2018

PFD Reports
Reports: 419 Areas: 64

69% response rate (above 63% average).

Clear 208 results
Robin McEwan
All Responded
2018-0325 10 Oct 2018 North Yorkshire
Harrogate & Rural District Clinical Com…
Concerns summary (AI summary) Disconnected communication between private therapy and GPs, lack of guidance on self-help resources, and insufficient involvement of family support for suicidal patients were identified.
Action Planned (AI summary) The CCG will review the primary care referral process for private counselling, look at developing Mental Health & Psychological First Aid within Primary Care and the CCGs, and further develop the CCG website to promote mental health and suicide prevention. It also offers the family a Serious Incident Review. A full action plan is attached with a six-month timescale.
James McLaren
All Responded
2018-0330 4 Oct 2018 Sunderland
Chartered Institution of Waste Manageme… Environmental Services Associations Health and Safety Executive +1 more
Concerns summary (AI summary) Inadequate securing of commercial and communal bins, including unsecured lids and easily opened locks, increases the risk of people sheltering inside and potentially becoming trapped.
Noted (AI summary) The HSE clarifies the meaning of 'secure' in the WISH WASTE 25 guidance, stating that it requires a risk assessment to determine appropriate measures to prevent bin access, but does not mandate a specific type of lock. They emphasize liaison between waste producers and collectors. The ESA has been raising awareness of the dangers of people in waste containers since 2009 through various means, including the press, a cross-sector steering group, a safety week, a safety alert to members, and contribution to the WISH Waste 25 guidance. CIWM has produced imagery promoting the use of WASTE25 guidance and encourages waste producers and waste collectors to check the bins while filling and unloading, which has been shared on social media. CIWM will aim to write an article for the CIWM journal / website to promote the ‘People in Bins’ Steering Group and call for volunteer waste collection companies to get involved by providing data to mirror the 2014 report by February 2019. The LGA will include an item on the risk of death and injury in large bins in relevant LGA bulletins and updates to councils to raise awareness at a national level.
William Edge
All Responded
2018-0417 4 Oct 2018 Birmingham and Solihull
Birmingham Clinical Commissioning Group NHS England
Concerns summary (AI summary) A suicidal patient was discharged without adequate follow-up from the Home Treatment Team, who could not revisit despite an urgent family request, due to critical bed shortages and underfunding.
Action Planned (AI summary) NHS England acknowledges concerns about mental health service demands and funding. They state that providers will make more robust plans to contact patients who do not attend appointments, and will ensure risk assessments are available 24/7; the CCG will meet with the local authority to address prevention services. Birmingham and Solihull CCG has already invested in various mental health services, including a new pathway for personality disorders, increased community provision, and staffing for 'step up step down' services.
Stephen Jackson
All Responded
2018-0416 4 Oct 2018 Birmingham and Solihull
Birmingham Clinical Commissioning Group NHS England
Concerns summary (AI summary) Mental health services failed to provide essential post-discharge follow-up from the home treatment team despite an urgent GP referral, leaving the patient unsupported due to underfunding.
Action Planned (AI summary) The CCG will be meeting the local authority to address differences in opinion regarding provision of services for alcohol, drug and substance misuse and homelessness. The Clinical network is currently providing support to review and plan services and the IST will be asked to provide support in December 2018. Birmingham and Solihull CCG has already invested in various mental health services, including a new pathway for personality disorders, increased community provision, and staffing for 'step up step down' services.
Michael Wheeler
All Responded
2018-0414 4 Oct 2018 Birmingham and Solihull
Birmingham Clinical Commissioning Group NHS England
Concerns summary (AI summary) Inadequate mental health service funding led to a lack of psychiatrist review for a patient with severe paranoia and inpatient bed shortages, overstretching Home Treatment Teams.
Action Planned (AI summary) The CCG provided funding to Forward Thinking Birmingham (FTB) for a personality disorder pathway and clinical lead, and invested in BSMHFT to appoint a clinical lead for personality disorder; they also invested in a primary care liaison model and increased staffing in 'step up step down' provision. NHS England will ensure services are commissioned and provided to ensure risk assessments are available 24/7, and the CCG will meet with the local authority to address differences in opinion regarding prevention services for alcohol, drug misuse and homelessness; the Intensive Support Team (IST) will provide support in December 2018.
Bradley Morgan
All Responded
2018-0412 4 Oct 2018 Birmingham and Solihull
Birmingham Clinical Commissioning Group NHS England
Concerns summary (AI summary) Mental health services suffered communication breakdowns and severe underfunding, resulting in excessive staff caseloads and a lack of timely patient follow-up, which created a risk to life.
Action Planned (AI summary) The CCG provided funding to Forward Thinking Birmingham (FTB) for a personality disorder pathway and clinical lead, and invested in BSMHFT to appoint a clinical lead for personality disorder; they also invested in a primary care liaison model and increased staffing in 'step up step down' provision. NHS England will ensure services are commissioned and provided to ensure risk assessments are available 24/7, and the CCG will meet with the local authority to address differences in opinion regarding prevention services for alcohol, drug misuse and homelessness; the Intensive Support Team (IST) will provide support in December 2018.
