2018

PFD Reports
Reports: 419 Areas: 64

69% response rate (above 63% average).

Clear 208 results
Adrian Jennings
All Responded
2018-0111 19 Apr 2018 Manchester (South)
Pennine Care NHS Trust NHS England Tameside Clinical Commissioning Group +2 more
Concerns summary (AI summary) Disjointed IT systems, lack of joined-up discharge planning, uncommissioned support services, and limitations in a national IT system hindered effective information sharing and patient care.
Noted (AI summary) Tameside and Glossop CCG acknowledges the need to expand mental health support and is investing in additional services, but does not recognize a gap in provision for individuals with high levels of needs like Mr. Jennings as they consider them covered by existing secondary care services. They will follow up on the other concerns with Pennine Care Foundation Trust through quality and performance monitoring. The Department of Health acknowledges the concerns raised and refers to national policy expectations and guidance, including the Mental Health Act 1983 Code of Practice and the Global Digital Exemplar programme. It also mentions the Healthcare Safety Investigation Branch's investigation into care for patients with mental health problems in emergency departments. NHS England notes the concerns and describes actions taken to address disparate IT systems (Global Digital Exemplar programme), joined-up discharge plans (national framework), and capturing when police bring in individuals (updated Emergency Department module in Lorenzo with mandatory data collection fields).
Matthew Wilmot
All Responded
2018-0107 17 Apr 2018 Bedfordshire and Luton
B & D Civil Engineering Limited M & S Water Services
Concerns summary (AI summary) Risk assessments for path closures are inadequate for unique routes without alternative access, leading pedestrians to disregard barriers and use hazardous excavations.
Action Taken (AI summary) M&S Water Services has amended its team briefing to include a procedure for operatives to escalate concerns about "unique" locations to a supervisor, who will then decide on appropriate control measures. The briefing will be mandatory for new operatives and refreshed for existing operatives every six months. B & D Civil Engineering reports that M&S will amend its team briefing to emphasize assessing suitability of alternative pedestrian routes and escalating concerns to supervisors. The revised briefing will be mandatory for new operatives and refreshed for existing operatives every six months.
Patricia Heslop
All Responded
2018-0102 12 Apr 2018 Sunderland
Department of Health and Social Care HC-One
Concerns summary (AI summary) Failures in care home included unreported falls, poor record-keeping, un-updated care plans, and staff inadequately trained in recognising patient deterioration and dementia care.
Noted (AI summary) The Department of Health acknowledges the concerns and refers to existing statutory guidance, CQC investigations, and national resources like the 'Falls and Fracture Consensus Statement' and NICE guidelines. They also mention the 'Quality Matters' initiative and plans to reform the social care system. HC-One describes actions taken following the incident, including internal investigations, informing staff of clinical concerns identified during meetings and supervision, and additional internal scrutiny of Hebburn Court. They also refer to improvements noted in a recent CQC inspection report.
James Sheffield
All Responded
2018-0214 12 Apr 2018 Manchester (West)
Salford Royal NHS Trust
Concerns summary (AI summary) Delays occurred in diagnosis and surgical intervention for a fracture, and a patient's essential CPAP machine went missing during hospital ward transfer.
Action Taken (AI summary) The Trust updated its electronic patient record system's ward-to-ward transfer document and circulated a safety alert to staff informing them of the changes. These changes have been fully implemented.
George Goldby
All Responded
2018-0104 11 Apr 2018 Nottinghamshire
HC-One
Concerns summary (AI summary) Nursing home staff were unaware of and failed to adhere to SALT recommendations for supervision and diet, resulting in missed re-referral opportunities and inadequate choking risk assessments.
Action Taken (AI summary) HC One allocated an Operational Project Manager, reviewed care plans, allocated staff to supervise eating and drinking, completed swallowing risk assessments, referred residents to SALT, and increased senior management cover; CQC inspection evidenced significant improvements in the quality and safety of care.
