2018
PFD Reports
Reports: 419
Areas: 64
69% response rate (above 63% average).
Barry Tucker
All Responded
2018-0018
17 Jan 2018
Brighton & Hove
Brighton and Sussex University Hospitals
NHS England
CCG, Eastbourne
+2 more
Concerns summary (AI summary)
No specific concerns were detailed in the provided text.
Action Taken
(AI summary)
The Trust will not accept bookings for major urology cancer surgery patients on the private patient unit. The urology specialty will conduct documentation audits to identify themes and improvements, and agree a process for ensuring Electronic Discharge notification is signed/checked by a senior doctor.
Keith Harwood
All Responded
2018-0017
16 Jan 2018
Blackpool & the Fylde
Blackpool Teaching Hospitals NHS Trust
Concerns summary (AI summary)
Medical professionals struggle to access urgent specialist advice for unfamiliar conditions despite Trust policies, potentially delaying appropriate care and requiring families to educate staff.
Action Planned
(AI summary)
The Trust will issue an internal alert reminding staff of the importance of timely management of patients with Parkinson's disease and timely referral to the Parkinson's Specialist Team and the availability of the procedure document on the Trust intranet.
Edwin Hooper
All Responded
2018-0016
16 Jan 2018
Manchester (South)
Manchester University NHS Trust
Concerns summary (AI summary)
Concerns exist regarding ensuring timely CT scanning for head injury patients on anti-coagulants, in line with NICE guidelines, especially when facing service issues with on-site CT scanners.
Action Taken
(AI summary)
The hospital has implemented a robust escalation and dissemination plan for CT scanner downtime, including senior managers on call, out-of-hours team reminders, and posters in clinical areas. Training on NICE guidelines for hospital-acquired head injuries has been undertaken, with ongoing induction training for new starters.
Antony Coughtrey
Historic (No Identified Response)
2018-0014
15 Jan 2018
Milton Keynes
HM Inspectorate of Probation
Concerns summary (AI summary)
The Probation Service failed to conduct an internal investigation or Serious Incident Review after a prisoner's death on licence and had a procedural failure in referring licence breaches back to the Parole Board.
Christopher Hutton
All Responded
2018-0011
12 Jan 2018
Manchester (South)
National Probation Service
Concerns summary (AI summary)
Significant backlogs and high demand within Probation services meant a critical court-ordered treatment program for the deceased was not commenced, despite his anxiety to complete it.
Action Planned
(AI summary)
To address the increased demand for sex offender treatment programs, the North West Division is increasing staff from 23 to 35 facilitators and training them, with the first 11 in post by June 2018 and another 10 by the end of 2018; it is also undertaking a scoping exercise for a central referral system to streamline the allocation process.
David Buttriss
All Responded
2018-0010
12 Jan 2018
Cornwall and the Isles of Scilly
Cornwall Health
Cornwall NHS Trust
NHS England
Concerns summary (AI summary)
Critical communication breakdowns between GP and mental health services, fragmented healthcare records, and a lack of clarity in mental health crisis pathways across multiple agencies hindered effective care.
Noted
(AI summary)
Devon Doctors no longer provides out-of-hours services in Cornwall and has passed the report to the new provider. They reviewed the concerns in relation to their Devon services, noting that information sharing is partly outside their control but that clinicians have appropriate pathways to escalate concerns, including Community Mental Health Practitioners in their Clinical Assessment Service. A Rapid Reassessment Pathway for individuals with mental health needs discharged from secondary to primary care has been developed by Livewell Southwest. NHS England proposes to disseminate a reminder to GPs to safety net urgent mental health referrals, and to consider giving patients written guidance on what to expect and when following a referral. Cornwall NHS Trust has implemented a new assessment service with designated administrators to manage referrals, and developed new Safety Plans for patients containing crisis information. The Trust is also reviewing the Out of Hours services and any changes will be communicated to external providers.
