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)
419 results
Stephen Buck
All Responded
31 Oct 2018 Oxfordshire
Waste Industry Safety & Health Forum
Concerns summary (AI summary) The common practice of operatives working in close proximity to reversing trucks for ticketing spoil removal increases safety risks, suggesting a need for technological solutions.
1 response from Stephen Buck
Karl Brunner
Partially Responded
2018-0310 29 Oct 2018 Bedfordshire & Luton
ACPO Bedfordshire Police
Concerns summary (AI summary) The incident highlights a risk of future deaths where individuals swallow drugs during police stops, requiring a review of procedures for managing such medical emergencies.
Noted (AI summary) Bedfordshire Police states that their officer training includes a module on managing choking detainees, and they issue officers with personal Pocket Face Masks. They believe their training complies with IOPC recommendations and College of Policing standards.
Thomas McAuley
Partially Responded
2018-0309 29 Oct 2018 London Inner (South)
Serco Ltd Metropolitan Police Service Oxlea NHS Trust +1 more
Concerns summary (AI summary) Disjointed communication and lack of universal access to medical records (DPMFs) across custody and prison healthcare services mean vulnerable individuals' medical assessments are not consistently reviewed by prison medical staff.
Action Planned (AI summary) The MPS is working to implement a communication network (N3) and hardware into all custody suites, to provide healthcare professionals with access to NHS Summary Care Records and is required for an EMRS, anticipated within a year. A new PER will be introduced in April 2019 and the MPS will introduce the EMRS platform within one year.
Elizabeth Self
All Responded
2018-0308 29 Oct 2018 South Yorkshire (West)
NHS England
Concerns summary (AI summary) Senior doctors lacked training in making proper X-ray requests. A communication breakdown caused a valid CT request to remain unattended for hours, leading to significant delays in diagnosis.
Action Planned (AI summary) NHS England acknowledges the concerns and states they have been working with hospitals to improve standards of care provided to patients under the seven-day services programme, including access to diagnostic imaging. They will disseminate learning from this case through quality structures across England and are undertaking a national review of vaccination and immunisation arrangements.
Rosario Cordero-Sanz
All Responded
2018-0307 29 Oct 2018 London Inner (North)
Metropolitan Police Service
Concerns summary (AI summary) Special police officers lacked essential equipment and training in mental health and missing person processes. Communication failures and inability to access critical information meant a high-risk patient's status was missed, delaying appropriate action.
Action Taken (AI summary) The MPS purchased and distributed 100 tablet devices for MSC officers in September 2018 and completed the rollout in November 2018. Local learning was implemented for MSC officers and a CAD operator regarding communication failures.
Timothy Mason
Partially Responded
2018-0351 26 Oct 2018 Kent (North-West)
Maidstone & Tunbridge Wells NHS Trust NHS England
Concerns summary (AI summary) Failures in the Emergency Department led to incorrect diagnosis and treatment of sepsis, and the discharge of an unwell patient. Concerns include inadequate staff instructions, training, and systems for providing the Men ACWY vaccination.
Action Taken (AI summary) The Saxonbury House Medical Group has switched on alerts prompting the offer for patients who have not received the Men ACWY vaccination and has written to EMIS requesting that Men ACWY is added to the list of vaccines flagged up in the alert box as a routine. All local practices have been written to and asked to check that the Men ACWY vaccination alert is activated and patients invited from the relevant cohort.
Andrea Franzosi
Historic (No Identified Response)
2018-0314 25 Oct 2018 Gloucestershire
Gloucestershire NHS Trust
Concerns summary (AI summary) Inadequate supervision of junior doctors on wards, specifically regarding patient discharges occurring without examination by a senior practitioner.
David Sargeant
All Responded
2018-0312 25 Oct 2018 Cornwall & the Isles of Scilly
Kernow Clinical Commissioning Group
Concerns summary (AI summary) The patient could not receive an ADHD diagnosis or treatment due to commissioning gaps, lack of specialist psychiatrists, and impracticalities of out-of-county referrals for ongoing care.
