2018
PFD Reports
Reports: 419
Areas: 64
69% response rate (above 63% average).
Bertram Crawford
All Responded
2020-0130
17 Dec 2018
Avon
Suspension Bridge Trustees
Concerns summary (AI summary)
A dangerous cluster of student deaths from the bridge, including three this year and four in two years, raises serious concerns about safety at this historical site.
Action Planned
(AI summary)
The Trust plans to extend the height of the parapet anti-climb fencing over the span and build a walkway beneath each of the buttresses, requiring planning permission and compliance with legislation.
Agnes Lambert
All Responded
2018-0410
17 Dec 2018
London Inner (North)
Camden & Islington NHS Trust
Concerns summary (AI summary)
Senior staff failed to ensure a nurse's ward transfer despite patient fixation concerns, leading to an incident. The trust also caused distress by taking an unacceptably long four months for a disciplinary investigation.
Action Planned
(AI summary)
The Trust is rolling out 'vital conversations' training for managers and reviewing its disciplinary policy to include clearer criteria for investigations. A specially-trained staff member will review cases to challenge whether a formal hearing is required, and the refreshed policy is expected to be complete in March 2019.
Barnaby Aylward
Partially Responded
2018-0387
14 Dec 2018
West Yorkshire (West)
SW Yorks NHS Trust
Together Housing
West Yorkshire Fire and Rescue Service
Concerns summary (AI summary)
Agencies did not collectively address the risks to a social housing tenant with serious mental illness, including heavy smoking and accumulating clutter. His care documentation also did not identify these behaviours as risks.
Action Planned
(AI summary)
West Yorkshire Fire and Rescue Service has agreed to a multi-agency programme of awareness training for staff from WYFRS, Together Housing and SWYFT to be delivered in June and July 2019.
Edward Farmer
All Responded
2018-0390
12 Dec 2018
Newcastle upon Tyne
Department for Education
Concerns summary (AI summary)
A national campaign is needed to highlight the inherent risks of rapid alcohol consumption and initiation events, focusing on identifying at-risk individuals and the importance of timely medical intervention.
Action Planned
(AI summary)
Following a roundtable event, Universities UK and Newcastle University published guidance to raise awareness of the dangers of initiations and excessive alcohol consumption among students. Public Health England is engaged in several actions targeted at young people about the dangers of excessive alcohol consumption. The Department for Education highlights the publication of comprehensive guidance by Universities UK and Newcastle University, "Initiations at UK Universities", which addresses the risks of initiations and excessive alcohol consumption among students. The guidance includes recommendations on staff training, disciplinary processes, reporting systems, and awareness raising. Newcastle University and the Students' Union have undertaken several actions, including enhanced training for student leaders, revised guidance, increased communications and awareness campaigns, and closer collaboration between university departments and the Students’ Union, with plans for continued monitoring and embedding of these practices. The Department of Health and Social Care will work with government colleagues and other health sector bodies to determine the best course of action regarding the risks of alcohol consumption. The Secretary of State for Education has deferred a response until the department has worked with colleagues in the health and education sectors on designing measures to raise awareness of the risks of alcohol consumption and initiation events. NUS plans to convene a meeting with the Home Office, Department for Education, Public Health England, Universities UK, and the Office for Students before the end of March 2019 to explore collaborative work on responsible alcohol consumption, potentially scaling up the Alcohol Impact program.
Benjamin Williamson
All Responded
2018-0384
12 Dec 2018
Cornwall and Isles of Scilly
Addaction
Kernow Clinical Commissioning Group
Concerns summary (AI summary)
The CMHT repeatedly discharged a patient with co-occurring mental health and alcohol issues, while Addaction failed to communicate with his GP or address consent for information sharing, creating a significant care gap.
Action Planned
(AI summary)
Addaction has reviewed and improved how they record confidentiality and consent reviews. They will provide the Health Centre with client numbers, have a designated worker attend practice multi-disciplinary team meetings with access to SystemOne, and inform GPs earlier about plans to cease structured treatment where consent exists. NHS Kernow is working with partner agencies to implement a multi-agency strategy, including developing a dynamic risk register for individuals with dual diagnosis, with priority given to immediate actions. Contract requirements for new contracts commencing April 2019 are being reviewed to strengthen monitoring of engagement with the implementation plan.
