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
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.
Grenfell Tower
Historic (No Identified Response)
2018-0262 19 Sep 2018 London Inner West
NHS England
Concerns summary (AI summary) No structured health screening programme is in place for individuals impacted by the Grenfell Tower incident, risking unaddressed future health issues.
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
Hubert Kelly
Partially Responded
19 Sep 2018 Black Country
Care Quality Commission The Dudley Group Trust Foundation Trust
Concerns summary (AI summary) Emergency department overcrowding leads to patients waiting in corridors without meaningful interaction or timely assessment, with waiting times frequently exceeding national standards.
1 response from Hubert Kelly
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."
Daniel Collins
Historic (No Identified Response)
2018-0283 14 Sep 2018 Birmingham and Solihull
Birmingham and Solihull Clinical Commis… Birmingham Women’s and Children’s NHS T…
Concerns summary (AI summary) A mental health service transferred a recently suicidal patient's care, requiring the patient to initiate contact with the new service, without proper handover or follow-up, risking loss of care during a crisis.
Terence Bennett
Partially Responded
2018-0282 14 Sep 2018 Wiltshire and Swindon
Avon and Wiltshire Mental Health NHS Tr… Care Quality Commission NHS England +1 more
Concerns summary (AI summary) The jury found that failures in mental healthcare contributed to the death, including inadequate care plans, insufficient staff knowledge of medical records, and a lack of family involvement.
Action Taken (AI summary) NHS Improvement is working with mental health trusts to improve patient safety through a national mental health safety initiative. They are also reviewing concerns and failings with the Trust and have put changes in place and are working on a support package for the Trust.
Laila Habibi and Daniel Ghafuri
Historic (No Identified Response)
2018-0285 13 Sep 2018 Warwickshire
Warwickshire County Council
Concerns summary (AI summary) A dangerous diversion road with a history of fatalities lacked crucial 'single carriageway' warning signs, and sat navs directed drivers into the wrong lane, posing significant road safety risks.
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.
Greg Hutchins
Historic (No Identified Response)
2018-0129 12 Sep 2018 Warwickshire
Birmingham & Solihull Mental Health Tru…
Concerns summary (AI summary) Mental health telephone triage was undocumented and unrecorded, with no system for rapid information sharing for out-of-area patients, indicating significant gaps in record-keeping and inter-area communication.
Kevin Sherwood
All Responded
2018-0289 11 Sep 2018 Hertfordshire
Network Rail
Concerns summary (AI summary) Insufficient railway boundary fencing, consisting only of post and wire, in an area frequented by walkers, creates a risk of trespass onto the train line.
Action Planned (AI summary) Network Rail has increased the frequency of fence inspections to three-monthly and scheduled renewal of the fencing in the Inckneild Hitchin area for 2019/2020. Platform End Anti-trespass measures have been added to Hitchin Station.
Gladys Williams
Historic (No Identified Response)
2018-0292 10 Sep 2018 North Wales (East and Central)
Betsi Cadwaladr University Health Board Welsh Ambulance Services
Concerns summary (AI summary) Ongoing, multifactorial problems with ambulance delays, emergency department overcrowding, and patient flow continue to risk lives, despite previous warnings and reported mitigation efforts.
Darren Urquhart
Historic (No Identified Response)
2018-0291 10 Sep 2018 Hertfordshire
Network Rail
Concerns summary (AI summary) Inadequate railway anti-trespass measures, including poor trespass mat placement, missing platform gates, and insufficient fencing, create a risk of future deaths from track access.
Elijah Shotade
All Responded
2018-0290 10 Sep 2018 North West Wales
North & Mid Wales Trunk Road Agency
Concerns summary (AI summary) Dangerous road layout design and misleading sat nav directions encourage westbound motorists to remain or enter the eastbound lane after overtaking, significantly increasing collision risk.
Action Taken (AI summary) The Department for Economy and Infrastructure has extended double white lines and lane arrows on Britannia Bridge. Further improvements to signage are planned before the end of the financial year, and road safety audits are being conducted.