Michael Cooper
All Responded
2018-0413 4 Oct 2018 Birmingham and Solihull
Birmingham Clinical Commissioning Group NHS England
Concerns summary (AI summary) Chronic underfunding of mental health services led to a critical lack of inpatient beds and excessive Care Coordinator caseloads, causing delayed follow-ups and inadequate risk assessments.
Noted (AI summary) The CCG will be meeting the local authority to address differences in opinion regarding provision of services for alcohol, drug and substance misuse and homelessness. The Clinical network is currently providing support to review and plan services and the IST will be asked to provide support in December 2018. The CCG provides background and context on mental health commissioning, including funding increases, but does not explicitly state actions taken or planned in direct response to the concerns raised in the report.
Theresa Button
All Responded
2018-0333 3 Oct 2018 West Yorkshire (East)
Leeds Teaching Hospitals NHS Trust
Concerns summary (AI summary) Inadequate nursing staff levels on a ward for complex patients resulted in poor implementation of treatment plans, insufficient patient support during mealtimes, and failures in maintaining contemporaneous records.
Action Taken (AI summary) The Trust reviews staffing levels daily and has a ward/department Healthcheck audit process. Nutrition and hydration standards were addressed with the ward team and the acting ward manager attends morning handovers weekly.
Charlotte Tripper
All Responded
2018-0327 3 Oct 2018 Black Country
National Express West Midlands
Concerns summary (AI summary) A bus driver practice of avoiding eye contact with other drivers at junctions may increase the risk of collisions.
Action Planned (AI summary) National Express will discuss the driver's comments with him, assess his driving standards, and provide refresher defensive driving training upon his return to work in early 2019.
Andrew Collins
All Responded
2018-0336-wp26400 2 Oct 2018 South Wales Central
Welsh Ambulance Service NHS Trust
Concerns summary (AI summary) A severe lack of ambulance resources caused a critical three-hour delay in dispatching a vehicle to a rapidly deteriorating patient, despite urgent clinical priority.
Action Planned (AI summary) • The Trust is working on strategic and operational quality improvements in patient safety that have been completed or are underway. • Continuous improvements are ongoing with Health Board colleagues and they are working collaboratively to progress safety, effectiveness and a positive experience for patients and their carers. • Initiatives include ensuring planned resources are sufficient to meet overall demand, aligning production against demand by local and time of day, reducing sickness absence, and reducing handover to clear duration.
Joshua Edwards
All Responded
2018-0335 2 Oct 2018 West Yorkshire (East)
Leeds City Council
Concerns summary (AI summary) Ambulance response was delayed by public event road closures and unclear authority for crews to cross them. Event organizers need to brief staff and public on emergency vehicle priority.
Action Taken (AI summary) Following a previous incident, the Ambulance Service implemented learning points, including education for staff. The council hosts a joint emergency services/council Safety Advisory Group and has discussed the events of May 2017 at length.
Joan Blaber
All Responded
2024-0090 1 Oct 2018 West Sussex, Brighton and Hove
Brighton and Sussex University NHS Hosp…
Concerns summary (AI summary) Significant failures in hospital housekeeping included non-compliance with COSHH regulations, inadequate staff training, confusion of roles, poor communication of protocols, and a lack of reporting unsafe practices.
Action Taken (AI summary) The Trust has revised COSHH procedures with updated folders and training that includes anonymised inquest evidence. The roles of Hosts and Housekeepers have been split and clarified and Datix incident reports are being reviewed and recoded.
Michael Hopkins
All Responded
2018-0331 1 Oct 2018 West Yorkshire (West)
Bradford Teaching Hospitals NHS Trust
Concerns summary (AI summary) Hospital discharge practices need review to ensure patients receive adequate information regarding the risk of thromboembolisms following recent surgery after sustaining trauma.
Action Planned (AI summary) The Trust has developed a revised patient leaflet regarding blood clot risk assessment, to be introduced on 1st December 2018. The Quality Committee will review the leaflet's use and impact.
Donald Berry
All Responded
2018-0324 28 Sep 2018 Manchester (South)
Department of Health and Social Care Health and Safety Executive Kendal Calling +1 more
Concerns summary (AI summary) The report outlined the medical cause of death resulting from injuries sustained years earlier, but did not detail specific coroner's concerns for future death prevention.
Noted (AI summary) The Department acknowledges the concerns but states that the issue falls under the remit of the Health and Safety Executive (HSE). Kendal Calling appointed Ground Control, an event production company, as their Health and Safety advisor after the incident. The HSE will raise awareness of the incident with industry stakeholders, emphasizing adherence to event safety guidance regarding overhead power lines.
Sheila Hadfield
All Responded
2018-0334 27 Sep 2018 Manchester (South)
Department of Health and Social Care
Concerns summary (AI summary) A national shortage of suitable care beds for individuals with complex mental health needs resulted in placements in inadequate facilities, with the care home struggling to meet the patient's requirements.
