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)
Clear 130 results
Ruth Perkins
Historic (No Identified Response)
2018-0236 20 Jul 2018 Coventry
Department for Health
Concerns summary (AI summary) A high-risk patient was discharged to a care home with insufficient staffing levels for her needs, particularly lacking 1:1 care, significantly increasing her risk of falls.
Jeroen Ensink
Historic (No Identified Response)
2018-0235 19 Jul 2018 London (Inner) North
Metropolitan Police Service
Concerns summary (AI summary) Police failures included not creating mental health alerts, inaccurate record-keeping regarding injuries and force, and failing to inform the forensic medical examiner of mental health concerns or family-reported history.
Ronald Harman
Historic (No Identified Response)
2018-0234 19 Jul 2018 Brighton & Hove
Brighton and Sussex University Hospital…
Concerns summary (AI summary) The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths without specifying particular issues.
Mohammed Ahmed
Historic (No Identified Response)
2018-0230 18 Jul 2018 Manchester (West)
Department for Health Manchester University NHS Trust RCOG
Ellie Knowles
Historic (No Identified Response)
2018-0202 18 Jul 2018 Newcastle Upon Tyne
Hoults Limited Shindig Events Limited
Concerns summary (AI summary) A venue maintains a license for high-risk events but lacks a robust internal protocol requiring consultation with police and council licensing officers before planning similar future events.
Sheila Ridgway
Historic (No Identified Response)
2018-0229-wp26291 16 Jul 2018 Manchester (City)
Care Quality Commission Manchester University NHS Trust NHS England +2 more
Concerns summary (AI summary) A lack of systemic communication between specialty consultants prevents identifying and documenting potential ongoing risks when patients receive simultaneous treatments from different departments.
Rita Giles
Historic (No Identified Response)
2018-0224 11 Jul 2018 Brighton & Hove
Brighton and Sussex University Hospital… NHS England Clinical Commissioning Group +1 more
Concerns summary (AI summary) The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths without specifying particular issues.
Eugeniusz Niedziolko
Historic (No Identified Response)
10 Jul 2018 Wiltshire and Swindon
Dyfed & Powys Police Wiltshire Police College of Policing +4 more
Concerns summary (AI summary) Police lacked appropriate options for managing a heavily intoxicated individual, leading to them being left alone in a public lavatory on a cold night, resulting in death.
Doris McCarthy
Historic (No Identified Response)
2018-0222 9 Jul 2018 London (South)
Baycroft Care Homes Senior Villages
Concerns summary (AI summary) Concerns persist about sensor system outages failing to alert staff to falls and inadequate safeguards for residents prone to sliding in chairs.
Lindsey Tyrrell
Historic (No Identified Response)
2018-0208 29 Jun 2018 Manchester (City)
Department of Health and Social Care NHS England
Concerns summary (AI summary) Routine testing for toxoplasmosis was not performed on stem cell transplant patients with infection signs, and local learning needs nationwide sharing.
Ashley Notson
Historic (No Identified Response)
2018-0207 29 Jun 2018 Suffolk
Care Quality Commission Department of Health and Social Care
Concerns summary (AI summary) There is no legal requirement for care home carers to have first aid training or to carry mobile phones, posing a risk in emergency situations.
Daphne Penn
Historic (No Identified Response)
2018-0206 29 Jun 2018 Suffolk
Newmarket Community Hospital Rookery Medical Centre West Suffolk Hospital
Concerns summary (AI summary) Inadequate communication of steroid risks and family concerns, alongside prescribing errors, led to an inadvertent rapid steroid dose reduction without sufficient clinical oversight.
Margaret Evans
Historic (No Identified Response)
2018-0197 26 Jun 2018 North Wales (East and Central)
BCUHB HM Stanley Site Welsh Ambulance Services NHS Trust +1 more
Concerns summary (AI summary) Persistent issues with ambulance delays, emergency department overcrowding, and resource availability continue to pose significant risks to patient safety.