Action Planned (AI summary) The CCG acknowledges the concerns about ADHD diagnosis and treatment and states that it has committed to developing a new adult ADHD pathway for Cornwall, due to be established in 2019, to address the identified gaps in service provision.
Eileen Cooke
All Responded
2018-0311 25 Oct 2018 West Yorkshire (East)
Mid Yorkshire Hospitals NHS Trust
Concerns summary (AI summary) A frail elderly patient was prematurely discharged with unresolved medical issues, inadequate care planning, and without a 'best interests' meeting or family involvement, highlighting a systemic problem with hasty discharges.
Noted (AI summary) The Trust describes its processes for safe discharge of elderly patients, including defining frailty, use of ACE units, care home liaison, and gathering patient feedback, but doesn't outline specific changes made in response to the report.
Catherine Gibbon
Historic (No Identified Response)
2018-0317 24 Oct 2018 London Inner (North)
DW Fitness First UK Active
Concerns summary (AI summary) Significant safety failures included inadequate health pledge guidance, untrained staff for medical conditions, insufficient CCTV monitoring with a broken camera, lack of emergency alarms/communication, and lapsed first aid certifications at the gym.
Maximilien Kohler
Partially Responded
2018-0316 24 Oct 2018 London Inner (West)
CNWL NHS Trust Department of Health and Social Care NHS England +1 more
Concerns summary (AI summary) Misdiagnosis of ASD was linked to over-reliance on questionnaires and less experienced clinicians, compounded by a lack of services for chronic, complex conditions.
Noted (AI summary) The Trust provides an account of their involvement with the patient's case, including the referral and assessment process for a possible co-morbid eating disorder, and explains why a full ASD assessment was not carried out by their service. The Department of Health and Social Care acknowledges concerns about outcomes for young people on the autistic spectrum and is launching a comprehensive review of the autism strategy, expected to report in November 2019, which will include a national call for evidence.
Jennifer Lacey
Partially Responded
2018-0315 24 Oct 2018 London Inner (West)
GPC NHS England
Concerns summary (AI summary) Concerns were raised about dangerous, addictive drugs being freely available online and prescribed by foreign doctors without patient contact or GP record access, potentially filled by UK pharmacies without adequate checks.
Noted (AI summary) NHS England acknowledges concerns about online availability of potentially dangerous drugs like Tramadol, but states that the death was not a result of NHS services. They are working with other health regulators like CQC and MHRA and remain committed to improving the safety of controlled drugs and online prescribing.
Nicola Lawrence
All Responded
2018-0318 23 Oct 2018 West Yorkshire (East)
National Offender Management Service
Concerns summary (AI summary) A critical concern was that some prison staff lacked essential cardiopulmonary resuscitation (CPR) training, both initial and refresher, jeopardizing emergency response.
Noted (AI summary) HM Prison & Probation Service acknowledges concerns about CPR training at HMP New Hall. They state that the governor has reviewed staff training and considers the current number of trained staff sufficient based on a first aid risk assessment, referring to PSI 29/2015.
Allan Shepard
Historic (No Identified Response)
2018-0313 23 Oct 2018 South Yorkshire (West)
City Wide Alarms Sheffield City Council
Concerns summary (AI summary) Response times for falls were missed due to inadequate staffing with one-person responder units, and crucial updated patient information was not passed to the third-party call centre.
Kalma Ram-Henman
All Responded
2018-0306 23 Oct 2018 Brighton and Hove
Brighton & Sussex University Hospitals …
Concerns summary (AI summary) Multiple clinical failings included an incomplete fluid chart, unadministered essential medications and fluids despite orders, missed ECG abnormalities, and neglected opportunities to assess a deteriorating patient after transfer.