Noted (AI summary) The Department acknowledges the issue of appropriately trained and resourced social care services and highlights initiatives such as Enhanced Health in Care Home Vanguards and the development of Integrated Care Systems.
Mary Ryder
All Responded
2018-0323 27 Sep 2018 Manchester (South)
Department of Health and Social Care
Concerns summary (AI summary) Post-operative care failed to provide sufficient anticoagulation therapy and clinical review for a patient with decreased mobility, and NICE guidance for D-dimer testing was not followed.
Noted (AI summary) The Department of Health and Social Care (DHSC) consulted NICE, who advised that existing guidelines on VTE prophylaxis and management are adequate and do not require amendment.
Bridget Marie Connell-Graham
All Responded
2018-0297 26 Sep 2018 Manchester (South)
Department for Health
Concerns summary (AI summary) The lack of a clear national definition for 'cervical trauma' leads to inconsistent approaches in investigating prior history and planning clinical treatment during pregnancy, risking premature births.
Action Planned (AI summary) NICE will add the definition of 'cervical trauma' to the 'Terms used in this guideline' section of the Preterm labour and birth (NG25) guideline to improve accessibility.
Caitlin Huddleston and Skye Mitchell
All Responded
2025-0056 25 Sep 2018 Cumbria
Department for Transport
Concerns summary (AI summary) Inexperienced young drivers carrying multiple passengers face increased distraction and risk, highlighting the need for a Graduated Driving Licence Scheme with passenger restrictions and other safety measures.
Noted (AI summary) The Department for Transport acknowledges the concerns regarding Graduated Driver Licensing (GDL) but states it has no current plans to enforce further restrictions due to the ongoing COVID-19 pandemic and potential detrimental effects on young people. They will continue to monitor the pilot scheme in Northern Ireland. The Department for Transport is using the introduction of GDL in Northern Ireland as a pilot to gather evidence on the potential for GDL in Great Britain. They have also allowed learner drivers on motorways when accompanied by an Approved Driving Instructor in a dual control car and increased the penalty for using a handheld mobile phone while driving.
Annette Hill
All Responded
2024-0602 21 Sep 2018 Avon
Southmead Hospital
Concerns summary (AI summary) An unresolved tension exists between Sepsis 6 guidelines and the BTS COPD care bundle for advanced respiratory disease, potentially leading to inappropriate antibiotic administration.
Disputed (AI summary) North Bristol NHS Trust states that it is satisfied with implementing the Sepsis Six guidelines before the BTS COPD care bundle, as the former addresses an immediate risk to a patient's welfare. This is supported by the fact there is no national guidance that says that Sepsis Six should not apply to patients with COPD.
Paul Price
All Responded
19 Sep 2018 Birmingham and Solihull
Birmingham and Solihull Mental Health T…
Concerns summary (AI summary) Critical delays in information sharing between mental health services and GPs, due to incompatible IT systems and communication failures, risk patient care and medication management.
2 responses from Paul Price, Paul Price Response2
Sufia Begum
All Responded
19 Sep 2018 Birmingham and Solihull
Clinical Commission Group NHS England
Concerns summary (AI summary) Many doctors are unaware of the BNF mobile app, a crucial tool for identifying potential drug interactions, risking preventable deaths from unknown medication interactions.
2 responses from Sufia Begum Response2, Sufia Begum
Mark Nicols
All Responded
17 Sep 2018 South Yorkshire (West)
AMEY
Concerns summary (AI summary) Inadequate signage and lighting at a construction site made pedestrian path access unclear, risking public safety, with no indication that future similar situations would be handled differently.
1 response from Amey LG Limited
Marian Grant
All Responded
15 Sep 2018 Oxfordshire
Oxford University Hospitals NHS Foundat…
Concerns summary (AI summary) Failure to prescribe VTE prophylaxis due to electronic patient record (EPR) issues and inadequate safeguards for trauma patients on non-trauma wards, coupled with ineffective EPR alerts, increased the risk of avoidable death.
1 response from Marion Grant
Paul Ryley
All Responded
2018-0284 14 Sep 2018 Birmingham and Solihull
Toxbase
Concerns summary (AI summary) Unclear Toxbase guidelines for paracetamol overdose re-presentations lead clinicians to misunderstand their applicability, risking patients not receiving crucial treatment for liver toxicity.
Action Taken (AI summary) The NPIS has added a statement to the paracetamol index in TOXBASE guidance: "If the patient re-presents following assessment and discharge, manage as per a new presentation."
Abigail Hall
All Responded
2018-0286 12 Sep 2018 South Yorkshire (West)
Derwent Students
Concerns summary (AI summary) The continued absence of a defibrillator and first aid trained staff at the premises creates a critical risk for emergency medical response in critical situations.
Action Planned (AI summary) Derwent Facilities Management Limited has commenced a program of emergency first aid training for staff, highlighted the location of the nearest AED within the Premises reception area, and approved the purchase and installation of an AED.