Pauline Pryor
All Responded
2018-0009
12 Jan 2018
Cornwall and the Isles of Scilly
NHS England
Concerns summary (AI summary)
Critical communication failures between the nursing home and GP, an inadequate system for monitoring lithium toxicity, and an unread consultant email led to missed essential blood tests and unmanaged medication changes.
Action Planned
(AI summary)
NHS England will raise the need for formal communication between agencies regarding patients with mental health issues in their GP bulletin and provide information to the LMC for distribution. They will also highlight the importance of up-to-date lithium monitoring guidelines to GPs and practices.
John Armstrong
All Responded
2018-0008
12 Jan 2018
Leicester (City & South)
Civil Aviation Authority
Concerns summary (AI summary)
A lack of mandatory, compatible anti-collision systems and the absence of Air Traffic Control at a busy airfield created significant collision risks, exacerbated by human eye limitations in adverse weather.
Action Planned
(AI summary)
The CAA will continue to drive forward the plan to ensure operators are `electronically conspicuous' which will help to reduce the incidence of such events. The MAC programme works closely and collaboratively with the UK Airprox Board, UK Flight Safety Committee, Military Aviation Authority and industry stakeholders to understand and assess risk and identify effective and collaborative mitigations.
Lee Daniel
All Responded
12 Jan 2018
Isle of Wight
Isle of Wight Council Highways Departme…
Concerns summary (AI summary)
Inadequate road markings, specifically the absence of double yellow lines, allowed legal parking to obstruct visibility, forcing drivers onto the wrong side of the road and increasing accident risk.
1 response
from Lee Daniel
Donald Till
All Responded
2018-0013
11 Jan 2018
Stoke-on-Trent & North Staffordshire
University Hospitals of North Midlands
Concerns summary (AI summary)
Unavailable medical records, inadequate equipment (missing bronchoscope part, no tilt trolley), and unutilised standard procedures (cricoid pressure, NG tubes) compromised patient care during anaesthesia.
Action Planned
(AI summary)
The evidence base regarding risk assessment for patients with bowel obstruction will be presented to clinicians at the departmental mortality and morbidity meeting, to remind them to ensure the surgical teams gave similarly considered the risk benefit for a nasogastric tube when booking cases for CEPOD (emergency) theatre.
John Chapman
All Responded
2018-0007
11 Jan 2018
Lancashire
HMP Wymott
Concerns summary (AI summary)
A critical lack of formal procedures for sharing prisoner self-harm and welfare alerts between prison reception staff and healthcare nurses during medical screenings created a risk of significant alerts being missed.
Action Taken
(AI summary)
All reception staff at HMP Preston have been given a copy of PSI 07/2015 and made it an objective to read and comply; revised suicide and self-harm prevention training is being rolled out, prioritising reception staff; emergency boxes with resuscitation aids are on all residential units, and all staff with prisoner contact will be issued resuscitation aids by June; contingency plans have been amended to ensure staff are informed about the manner of all non-natural deaths. The prison and healthcare services have agreed that PER forms will be passed to the reception nurse as a matter of routine, who must then document within the SystemOne record that the form has been received and considered; they are exploring incorporating this check into the record system as part of the existing reception health screen template.
John Edwards
Partially Responded
2018-0015
10 Jan 2018
Staffordshire (South)
Community Disability Nurse
Independent Futures, Southwinds Care Ho…
Concerns summary (AI summary)
The care home was unable to manage complex needs, demonstrating inadequate policies for falls and pressure sores, poor record-keeping, and a failure to administer prescribed medication or seek timely medical assistance for deterioration.
Disputed
(AI summary)
Response Southwinds Limited disputes the implication that neglect contributed to the death of Mr. Edwards, argues that other evidence was not sufficiently taken into account, and asserts that they were not given full pre-admission information.
John O’Meara
All Responded
2018-0012
10 Jan 2018
London (West)
HMP Wormwood Scrubs
Concerns summary (AI summary)
Prison officers inconsistently followed Code Blue/Red procedures, delaying emergency response and Naloxone administration due to inadequate training. There's also an insufficient number of passive drug detection dogs to control Novel Psychoactive Substances.