Neil Swaisland
All Responded
2018-0385
12 Dec 2018
Milton Keynes
Milton Keynes Clinical Commissioning Gr…
Milton Keynes Council
Concerns summary (AI summary)
The withdrawal of funding for MIND's counselling services by the Council and CCG risks future deaths from self-harm and suicide among vulnerable individuals.
Noted
(AI summary)
Milton Keynes Council has a contract for counselling services in place with MIND, which will be maintained until April 2019 whilst MIND develop additional funding opportunities for their services. Milton Keynes CCG has invested year on year into Improving Access to Psychological Therapies (IAPT) service provision and invested in a Primary Care Plus (PCP) service working with general practice to provide access to specialist support for people with serious mental illness and increasing mild and moderate need in primary care.
John Mayhew
Historic (No Identified Response)
2018-0381
11 Dec 2018
County Durham and Darlington
HM Inspector of Prisons
Independent Advisory Panel on Deaths in…
National Offender Management Service
Concerns summary (AI summary)
Clarification, redrafting, and improved guidance are needed for the PSI64/2011 section on first case reviews of ACCT assessments to ensure consistent and effective application across all prisons.
Rowan Lloyd
All Responded
2018-0380
11 Dec 2018
Dorset
Dorset Highways Department
Concerns summary (AI summary)
A busy road junction, frequently used by school children, lacks safe pedestrian crossings, cycle lanes, or barriers, leading to obscured views and high risk for pedestrians and cyclists.
Action Taken
(AI summary)
Dorset Council completed the proposed hatched lining on footways on the A354 approaches to signals, and a pre-feasibility study of the signalled junction between Portland Road, Merley Road and Langton Avenue has been completed. A redundant lighting column on Merley Road is hoping to be completed later this month.
Paliben Dullabh
All Responded
11 Dec 2018
London Inner (North)
Homerton Healthcare NHS Foundation Trust
Concerns summary (AI summary)
The hospital lacks arrangements for obtaining out-of-hours radiology reports for X-rays, unlike its provision for CT and MRI scans.
1 response
from paliben dullabh
Christopher McGuffie
All Responded
2018-0386
10 Dec 2018
County Durham and Darlington
Northern Rail Limited
Concerns summary (AI summary)
Railway stations lack immediate and effective alert systems for detecting and reporting persons on the line.
Action Planned
(AI summary)
Arriva Rail North is developing a campaign using various media, providing bespoke training for customer service controllers and are looking to bring forward the planned installation of CCTV at Chester le Street station.
John Kirby
Partially Responded
2018-0379
6 Dec 2018
Brighton and Hove
Medico Legal Manager
Sussex NHS Trust
Concerns summary (AI summary)
Evidence from the inquest revealed matters of concern and a risk of future deaths, necessitating action.
Action Taken
(AI summary)
Sussex Partnership NHS Foundation Trust has reduced the lead practitioner's caseload, implemented an information-sharing protocol between mental health liaison team and Pavillions A&E to improve communication, shared the ADHD NICE guidance with all doctors via Mediconnect and will present issues arising from this case for learning and discussion at the Trust's forthcoming Effective Care & Treatment Conference.
Veronica Gregory
All Responded
2018-0377
6 Dec 2018
Manchester (City)
Zinnia Healthcare Limited
Concerns summary (AI summary)
Care plans were inadequate, lacked specific risk issues, and were not appropriately reviewed or reassessed, either after incidents or as routine practice.
Action Taken
(AI summary)
Care plans now incorporate specific risk issues like falls, with monthly reviews and audits. Staff have been retrained and reminded to record incidents, and a new qualified nurse has been employed as Manager since February 2018.
