compromise care.
Noted (AI summary) NICE notes the coroner's concerns but believes its existing guidelines on venous thromboembolism and head injury appropriately reflect available evidence. The issues have been logged with the NICE guideline surveillance team for future review.
William Abrahams
All Responded
2018-0074 6 Mar 2018 London Inner (North)
NHS England
Concerns summary (AI summary) The current AAA screening program excludes individuals over 65 at its introduction, and the "opt-in" nature for asymptomatic conditions may hinder participation, risking undetected aneurysms.
Action Planned (AI summary) NHS England London Region Public Health Commissioners will continue to support London AAA screening programmes to improve men's awareness of their options to attend screening. Targeted work with GPs in areas of higher deprivation and potential inequalities in access.
Mike Fell
All Responded
2018-0100 5 Mar 2018 London Inner (North)
Barts Health NHS Trust Royal College of Anaesthetists
Concerns summary (AI summary) Unused trauma lines lack a clear mechanism and documentation for ensuring they are "closed to air," with some lines lacking essential clamps, creating a risk of accidental opening.
Action Planned (AI summary) Barts NHS Trust has rewritten its policy on the use of central lines and three-way taps, stating that three-way taps should not be used on central lines but self-sealing injection ports should be used. They are also discussing with their current supplier a change in design to allow a clamp to be fitted; they are interested in working with us as they see this as a problem nationally which has not been raised before in relation to this complication. The RCoA will publish information on central venous access line safety in the Patient Safety Update and include these issues in the updated AAGBI guideline Safe Vascular Access. The FICM and ICS are developing national guidelines on the prevention, detection, referral and treatment of air embolism associated with central venous access.
Emily Hartley
Partially Responded
2018-0063 2 Mar 2018 West Yorkshire (East)
Department for Health HM Prison Service
Concerns summary (AI summary) Prison was not the appropriate environment for someone with the deceased's mental health problems, and there is a need for secure, therapeutic environments for prisoners with similar mental health needs.
Action Planned (AI summary) The Government is developing a strategy to improve outcomes for women in the community and in custody. A project is piloting to work with women who are prolific self-harers and who do not meet the criteria for other services. NHS England has developed a Ten Point Plan for Mental Health which will describe how the secure care pathway can be improved to ensure it works more effectively and efficiently.
Cyril Anderton
Historic (No Identified Response)
2018-0065 1 Mar 2018 Warwickshire
George Eliot Hospital
Concerns summary (AI summary) Medical staff failed to attempt CPR due to a critical error, consulting and acting upon the wrong set of patient medical notes.
George French-Russell
Partially Responded
2018-0062 1 Mar 2018 Manchester (South)
Department of Health and Social Care East Midlands Ambulance Service Healthcare Safety Investigation Branch +1 more
Concerns summary (AI summary) Inadequate information sharing and unstructured communication between EMAS and hospital staff, combined with paramedics lacking experience and support for complex obstetric emergencies, compromised patient care.
Noted (AI summary) EMAS has shared a revised handover tool with network partners and plans to implement it across its footprint in May 2018, subject to governance approval; is working to promote the use of recorded facilities at receiving units; is exploring expanding its recording ability, incorporated into a wider IT infrastructure plan; clinical staff have been provided with clinical guideline books and an electronic app version is planned for launch in April 2018; staff have been reminded of the importance of escalating advice call failings. The Department of Health references existing NICE guidance and a forthcoming guideline on intrapartum care for high-risk women. It also describes the role of the Healthcare Safety Investigation Branch (HSIB) in investigating serious incidents and the "Safer Maternity Care" initiative which sets an expectation of a 20% reduction in serious incidents by 2020. HSIB acknowledges receipt of the coroner's concerns but states that the case occurred before their operational start date and therefore does not meet their criteria for investigation. They will use the information to help build a wider picture of safety issues in the NHS.
Andrea McHugh
Partially Responded
2018-0060 28 Feb 2018 Northamptonshire
Groupo de Turismo Gaviota S.A Thomas Cook
Concerns summary (AI summary) Waivers for recreational water activities fail to disclose risks for participants with epilepsy or gather essential past medical history, compromising safety for vulnerable individuals.
Action Planned (AI summary) Thomas Cook will request that Groupo Turismo Gaviota S.A. amend their waiver form to include reference to epilepsy, review the waiver form to include reference to any medical history that may make it dangerous for their customers to go in to the sea, and conduct a wider review of supplier processes in connection with sea-based excursions.