Lea Hunsley
All Responded
2018-0101 10 Apr 2018 Manchester (North)
EAM Care Group
Concerns summary (AI summary) The care facility lacked an SUI protocol, and staff demonstrated inadequate skills in identifying and escalating deteriorating patients, poor observation, and insufficient use of care records.
Action Taken (AI summary) EAM Care Group completed a root cause analysis with commissioners, will obtain post-operative care plans prior to admission, and introduced new handover procedures including lunchtime handovers and archiving of staff notes; they also completed an action plan following a CQC inspection.
Andrew Reid
All Responded
10 Apr 2018 Manchester (West)
Trafford Clinical Commissioning Group Greater Manchester
Concerns summary (AI summary) Inconsistent mental health service commissioning in Greater Manchester means Trafford residents lack out-of-hours emergency GP referrals, forcing A&E attendance or police involvement.
2 responses from Andrew REID Response2, Andrew REID
Naseeb Chuhan
All Responded
2018-0099 9 Apr 2018 West Yorkshire (East)
Financial Conduct Authority
Concerns summary (AI summary) Payday loan companies contributed to the deceased's dependency by encouraging loans despite awareness, and their financial checks were inadequate.
Action Planned (AI summary) The FCA is inviting views on overdraft pricing and monitoring repeated overdraft use, aiming to consult on proposed rules by the end of 2018; they are also fostering growth of alternatives to high-cost credit and invited firms with innovative alternatives to trial their approaches.
Darryl Souza
All Responded
2018-0098 9 Apr 2018 Northamptonshire
Highways Agency Northamptonshire County Council Northamptonshire Highways
Concerns summary (AI summary) Compromised visibility at a crossroads junction, despite existing signage, necessitates urgent improvements like renewed signs, rumble strips, and "Stop" signs, but these lack an implementation timeframe.
Action Planned (AI summary) Northamptonshire County Council will introduce 'rumble strips' in advance of the Clipston junction and convert the junction to a 'Stop' requirement, aiming to complete the work by the end of June 2018.
Matthew Faulkner
All Responded
2018-0097 29 Mar 2018 Hertfordshire
East of England Ambulance Service Lister Hospital Luton and Dunstable Hospital +1 more
Concerns summary (AI summary) Emergency ambulance services face severe resource shortages, unsustainable demand, and significant hospital handover delays, reducing ambulance availability for emergency calls.
Action Planned (AI summary) Luton and Dunstable Hospital prioritise cubicle space for new patients from ambulances, transfer existing patients, open contingency areas, and transfer patients to wards where beds will shortly become available. The East of England Ambulance Service will increase frontline patient staff by 330 FTE by 2020/2021 and is planning to arrange a further briefing for HM coroners; other actions include reviewing PSIT and HALO functions, adding staff to the Emergency Operations Centre, and collaborating with CCGs to review inter-hospital transfers. Princess Alexandra Hospital NHS Trust refurbished the Emergency Department, introduced a Steaming Process and Rapid Assessment of patients (RAT), and has a clear escalation process for ambulance handover delays, supported by an allocated Paramedic. East North Hertfordshire NHS Trust reconfigured the ambulance handover process, removing non-essential tasks and reducing handover time; they are conducting a focus week in June 2018 to improve performance further, monitoring it weekly.
Margaret Spencer
All Responded
29 Mar 2018 Black Country
Walsall Healthcare NHS Trust (Manor Hos…
Concerns summary (AI summary) Inadequate staff training for a new IT system resulted in premature closure of patient access plans and lack of reviews, placing multiple patients at risk.
1 response from Margaret Spencer
Joan Osborne
All Responded
2018-0091 26 Mar 2018 Nottinghamshire
Adbolton Hall Nursing Home
Concerns summary (AI summary) Numerous failures in nursing home care included not seeking specialist advice, missing appointments, inadequate record-keeping, and poor recognition/response to deteriorating patient condition and insulin refusal.
Action Taken (AI summary) Adbolton Hall outlines several actions already implemented, including appointing a new Home Manager, providing diabetes awareness training to staff, purchasing new blood glucose monitoring machines, removing Lucozade from the premises, and ensuring nurse-led interventions for diabetic residents.