Simon Healey
Partially Responded
2018-0378
6 Dec 2018
Berkshire
Independent Healthcare Providers Network
Ramsay Healthcare UK
Concerns summary (AI summary)
NEWS policies at private hospitals should be reviewed, particularly regarding escalation of care for critically unwell patients, considering their limited critical care capacity. Nursing staff on general wards may lack experience in managing post-operative complications like leaks or sepsis.
Noted
(AI summary)
The IHPN acknowledges the coroner's concerns, states that all IHPN board members have been made aware and highlights the competency and training of nursing staff in the independent sector and notes the shift to more openness and transparency with whistleblowing policies and training.
Sylvia Mitchell
All Responded
2018-0383
5 Dec 2018
Black Country
Oaks Medical Centre
Sandwell and West Birmingham NHS Trust
Concerns summary (AI summary)
Inadequate communication between the Trust and GP regarding the urgent removal of a pessary, and insufficient follow-up for pessary use, led to heightened infection risks.
Noted
(AI summary)
The GP provides a summary of the patient's medical history and care, noting cancelled appointments and home visits. The hospital acknowledges the patient cancelled her appointment and asks the GP to inform them when she is ready to reschedule. Every person attending for pessary insertion now receives an information leaflet. Processes have been amended to tighten follow up, including letters and offering a further appointment if there is no response. Patients who have missed follow-ups are being recalled for review.
Thomas Nicol
Partially Responded
2018-0375
30 Nov 2018
Hertfordshire
Ministry of Health
MOJ
NHS England
Concerns summary (AI summary)
Significant delays in transferring prisoners experiencing acute mental health crises to appropriate secure hospitals potentially endanger lives.
Action Planned
(AI summary)
NHS England is reviewing the Good Practice Guidance 2011 on prisoner transfers under the Mental Health Act, aiming for more clinically informed timescales. A revised document has been developed with stakeholders and is currently being prepared in readiness for public consultation anticipated in early 2019. NHS England is conducting service reviews across all adult high, medium, and low secure services, considering service capacity, security levels, gender, service types, and geographical location. It is also reviewing prison transfer and remission guidance and implementing a new service specification for integrated mental health services in prisons.
Bradley Brown
Partially Responded
2018-0374
30 Nov 2018
Manchester (North)
MOJ
NHS England
Concerns summary (AI summary)
Late prisoner transfers, particularly on weekends, are unsafe due to unavailable mental health assessments and limited access to healthcare records, heightening risk for vulnerable individuals.
Action Taken
(AI summary)
HMP Buckley Hall has instructed governors not to accept transferred prisoners on Fridays, pending healthcare changes. First night procedures have been strengthened with 72-hour monitoring and welfare checks. Healthcare staff must notify the orderly officer if prisoners miss appointments. Staff at HMP Haverigg were reminded to confirm transfers with healthcare so records are reassigned promptly.
Luke Saxton
All Responded
2018-0373
29 Nov 2018
North Yorkshire
North Yorkshire County Council
Concerns summary (AI summary)
The absence of street lighting in a dark area with bus stops near a popular venue creates a significant road safety risk for pedestrians.
Action Planned
(AI summary)
North Yorkshire County Council will give further consideration to installing non-prescribed signs at the A59/Broughton Hall junction, despite concerns about accountability. Improvements to signing and road markings will be introduced at the nearby A59/Gargrave Road junction.
Ronald Houchin
Historic (No Identified Response)
2018-0376
28 Nov 2018
South Yorkshire (West)
Rosehill House Care Home
Concerns summary (AI summary)
Falls risk assessments were not consistently followed, resulting in inadequate assistance and supervision for mobilising, and multiple preventable falls for the patient.
Michelle Roach
Historic (No Identified Response)
2018-0302
28 Nov 2018
Berkshire
Royal Berkshire Hospital
Waterfield Practice
Concerns summary (AI summary)
GP's knowledge of VTE symptoms and record-keeping were inadequate. The GP practice lacked a robust system for learning from unexpected deaths, and hospital night-time medical registrar cover was insufficient.