Kevan Funnell
All Responded
2024-0095 27 Feb 2018 West Sussex, Brighton and Hove
South East Coast Ambulance Service
Concerns summary (AI summary) No specific concerns for future deaths were detailed in the provided text.
Action Planned (AI summary) South East Coast Ambulance Service is working with commissioners in a jointly commissioned demand and capacity review, intended to better align resource requirements to the demands on our service, particularly in the light of the newly introduced Ambulance Response Programme standards. The recent NHS Pathways upgrade will significantly reduce the risk of such an error recurring.
Adrian King
All Responded
2018-0061 27 Feb 2018 Staffordshire (South)
Foreign Office
Concerns summary (AI summary) British consulate/embassy communication channels were inadequate and unresponsive to family attempts to assist with medical treatment for an ill British national abroad, potentially impacting care outcomes.
Action Taken (AI summary) The FCO has reminded consular staff of policy guidance and best practices to ensure timely action. Since July 2017, all consular calls are answered at in-house Consular Contact Centres providing a 24/7 service. They are also encouraging British travellers to take out appropriate travel insurance before they travel.
Raymond Davidson
Historic (No Identified Response)
2018-0059 27 Feb 2018 Sunderland
North East Ambulance Service NHS Trust
Concerns summary (AI summary) Persistent operational staff shortages and overwhelming demand are causing severe and unacceptable ambulance response delays. Additionally, telephone contact not directly with the patient compromised the initial clinical review.
David Ireland
All Responded
2018-0057 27 Feb 2018 Exeter and Greater Devon
Devon NHS Trust
Concerns summary (AI summary) The crisis team failed to advise that presenting at the emergency department was an option for urgent mental health assessment, and the patient's friend was unaware of this critical pathway.
Action Planned (AI summary) Devon Partnership NHS Trust will include specific reference to providing advice about emergency department attendance options in their next Trust-wide 'Safety Briefing' and in local induction for temporary workers. They have also asked teams to review answer machine messages to include appropriate support information.
Kay Morrison
Historic (No Identified Response)
2018-0058 26 Feb 2018 South Yorkshire (West)
Department for Health Royal College of Surgeons
Concerns summary (AI summary) There is an insufficient system for collating appropriate antibiotic history, potentially across many hospitals, and a lack of clear requirements for Trusts to adhere to national guidelines on this crucial patient information.
James Quinton
All Responded
2018-0056 22 Feb 2018 South Yorkshire (East)
Doncaster Royal Infirmary
Concerns summary (AI summary) Poor nursing documentation and observation charts hindered clinical oversight. A critical medication was incorrectly administered due to a verbal prescription, highlighting a lack of essential checking procedures.
Action Planned (AI summary) Doncaster and Bassetlaw Teaching Hospitals are training individuals as scribes, obtaining a software update for monitors, and have set up a working group with ED and Anaesthetics to explore the issue of IV drug administration in emergencies during resuscitation. The clinical educator is reviewing IV competencies for staff within ED in relation to their current revalidation status.
Christopher Brookes
Partially Responded
2018-0055 22 Feb 2018 Black Country
Black Country North Fire Safety team Transport for West Midlands West Midlands Combined Authority +2 more
Concerns summary (AI summary) Security guards failed to respond to an activated fire exit alarm at a location with a history of a near-fall incident, indicating inadequate safety protocols and response.
Action Taken (AI summary) City of Wolverhampton Council has worked with the health and safety executive and the fire service to review the index area, has installed additional safety lighting on the fire escape route and signage highlighting the drop below, and is working with relevant parties.
Richard Phillips-Schofield
Partially Responded
2018-0054 21 Feb 2018 Portsmouth and South East Hampshire
British Cycling Cycling Time Trials League of Veteran Racing Cyclists +3 more
Concerns summary (AI summary) There are no formal, effective national procedures for halting cycle races after an accident, leading to other riders passing through dangerous aftermaths.
Action Planned (AI summary) British Cycling, Scottish Cycling and Welsh Cycling will implement improvements to training and communication, including scenario-based activities and better reference materials in educational resources. British Cycling also intends to communicate with existing circuit and track commissaires to ensure that as part of the rider pre-race briefing they communicate how a race will be slowed or stopped and the organisation will also communicate any revised education and training content related to how to slow or stop a race to existing commissaires.