Barbara Johnson
All Responded
2018-0084 21 Mar 2018 Manchester (South)
Pennine Acute NHS Trust
Concerns summary (AI summary) Junior doctors routinely ignored diagnostic printouts from ECG machines, which flagged abnormalities, raising concerns about the impact on clinical interpretation and judgment.
Noted (AI summary) GMMH will include the handover process and expectations in the local induction template and implement electronic handover sheets, aiming for full implementation by July 31, 2018. Northern Care Alliance NHS Group states that the junior doctors concerned were employed by Pennine Acute NHS Trust, but placed at Tameside General Hospital, so they are not responsible for implementing changes and suggest the report be amended and addressed to Tameside Hospital.
Peter O’Donnell
All Responded
2018-0201 20 Mar 2018 Manchester (West)
Department of Health and Social Care
Concerns summary (AI summary) Private hospital care had no clear consultant review agreements, inadequate junior doctor oversight/training, absent patient transfer protocols, and failed to report nurse misconduct, creating systemic safety risks.
Noted (AI summary) The Department of Health acknowledges concerns regarding independent hospitals and refers to existing standards, CQC ratings, and quality monitoring data submissions, also noting the ongoing Paterson Inquiry looking into accountability and quality of care in the independent sector.
Kellie Taylor
All Responded
2018-0083 19 Mar 2018 East Riding and Kingston upon Hull
Humber Bridge Board
Concerns summary (AI summary) The poor resolution of the CCTV system hindered accurate monitoring of individuals and delayed timely intervention during potential emergencies at the bridge.
Action Taken (AI summary) The Humber Bridge Board has purchased two Impact Protection Vehicles, liaised with the Samaritans to place signs, implemented a specialist training programme for staff and Police, and trained Control Room staff to recognize signs of emotionally distressed individuals.
Jean Griffiths
All Responded
2018-0080 15 Mar 2018 Manchester (West)
Department of Health and Social Care
Concerns summary (AI summary) A national audit revealed widespread poor oxygen prescribing practices in hospitals, with many patients lacking valid prescriptions, risking inappropriate oxygen levels and increased mortality.
Action Planned (AI summary) The Department of Health acknowledges concerns regarding oxygen prescribing practices. NICE is updating its guideline CG101 to tighten prescribing practice and the BTS and Royal Colleges will have opportunity to participate in the development and comment on the draft guidance.
Thomas Curtin
All Responded
2018-0076 14 Mar 2018 Cornwall and the Isles of Scilly
NHS England
Concerns summary (AI summary) Private mental health locked rehabilitation units lack a national framework for referral response times, potentially leaving patients on inappropriate wards and risking their safety.
Action Planned (AI summary) NHS England is working with other bodies to improve national-level understanding of CCG commissioned rehabilitation services and support local areas to plan and commission the rehabilitation pathway more effectively, following a CQC report on mental health rehabilitation inpatient services.
Catherine Kennedy
All Responded
2018-0075 13 Mar 2018 Manchester (South)
Pennine Care NHS Trust
Concerns summary (AI summary) Miscommunication between ward staff and an on-call doctor led to a significant delay in patient review after an overdose, highlighting the lack of a consistent communication paradigm.
Action Taken (AI summary) The Situation, Background, Assessment, Recommendation (Decision) tool is currently taught within several courses and the Organisation Learning and Development have been supplying learners with a copy of the A5 SBAR(D) telephone pads, to write on as handing over. The organisation has developed an action plan relating to the points raised during the inquest, which includes the re-design of Community Mental Health Services and an apology to Ms Kennedy's brother. The actions described in the letter are incorporated in an enclosed action plan.
William Abrahams
All Responded
2018-0074 6 Mar 2018 London Inner (North)
NHS England
Concerns summary (AI summary) The current AAA screening program excludes individuals over 65 at its introduction, and the "opt-in" nature for asymptomatic conditions may hinder participation, risking undetected aneurysms.