Jack Riding
Partially Responded
2018-0303
26 Nov 2018
Liverpool & Wirral
Football Association
Goals Soccer Centres PLC
Concerns summary (AI summary)
There were significant delays in defibrillator deployment and ambulance access due to equipment placement, lack of staff direction, and insufficient emergency training, coupled with inadequate medical emergency risk assessments.
Action Planned
(AI summary)
The Football Association requests a copy of the Independent Consultant review of Goals Soccer Centre Plc's health and safety processes to inform a substantive response. Goals Soccer Centres Plc plan to create scenario-based training to emulate Emergency First Aid procedures in each club with all staff members and implement an annual refresher
Matthew Craven
All Responded
2018-0365
22 Nov 2018
Manchester (South)
Pennine Care NHS Trust
Concerns summary (AI summary)
A patient died from pregabalin toxicity after consuming excess prescribed medication post-discharge, raising concerns about managing medication risks for individuals with a history of misuse.
Action Planned
(AI summary)
The Trust will develop an escalation process for rejected referrals in Stockport, clarify and communicate target timescales for routine appointments, implement an escalation protocol for disagreements on face-to-face appointments, and co-locate alcohol liaison practitioners with the all-age liaison mental health service by the end of February 2019.
Savannah-Rose Owen
All Responded
2018-0367
22 Nov 2018
Manchester (South)
Department for Business
Department of Health and Social Care
Concerns summary (AI summary)
Multi-purpose nursing pillows lack specific safety regulations and have inconsistent, often misleading, warning labels that are easily lost, promoting unsafe sleep practices for infants.
Noted
(AI summary)
The Department has passed concerns about a nursing pillow lacking proper safety warnings to the Office for Product Safety and Standards (OPSS) for investigation and potential action with Local Authority Trading Standards. The Department clarifies that nursing pillows aren't medical devices and directs safety regulation concerns to the Department for Business, Energy and Industrial Strategy. They highlight existing guidance and resources from health visitors, midwives, Public Health England, the Lullaby Trust, Start4Life, and NHS Choices regarding safe sleeping and SIDS prevention.
Karen Moran
All Responded
2018-0336
22 Nov 2018
Manchester (South)
Tameside and Glossop Clinical Commissio…
Concerns summary (AI summary)
The deceased had a long-term addiction to prescribed medication, but repeat prescriptions continued without a referral to address the addiction, giving her access to significant amounts of medication.
Action Planned
(AI summary)
• The Trust is working on strategic and operational quality improvements in patient safety to improve available resources to respond to patients.
• The Trust is working collaboratively with Health Board colleagues to progress safety, effectiveness and a positive experience for patients and their carers.
• The Trust is working on initiatives to deliver and enable an improved resourcing picture, including planned resources sufficient to meet overall demand, aligning production against demand, reducing sickness absence, and reducing handover duration.
Ursula Keogh
All Responded
2018-0370
21 Nov 2018
West Yorkshire (West)
Calderdale Council
Department of Health and Social Care
NHS Calderdale Clinical Commissioning G…
Concerns summary (AI summary)
Inconsistent and contradictory advice from GPs and schools regarding CAMHS referrals, exacerbated by a school lacking the necessary Psychology Team, highlighted poor communication between health and education professionals.
Action Planned
(AI summary)
The Department of Health and Social Care highlights national initiatives like 'Future in Mind' and the Suicide Prevention Workplan. They also mention plans to set up 24/7 crisis care for children and young people by 2023/24 and efforts with DCMS to address harmful online content. Calderdale CCG and Calderdale Council have reviewed and revised processes and identified new actions related to CAMHS referrals and communication between professionals, overseen by the multi-agency Open Mind Partnership. Calderdale Council is progressing with the installation of anti-climb mesh and CCTV at North Bridge, with completion expected by the end of 2019.
Roy Burgess
Historic (No Identified Response)
2018-0364
21 Nov 2018
South Yorkshire (East)
Department of Health and Social Care
Doncaster Bassetlaw Teaching Hospital
Concerns summary (AI summary)
The hospital's Early Warning System was not adhered to, leading to missed senior medical reviews. Inadequate and non-chronological record-keeping by clinicians resulted in a lack of documented doctor input.