2018
PFD Reports
Reports: 419
Areas: 64
69% response rate (above 63% average).
Tom Cribley
Historic (No Identified Response)
2018-0329
9 Oct 2018
Liverpool and Wirral
Aintree University Hospital NHS Trust
Care Quality Commission
General Medical Council
+4 more
Concerns summary (AI summary)
Repeated systemic failings included poor documentation, delayed escalation of patient deterioration and NMEWS, inadequate clinical handovers, and delayed administration of crucial antibiotics for sepsis, issues previously identified by CQC.
Natasha Ednan-Laperouse
Partially Responded
2018-0279
8 Oct 2018
London (West)
Department for the Environment, Food an…
Medicines and Healthcare products Regul…
Pfizer
+1 more
Concerns summary (AI summary)
Allergens were not adequately labelled on Pret-a-Manger packaging, and there was no coordinated system for monitoring customer allergic reactions. Additionally, the needle length and adrenaline dose of Epipens may be inadequate for treating anaphylactic reactions.
Action Planned
(AI summary)
The MHRA has already undertaken a review of adrenaline auto-injectors, progressed this within Europe, resulting in improved training, additional risk minimisation measures and factual disclosures within the product information. They are also undertaking a rigorous evaluation of the clinical study data for each brand of adrenaline auto-injector and will ensure any necessary measures are taken to increase effectiveness. The Department is undertaking an urgent review of allergen information provision for food which is pre-packed for direct sale, with a consultation on policy options planned for early in the new year and any needed legislation to follow as soon as possible. The FSA has been working with local authorities in Lancashire on a pilot scheme to improve the notification of incidents between businesses, local authorities and the NHS.
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.
Simon Graham
Partially Responded
2018-0418
4 Oct 2018
Birmingham and Solihull
Birmingham Clinical Commissioning Group
Future Care & Social Care Association
NHS England
Concerns summary (AI summary)
Respite home had critical safety failures including lone working delaying emergency response, incorrect room labelling impeding access, and unqualified staff conducting suicide risk assessments without training.
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.
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)
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. 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.
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.
Canon Frost
Partially Responded
2018-0362
3 Oct 2018
Suffolk
East Coast Community Healthcare Team
Head of the Roman Catholic Church of En…
The Diocese of Westminster
Concerns summary (AI summary)
Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits failed to conduct health and safety risk assessments.
Action Planned
(AI summary)
The Diocese will conduct annual property and safety assessments for retired priests, involving a surveyor, welfare officer, and the priest. Necessary repairs will be organised and paid for by the Diocese, with escalation procedures for disagreements.
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.
Brian Frost
Historic (No Identified Response)
2018-0332
3 Oct 2018
Suffolk
Diocese of Westminster
the Roman Catholic Church of England an…
Patrick Stead Hospital
Concerns summary (AI summary)
Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits failed to conduct health and safety risk assessments.
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.
Hayley Gascoigne
Partially Responded
1 Oct 2018
East Riding and Kingston-upon-Hull
HM Courts and Tribunals Services
The Hull Combined Court Centre, Lowgate…
Concerns summary (AI summary)
The Hull Combined Court Centre lacked a defibrillator, despite expert opinion that all public buildings should be equipped with such apparatus to improve survival rates in cardiac arrest.
1 response
from HG
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.
Julia MacPherson
Partially Responded
2018-0298
27 Sep 2018
London (South)
Care Quality Commission
Department for Health
Oxleas NHS Trust
Concerns summary (AI summary)
Failure to review a patient despite severe side effects and family concerns, inadequate mental capacity assessments, poor record-keeping for off-label medication consent, and unread clinical notes, compounded by a lack of statutory consent process for informal patients.
Noted
(AI summary)
The DHSC acknowledges the lack of a statutory process for recording consent to medication for voluntary mental health patients. They state that the Trust will implement additional safeguards, including pharmacist reviews of medications and capacity assessments, with concerns raised to the responsible clinician and clinical director. The CQC notes the concerns but states some relate to specific circumstances so they are unable to comment, but intends to follow through some areas of concern in more detail during an inspection later in the year.
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.
Angela Jackson
Partially Responded
26 Sep 2018
Manchester (West)
Liverpool Heart and Chest Hospital NHS …
Lancashire Teaching Hospitals NHS Found…
Manchester University NHS Foundation Tr…
+1 more
Concerns summary (AI summary)
A critical absence of clear, documented national and regional pathways for aortic aneurysm referrals, including correct hospital names and contact details, leads to inefficient and potentially delayed emergency treatment.
2 responses
from Angela Jackson, Angela Jackson Response2
John Waite
Partially Responded
26 Sep 2018
Manchester (West)
British Renal Society, EBS Ltd.
Intensive Care Society
The Renal Association
+2 more
Concerns summary (AI summary)
Inadequate visual observation protocols following central venous catheter removal, with only 5-minute dressing checks risking significant, rapid blood loss, compounded by a lack of national guidelines for this procedure.
2 responses
from John Waite Response2, John Waite