Alan MacDonald
All Responded
2018-0053 21 Feb 2018 London Inner (North)
Addcounsel
Concerns summary (AI summary) A non-medically qualified counsellor charged an inpatient for non-treatment visits and failed to advise them on financial alternatives, revealing a systemic omission in Addcounsel's practices.
Action Taken (AI summary) Addcounsel has changed its system so that clients are discharged entirely to the care of the service deemed more suitable and only case manages clients to whom they are delivering services. Interim measures are in place to ensure the MDT is aware of this change while a formal policy is being agreed and ratified.
Molly Mills
All Responded
2018-0051 21 Feb 2018 Nottinghamshire
Nottingham County Council
Concerns summary (AI summary) A complex road junction suffers from poor visibility due to an incline and queuing right-turning vehicles. Unclear right-of-way indications, inadequate signage, and a problematic solid white line create significant safety risks.
Action Planned (AI summary) Nottinghamshire County Council is considering highway improvement measures, including potentially closing access to Home Farm and revisions to the position of the existing central traffic island. They are also considering a localised reduction in the speed limit, all subject to consultation and detailed design work.
Bethany Shipsey
All Responded
2018-0049 15 Feb 2018 Worcestershire
Department for Health
Concerns summary (AI summary) The highly toxic and antidote-less drug DNP is readily available online and popular as a 'diet drug.' There is a lack of legislation making its possession or supply illegal.
Action Taken (AI summary) The Department of Health acknowledges concerns about DNP and highlights existing actions including FSA's '#dnpkills' campaign, monitoring by the National Poisons Information Service, and warnings issued to GPs and emergency departments; they will continue to consider further actions.
Charlie Craig
All Responded
2018-0048 15 Feb 2018 Manchester (South)
British Cycling
Concerns summary (AI summary) British Cycling does not conduct health assessments or medical screening for young riders on its World Class Programme, missing opportunities to identify potential cardiac abnormalities.
Action Planned (AI summary) British Cycling will implement new cardiac screening guidelines developed with Liverpool John Moores University for all athletes on the World Class Programme and apprentice level. Apprentice riders will not be allowed to participate until they have completed a health questionnaire, provided a fitness certificate from their GP, and provided evidence of cardiac screening.
Timothy Shaw
Partially Responded
2018-0047 15 Feb 2018 Essex
Care UK Clinical Services Essex Partnership University NHS Founda… Farleys Solicitors LLP +2 more
Concerns summary (AI summary) Healthcare staff showed confusion regarding intelligence reports, communication between departments was poor, and systems for reducing illegal substances and managing referrals needed improvement. Record-keeping was also substandard.
Noted (AI summary) Care UK acknowledges receipt of the report but states they ceased providing healthcare at HMP Chelmsford on 26 May 2017 and therefore will not be filing a substantive response.
John Lambton
Historic (No Identified Response)
2018-0046 14 Feb 2018 Sunderland
Dairy Lane Care Centre
Concerns summary (AI summary) Care home staff, without medical training, made assumptions about a resident's health after falls, disregarded an ambulance request, and communicated insufficiently with the GP.
Elaine Bradbrook
All Responded
2018-0044 14 Feb 2018 Nottinghamshire
United Lincolnshire Hospitals NHS Trust
Concerns summary (AI summary) Multiple failures in escalating care for a deteriorating patient, inadequate risk reduction during transfer, and lack of internal investigation or learning by the trust contributed to serious concerns.
Action Taken (AI summary) United Lincolnshire Hospitals NHS Trust acknowledges communication issues and historical problems with their Serious Incident (SI) process. They have made significant improvements to the SI process in the last 12 months including training and have asked the Risk Team to commence a SI investigation to review the care and submit an action plan.
Natasha Ford
Partially Responded
2018-0052 13 Feb 2018 Black Country
Cambian Group Raglan House
Concerns summary (AI summary) A previous self-harm incident involving a plastic bag led to temporary restrictions, but these were later removed due to a policy change prioritizing reduced restrictive practices.
Action Taken (AI summary) CAS Behavioural Health has introduced a blanket policy restricting the use of plastic bags in all their hospitals, following a review of their Reducing Restrictive Practice policy after the incident.