2018
PFD Reports
Reports: 419
Areas: 64
69% response rate (above 63% average).
Ben Walmsley
Historic (No Identified Response)
2018-0363
21 Nov 2018
Manchester (North)
Department for Education
Concerns summary (AI summary)
The school's IT system lacked a mechanism to alert staff when students attempted to access blocked self-harm content, relying solely on teacher monitoring and risking missed safeguarding opportunities.
Suleyman Yalcin
All Responded
2018-0368
20 Nov 2018
London (North)
Metropolitan Police
Concerns summary (AI summary)
Insufficient refresher training in emergency response driving, police under-resourcing, and inadequate terminology for communicating urgency posed risks during critical incidents.
Action Taken
(AI summary)
The Metropolitan Police Service provides refresher driver training every three to five years. They will remind staff to clarify the urgency of requests and this will be incorporated in Met CC professional development days and initial training. The Metropolitan Police Service highlights that all MPS officers now undertake refresher training every 3 to 5 years. The Command and Control Centre (MetCC) has informed all call handlers to clarify the reason for their request. Call despatch courses now include a session on clarifying terminology.
Austin Thomas
Historic (No Identified Response)
2018-0360
20 Nov 2018
North Wales (East & Central)
Haulage Contractors Limited
Concerns summary (AI summary)
Drivers of heavy machinery could be distracted by high-volume music, lacking a specific policy. The drug policy was inadequate, with no random testing despite evidence of an employee's drug use.
Beryl Walsh
All Responded
2018-0359
19 Nov 2018
Manchester (North)
Beechwood Lodge Care Home
Concerns summary (AI summary)
There were multiple missed opportunities to identify the deceased as a high falls risk, escalate care to the falls team, or implement falls prevention equipment and assessments.
Action Taken
(AI summary)
Beechwood Lodge has put in place more robust risk assessments for residents who have had falls, documenting all conversations with relatives and professionals. They have added new risk assessments in all care plans about safety equipment, and have a falls matrix to monitor falls and make referrals.
Emmett Gillah
Historic (No Identified Response)
2018-0357
16 Nov 2018
Surrey
Kent and Medway NHS Social Care Trust
Concerns summary (AI summary)
Discharge letters lacked detail for GPs, KMPT failed to maintain post-discharge contact as per policy, and communication with patient families regarding discharge decisions was inadequate. Staff were also unaware of KMPT's discharge policies.
Sheila Graham
Historic (No Identified Response)
2018-0355
16 Nov 2018
Stoke-on-Trent & North Staffordshire
Midlands Partnership NHS Trust
Concerns summary (AI summary)
Prolonged social isolation for a patient with C. difficile negatively impacted her well-being, compounded by inadequate nutritional information recording and assessment.
Dawn Gill
All Responded
2018-0354
16 Nov 2018
London Inner (North)
Royal London Hospital
Concerns summary (AI summary)
The hospital lacked a nursing care plan addressing the patient's likely continued drug use while admitted, and the drug chart went missing. A search of the patient's room also did not detect her body under clothing on the floor until hours later.
Action Taken
(AI summary)
Barts Health NHS Trust is reminding nursing teams about documenting suspected illicit drug use in care plans and handovers. They have reviewed the missing person policy and reminded nursing teams about the risks of making assumptions.
Eleanor Brabant
Historic (No Identified Response)
2018-0301
16 Nov 2018
Southampton and New Forest
Southern Health NHS Trust
Concerns summary (AI summary)
Observation policies for vulnerable patients were unclear, staff lacked training on safeguarding and reporting crimes, and nurses misunderstood their powers to detain informal patients. Confusion also existed regarding family involvement in care planning.
Kendall Chadwick
All Responded
2018-0352
15 Nov 2018
Staffordshire (South)
Staffordshire County Council
Concerns summary (AI summary)
The coroner recommends a review of a bend on the road close to Leese Hill, to see if additional safety steps would be advisable. The chevron boards were also in a dirty condition and there may be issues about maintenance.
Action Planned
(AI summary)
• The issue of monitoring blood plasma levels in people taking clozapine (or other antipsychotics) has been logged for consideration by the NICE guideline surveillance team undertaking the review process of clinical guideline CG178.
Richard Hill
All Responded
15 Nov 2018
Nottinghamshire
Network Rail
Concerns summary (AI summary)
The railway crossing lacked essential telephones and Network Rail contact information, posing a risk of repeat incidents due to inadequate emergency communication at the site.
1 response
from Richard Hill
Matthew Arkle
All Responded
2018-0361
13 Nov 2018
Suffolk
Norfolk and Suffolk NHS Trust
Concerns summary (AI summary)
Failures in mental health patient risk assessment, undocumented family concerns about unescorted leave, and significant delays in raising the alarm due to chaotic ward conditions and lack of CCTV review policy contributed to the incident.
Action Taken
(AI summary)
The Trust issued an internal alert to inpatient wards directing reflection on points where information is received from external sources. It also referenced the Trust policy on Missing Persons and Failure to return from Leave created with Norfolk and Suffolk Police and published in May 2017.
Thomas Jackson
Partially Responded
2018-0352-wp26415
13 Nov 2018
Staffordshire (South)
Department of Health and Social Care
Midlands Partnership NHS Foundation Tru…
Concerns summary (AI summary)
Poor record-keeping, inadequate preparation and attendance at multidisciplinary meetings, and staff unfamiliarity with Clozapine's significance hindered patient care. Inaccuracies in serious incident reviews also compromised learning.
Action Planned
(AI summary)
• Officials have made enquiries with a number of bodies regarding routine therapeutic blood monitoring for patients prescribed clozapine.