Action Taken (AI summary) Brighton and Sussex University NHS Trust conducted team meetings and a Serious Incident Review Meeting to address inadequacies in the patient's care. They issued a Trust Safety Alert instructing staff not to use the 'once-only' section of the drug chart for infusions, and implemented a new system for Acute Medicine Consultants to cover telephone calls.
Trystan Bryant
Partially Responded
2018-0382 19 Oct 2018 Plymouth, Torbay and South Devon
Dyfed-Powys Police National Police Chiefs’ Council
Concerns summary (AI summary) Stationary ambulance doors that cannot be locked pose a risk to police containment of individuals detained under the Mental Health Act, potentially allowing egress from the vehicle.
Action Taken (AI summary) The National Police Chiefs' Council issued a reminder to all Chief Constables to treat all ambulances as non-secure environments when detaining individuals under S136 of the Mental Health Act.
John Lee
Historic (No Identified Response)
2018-0349 19 Oct 2018 Mid Kent and Medway
Medway NHS Trust
Concerns summary (AI summary) A clerical error severely delayed an urgent vascular appointment, changing an elective procedure to an emergency and contributing to the patient's death, highlighting issues with ambiguous terminology and inadequate checking systems.
Robert McLoughlin
Historic (No Identified Response)
2018-0320 19 Oct 2018 West Yorkshire (East)
HMPPS
Concerns summary (AI summary) The jury identified errors and omissions in the care of an HMP Leeds inmate, which potentially contributed to his death by ligature.
Joseph Grantham
Historic (No Identified Response)
2018-0322 18 Oct 2018 Manchester (South)
Department of Health and Social Care Healthcare Safety Investigation Branch Manchester University NHS Foundation Tr…
Concerns summary (AI summary) Key concerns include significant delays in discharge paperwork and specialist letters, unclear care responsibility, missing patient notes, inadequate instructions for community monitoring, and a lack of protocols for inter-hospital care transfers.
Anne Roberts
Historic (No Identified Response)
2018-0321 18 Oct 2018 Berskhire
NHS Professionals Limited Prospect Park Hospital
Concerns summary (AI summary) Inadequate training for bank staff on choking risks, poor dissemination of this information in patient records, and difficulties managing choking risks alongside self-harm concerns for patients eating in bedrooms were identified.
Jordan Sheils
All Responded
2018-0319 16 Oct 2018 West Yorkshire (West)
Calderdale Metropolitan Borough Council
Concerns summary (AI summary) The council is delaying the implementation of anti-climbing mesh and CCTV cameras on a bridge, despite measures to deter tragedies being under consideration.
Action Planned (AI summary) Calderdale Council submitted planning and listed building consent applications for anti-climb mesh and steeple coping on North Bridge, with works expected to be complete by May 2019. CCTV has been installed. These measures were discussed and agreed with their Public Health colleagues who lead the Suicide Prevention Group.
Jacqueline Oakes
Partially Responded
2018-0419 16 Oct 2018 Birmingham and Solihull
Home Office MOJ
Concerns summary (AI summary) There is no system to alert other agencies when high-risk offenders are released after completing their full sentence, preventing effective risk management.
Noted (AI summary) HM Prison and Probation Service describes existing arrangements for sharing risk information with partner agencies when a high-risk offender is released, including MAPPA and MASH. Guidance on activity required at the termination of sentence is currently being written.
Thomas Lear
Historic (No Identified Response)
11 Oct 2018 Stoke-on-Trent and North Staffordshire
Staffordshire Police Ministry of Justice
Concerns summary (AI summary) A released prisoner was offered no accommodation support, and urgent suicide threats sent to his offender manager's mobile went unaddressed due to no out-of-hours coverage.
Dean Barrell
All Responded
11 Oct 2018 East Sussex
Prison and Probation Service
Concerns summary (AI summary) A seven-day delay in communicating a vulnerable prisoner's actual release date to HMP Lewes contributed to his suicide, highlighting unacceptable communication delays for vulnerable individuals.
1 response from Dean BARRELL
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.