Sylvia Davies
Historic (No Identified Response)
2023-0415 25 Jun 2018 Inner North London
Coventry and Rugby Clinical Commissioni… Virgin care Coventry LLP
Concerns summary (AI summary) Virgin Care's delay in adopting new urgent care assessment standards and the failure to transcribe or retain crucial patient information provided by families create ongoing safety risks.
Marjorie McMahon
Historic (No Identified Response)
2018-0196 25 Jun 2018 Manchester (South)
Department of Health and Social Care NHS England
Concerns summary (AI summary) Significant ambulance response delays occurred for a high-priority patient due to high demand and insufficient resources, far exceeding the guideline response time.
Alexia Walenkaki
Historic (No Identified Response)
2018-0193 22 Jun 2018 London Inner (North)
Tower Hamlets Borough Council
Concerns summary (AI summary) Organisational failures, including the use of inappropriate wood in equipment and a lack of accountability for annual inspections due to unclear role demarcation, led to a fatal incident.
Derek Smith
Historic (No Identified Response)
2018-0186 19 Jun 2018 Staffordshire (South)
Virgin Care Services Limited
Concerns summary (AI summary) Poor communication between the District Nursing team, family members, and other agencies, alongside issues with nursing record availability, hindered patient care and decision-making.
Colin Johns
Historic (No Identified Response)
2018-0203 18 Jun 2018 Black Country
Black Country NHS Foundation Trust Care Quality Commission
Concerns summary (AI summary) There was inadequate communication and history-taking during mental health assessments, failing to record critical self-harm attempts, and insufficient effort to find a suitable bed for a high-risk patient.
Bryan Allsop
Historic (No Identified Response)
2018-0185 18 Jun 2018 Derby and Derbyshire
Department for Transport
Concerns summary (AI summary) Pilot licensing does not mandate instruction and testing in partial engine power loss scenarios for light aircraft, despite this being a common and challenging factor in crashes.
Sneh Chaudhry
Historic (No Identified Response)
2018-0182 15 Jun 2018 London (West)
NHS England
Concerns summary (AI summary) Drug confusion due to similar vial appearance between Fungizone and Ambisone, combined with passive nursing checks, created a risk of administering the wrong, more toxic medication.
Karen Wiggins
Historic (No Identified Response)
2018-0177 13 Jun 2018 Wiltshire and Swindon
Swindon Borough Council
Concerns summary (AI summary) Multi-storey car parks in Swindon lack physical barriers or warning notices, despite previous suicidal falls, failing to prevent individuals from jumping.
Kevin Freely
Historic (No Identified Response)
2018-0180 7 Jun 2018 London (West)
Care Quality Commission Skillsforcare Home Office
Concerns summary (AI summary) Insufficient awareness and adherence to fire safety warnings regarding paraffin-based emollients, smoking in bed, and air-flow mattresses, combined with inadequate risk assessments, pose significant fire risks.
Ester Wood
Historic (No Identified Response)
2018-0176 6 Jun 2018 North Wales (East and Central)
BCUHB HM Stanley Site Welsh Ambulance Services NHS Trust +1 more
Concerns summary (AI summary) Ongoing, systemic problems with ambulance delays, emergency department access, and patient flow continue to place lives at risk, despite repeated prior warnings.
William Bartram
Historic (No Identified Response)
2018-0174 6 Jun 2018 London (East)
Barts Health NHS Trust
Concerns summary (AI summary) Unclear processes for repeat blood samples in babies, failure to highlight abnormal test results, and inadequate discharge advice to parents led to missed critical health issues.
John Derwent
Historic (No Identified Response)
2018-0171 4 Jun 2018 Manchester (South)
Pennine NHS Trust Tameside and Glossop Clinical Commissio…
Concerns summary (AI summary) Excessive waiting times for CBT (12 months) due to insufficient capacity and ineffective escalation mechanisms between commissioning and service providers prevented timely access to essential mental health treatment.