Alba Pemberton
All Responded
2018-0288 10 Sep 2018 London (North)
Department of Health and Social Care
Concerns summary (AI summary) Protocols for meconium classification and equipment use are inadequate, and there's insufficient obstetric review and multidisciplinary collaboration in birthing centres and low-risk maternity cases.
Noted (AI summary) The Department of Health and Social Care references NICE guidelines on intrapartum care and states NICE will log the coroner's concerns for future review but does not plan to update the guideline at this time.
Scott Carton
Historic (No Identified Response)
2018-0287 7 Sep 2018 West Yorkshire (East)
MOJ National Probation Service
Concerns summary (AI summary) Inadequate psychological support for prisoners with mental health and drug issues upon release, including unsuitable hostel placements without specialist input, compromises rehabilitation and increases re-offending risk.
Colin Griffiths
All Responded
2018-0295 4 Sep 2018 London Inner (North)
Masta Limited
Concerns summary (AI summary) Medical history recording relies solely on verbal communication, leading to inaccuracies, and there is no audit system to verify the accuracy of patient records made by nurses.
Action Taken (AI summary) The MHRA considered the adequacy of statutory information for prescribers and patients on the safe use of yellow fever vaccine. They intend to issue a further reminder about the risks of live vaccines in immunocompromised patients via its Drug Safety Update (DSU) bulletin, and has added the report of Mr Griffiths' adverse reaction to Yellow Fever vaccine to the MHRA's Yellow Card database. MASTA has re-evaluated policies and systems, introduced a tick box questionnaire for patients, implemented face-to-face audits at clinics, and observed/documented post-injection advice. They also plan to re-audit clinics of concern and are calling for other Yellow Fever Vaccination Centres to adopt similar preventative measures.
Andrew Dickson
All Responded
2018-0296 3 Sep 2018 Manchester (South)
Edgeley Medical Centre Stockport Medical Group
Concerns summary (AI summary) Critical information about suicidal ideation from telephone triage is not reliably transferred to the doctor's screen for face-to-face appointments, creating significant safety risks for vulnerable patients.
Action Planned (AI summary) Stockport Medical Group will use a new EMIS template when booking patients onto the triage list to ensure clinical information is visible and auditable. Training on the new template is scheduled for reception supervisors over the next 4 weeks, who will then train staff at each site. The practice has also requested that EMIS automate information transfer from triage slots into clinical notes.
Doris Douthwaite
Historic (No Identified Response)
2018-0294 3 Sep 2018 Manchester (South)
HC-One
Concerns summary (AI summary) Vulnerable residents with dementia were left unsupervised due to unclear policies, an ambiguous falls risk assessment tool, and a lack of investigation into multiple falls, missing learning opportunities.
Michael Drewell
All Responded
2018-0259 30 Aug 2018 West Yorkshire (Eastern)
Leeds Teaching Hospitals NHS Trust
Concerns summary (AI summary) A senior clinician's critical medication advice was not followed by a junior doctor, as it wasn't on electronic notes, highlighting a dangerous reliance on digital records over handwritten instructions.
Action Planned (AI summary) Leeds Teaching Hospitals NHS Trust will remind clinicians about the importance of robust handover and communication. They will also ensure individual clinicians prescribing 'off protocol' either action this themselves personally or leave clear unambiguous instructions within the electronic record.
Daniel O’Mahony
All Responded
2018-0258 30 Aug 2018 Hertfordshire
London North Western Railways
Concerns summary (AI summary) Inadequate railway anti-trespass measures, including missing gates, gaps in fencing, and unreviewed signage, increase access to railway lines and the risk of future deaths.
Action Planned (AI summary) West Midlands Railway (operated by West Midlands Trains) removed an outdated Samaritans sign and will install new signs at the Hemel Hempstead Railway Station. Network Rail have submitted a remit to install fencing and a swing gate, and to fill gaps between platforms 2 and 3 with sliding gates.