• The NICE guideline CG178, which supports routine monitoring of physical health for people prescribed antipsychotic medication, is to undergo a surveillance review.
• The issue of monitoring blood plasma levels in people taking clozapine has been logged for consideration by the guideline surveillance team undertaking the review process.
Joseph Page
Historic (No Identified Response)
2018-0347
12 Nov 2018
South Wales Central
Cardiff & Vale University Health Board
Concerns summary (AI summary)
Hospital policies for storing patients' own medication were breached, allowing a patient unsupervised access to prescription drugs which led to an overdose.
John Graham
All Responded
2019-0348-wp26412
9 Nov 2018
Manchester (North)
Rochdale Borough Council
Concerns summary (AI summary)
Lack of routine installation of carbon monoxide detectors in residential accommodation rented by Rochdale Borough Housing Limited creates a risk of future deaths.
1 response
from Rochdale Boroughwide Housing Limited
Ryan Williams
Historic (No Identified Response)
2018-0341
6 Nov 2018
Bedfordshire & Luton
Network Rail
Concerns summary (AI summary)
Unsupervised, unmanned stations pose a risk, as vulnerable individuals can remain on premises for extended periods without any oversight or means of intervention.
Gerwyn Thomas
All Responded
2018-0342
6 Nov 2018
Camarthenshire and Pembrokeshire
West Wales General Hospital
Concerns summary (AI summary)
Insufficient dietetic staff, lack of mandatory training for nutritional assessment tools, and nursing staff's failure to act on doctor referrals to dietetics led to inadequate patient nutrition.
Action Taken
(AI summary)
The dietetic service is actively working to address the staffing deficit in acute services via recruitment and reviewing skill mix. The Head of Nursing at Glangwili General Hospital has sent a memo to all ward staff detailing the action required and asking them to sign to say they understand their responsibilities.
REDACTED
Partially Responded
2022-0036
5 Nov 2018
London Inner South
Broadgate General Practice
General Medical Council
Concerns summary (AI summary)
A GP failed to adequately inquire into psychiatric history, made inappropriate medication changes, prescribed excessive quantities, and demonstrated poor record-keeping, missing opportunities for urgent psychiatric referral.
Action Planned
(AI summary)
The GMC has opened an investigation in relation to Dr. A and will require an expert report to comment on the care provided. The outcome of the investigation may result in the doctor being given advice, issued a warning, agreeing to undertakings, or referral to the Medical Practitioners Tribunal Service.
Daniel Stokes
Historic (No Identified Response)
2018-0346
5 Nov 2018
South Yorkshire (East)
NHS England
Concerns summary (AI summary)
Prison healthcare staff possessed diazepam but were not trained or authorised to administer it, potentially hindering response to drug abuse incidents.
Gareth Jones
Historic (No Identified Response)
2018-0340
5 Nov 2018
Worcestershire
Worcestershire County Council
Concerns summary (AI summary)
The road surface quality was below Highways Agency standards for three years, likely contributing to the death. This location has a history of fatal road traffic incidents.
Patricia Chambers
Historic (No Identified Response)
2018-0350
4 Nov 2018
London (West)
Shepherds Bush Medical Centre
West London Mental Health Trust
Concerns summary (AI summary)
Concerns were identified regarding practices at West London Mental Health Trust, indicating a risk of future deaths if appropriate action is not taken.
Karl Cassimjee
Historic (No Identified Response)
2018-0339
2 Nov 2018
Manchester (West)
Greater Manchester Mental Health NHS Tr…
Manchester Royal Infirmary
Billie Lord
All Responded
2018-0338
1 Nov 2018
Milton Keynes
Milton Keynes Clinical Commissioning Gr…
Concerns summary (AI summary)
The mental health inpatient facility uses inappropriate three-bedded dormitories, which contributed to patient stress and requires modernization according to Royal College of Psychiatrists' recommendations.
Action Planned
(AI summary)
CNWL Mental Health Trust has informed the CCG that they are commissioning a study to assess the feasibility of creating a new inpatient campus in Milton Keynes, bringing together acute wards, older adult wards and rehabilitation services. The first meeting with planners is scheduled for 28th January.
Colette Dunn
Historic (No Identified Response)
2018-0337
1 Nov 2018
Milton Keynes
Milton Keynes Clinical Commissioning Gr…
Concerns summary (AI summary)
A full Mental Health Act assessment was omitted before discharge despite police concerns. A lack of clear discharge protocols between agencies and inadequate facilities for mental health crisis intervention were identified.
Stephen Taylor
All Responded
1 Nov 2018
Worcestershire
University Hospital Coventry and Warwic…
Concerns summary (AI summary)
Neurosurgical patients lacked consultant physician support, leaving junior doctors to manage complex medical issues. An unclear alcohol withdrawal protocol led to incorrect medication prescriptions.
1 response
from Stephen Taylor
Dorothy Strickley
All Responded
2018-0305
31 Oct 2018
Leicester City and Leicestershire South
University of Leicester Hospitals NHS T…
Concerns summary (AI summary)
Critical discharge instructions for anti-embolism stockings were not communicated, leading to the patient's unawareness of their necessity. This highlighted a failure in staff training and discharge documentation protocols.
Action Taken
(AI summary)
Following concerns raised, the Clinical Management Group undertook an exercise with the medical team to reinforce the importance of good communication. Additionally, a Task and Finish Group was established to review VTE management, UHL guidance, written discharge information, thromboprophylaxis practice, training, governance, and develop a Standard Operating Procedure. A VTE Learning Bulletin was issued to all clinical staff, reiterating guidelines for Thromboprophylaxis for VTE and lessons learned.