Action Planned (AI summary) NHS England London Region Public Health Commissioners will continue to support London AAA screening programmes to improve men's awareness of their options to attend screening. Targeted work with GPs in areas of higher deprivation and potential inequalities in access.
Mike Fell
All Responded
2018-0100 5 Mar 2018 London Inner (North)
Barts Health NHS Trust Royal College of Anaesthetists
Concerns summary (AI summary) Unused trauma lines lack a clear mechanism and documentation for ensuring they are "closed to air," with some lines lacking essential clamps, creating a risk of accidental opening.
Action Planned (AI summary) Barts NHS Trust has rewritten its policy on the use of central lines and three-way taps, stating that three-way taps should not be used on central lines but self-sealing injection ports should be used. They are also discussing with their current supplier a change in design to allow a clamp to be fitted; they are interested in working with us as they see this as a problem nationally which has not been raised before in relation to this complication. The RCoA will publish information on central venous access line safety in the Patient Safety Update and include these issues in the updated AAGBI guideline Safe Vascular Access. The FICM and ICS are developing national guidelines on the prevention, detection, referral and treatment of air embolism associated with central venous access.
Kevan Funnell
All Responded
2024-0095 27 Feb 2018 West Sussex, Brighton and Hove
South East Coast Ambulance Service
Concerns summary (AI summary) No specific concerns for future deaths were detailed in the provided text.
Action Planned (AI summary) South East Coast Ambulance Service is working with commissioners in a jointly commissioned demand and capacity review, intended to better align resource requirements to the demands on our service, particularly in the light of the newly introduced Ambulance Response Programme standards. The recent NHS Pathways upgrade will significantly reduce the risk of such an error recurring.
Adrian King
All Responded
2018-0061 27 Feb 2018 Staffordshire (South)
Foreign Office
Concerns summary (AI summary) British consulate/embassy communication channels were inadequate and unresponsive to family attempts to assist with medical treatment for an ill British national abroad, potentially impacting care outcomes.
Action Taken (AI summary) The FCO has reminded consular staff of policy guidance and best practices to ensure timely action. Since July 2017, all consular calls are answered at in-house Consular Contact Centres providing a 24/7 service. They are also encouraging British travellers to take out appropriate travel insurance before they travel.
David Ireland
All Responded
2018-0057 27 Feb 2018 Exeter and Greater Devon
Devon NHS Trust
Concerns summary (AI summary) The crisis team failed to advise that presenting at the emergency department was an option for urgent mental health assessment, and the patient's friend was unaware of this critical pathway.
Action Planned (AI summary) Devon Partnership NHS Trust will include specific reference to providing advice about emergency department attendance options in their next Trust-wide 'Safety Briefing' and in local induction for temporary workers. They have also asked teams to review answer machine messages to include appropriate support information.
James Quinton
All Responded
2018-0056 22 Feb 2018 South Yorkshire (East)
Doncaster Royal Infirmary
Concerns summary (AI summary) Poor nursing documentation and observation charts hindered clinical oversight. A critical medication was incorrectly administered due to a verbal prescription, highlighting a lack of essential checking procedures.
Action Planned (AI summary) Doncaster and Bassetlaw Teaching Hospitals are training individuals as scribes, obtaining a software update for monitors, and have set up a working group with ED and Anaesthetics to explore the issue of IV drug administration in emergencies during resuscitation. The clinical educator is reviewing IV competencies for staff within ED in relation to their current revalidation status.
Alan MacDonald
All Responded
2018-0053 21 Feb 2018 London Inner (North)
Addcounsel
Concerns summary (AI summary) A non-medically qualified counsellor charged an inpatient for non-treatment visits and failed to advise them on financial alternatives, revealing a systemic omission in Addcounsel's practices.
Action Taken (AI summary) Addcounsel has changed its system so that clients are discharged entirely to the care of the service deemed more suitable and only case manages clients to whom they are delivering services. Interim measures are in place to ensure the MDT is aware of this change while a formal policy is being agreed and ratified.