Action Taken
(AI summary)
Regular notices to staff are published, signs are displayed in all offices and information about emergency response procedures is included in the induction for all new staff; notices have been attached to all cell doors in the First Night Centre; the London and Thames Valley regional search team is currently recruiting additional dog handlers to increase the service provided to prisons in the region, including HMP Wormwood Scrubs, which will be provided with a total of seven dog handlers, with both passive and active search and patrol dogs.
Patrick Moran
Historic (No Identified Response)
2018-0006
5 Jan 2018
London Inner (North)
Royal Free Hospital
Concerns summary (AI summary)
An insulin overdose occurred due to the common practice of using incorrect syringes, exacerbated by the removal of diabetes from mandatory training and the lack of a system to review compliance with safety alerts.
Marcus Hamilton
Historic (No Identified Response)
2018-0005
5 Jan 2018
Manchester (South)
Greater Manchester Mental Health NHS Fo…
Concerns summary (AI summary)
The mental health service's rigid 28-day prescription policy for maintenance medication left a patient vulnerable during extended travel, providing unreliable advice about obtaining drugs illicitly abroad.
Dylan Hill
All Responded
2018-0004
4 Jan 2018
South Yorkshire (West)
Department for Health
Food Standards Agency
Concerns summary (AI summary)
A critical lack of communication procedures meant a previous non-fatal anaphylactic reaction at a food business was not reported to Trading Standards, preventing timely regulatory action and risking future deaths.
Action Planned
(AI summary)
The FSA will be meeting with other government departments and organisations to discuss tackling food allergy issues, and welcomes the Coroner's contribution to these discussions; will also be placing more emphasis on reporting near misses and deaths from food allergy in the Practice Guidance and writing to local authorities to highlight lessons learned and reinforce expectations on good allergen management practices. The Trust has reviewed and updated its anaphylaxis draft protocol and included a referral form to inform Trading Standards of cases of anaphylactic reaction from commercial premises. The draft protocol will be reviewed and ratified at a meeting in March 2018. The FSA will set up a cross-government discussion to consider the reporting of non-fatal anaphylaxis, while Barnsley and Sheffield are exploring the development of local notification systems and considering ways to raise awareness among GPs.
Margaret Silver
All Responded
2018-0002
3 Jan 2018
Surrey
Ashford and St Peter’s Hospital NHS Tru…
Concerns summary (AI summary)
Contradictory information in discharge summaries led to the discontinuation of life-saving medication, which clinicians failed to identify despite patient contact. Additionally, occupational therapy recommendations for support were not ensured post-discharge.
Action Taken
(AI summary)
The trust is amending the discharge letter template to improve clarity regarding medications. They also intend to introduce electronic prescribing in 2019, and are implementing a 'Red Bag' process to improve communication between providers.
Paul Daniels
All Responded
2018-0003
2 Jan 2018
Manchester (South)
Arboricultural Association
Forestry Commission
Health and Safety Executive
Concerns summary (AI summary)
An inadequate staffing ratio meant tree surgeons lacked qualified aerial support, and poor communication methods via shouting and hand signals hindered safety during work at height.
Action Planned
(AI summary)
The Arboricultural Association will publish a summary of the events in a safety bulletin to its members and partner organisations by the end of February 2018 and in their quarterly magazine in June 2018, reminding arborists to use correct methods and techniques. The Forestry Commission will circulate the Arboricultural Association safety bulletin, review emergency procedures with in-house arborists, re-brief employees supervising arboricultural contracts, and update the training module for supervisors. The Arboriculture and Forestry Advisory Group (AFAG) will promulgate learning points from the incident via its committee members, and will ensure that these points are considered when specific guidance leaflets are next reviewed.
Kristina Cross
Historic (No Identified Response)
2018-0001
2 Jan 2018
Lancashire & Blackburn with Darwen
Department for Health
Ministerial Correspondence and Public E…
Concerns summary (AI summary)
Delayed surgical fixation of a traumatically fractured femur, caused by initial and subsequent misdiagnoses, led to post-operative complications and significantly contributed to the patient's death.