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
Jerome Jones
Partially Responded
2018-0369 1 Aug 2018 Shropshire, Telford & Wrekin
Forward Trust HMP Stoke Shropshire Community Health NHS Trust
Concerns summary (AI summary) Insufficient specific checks and a lack of policy for prisoners with multiple NPS use, combined with poor communication of medical risks and drug workers' limited access to medical records, posed significant dangers.
Noted (AI summary) The trust describes current practices for observing prisoners using illegal substances and referring them to support services. It notes that Forward Trust's access to medical records is under discussion with NHS England. An updated drug strategy has been launched at the establishment, and staff were reminded of communication protocols for prisoners at risk from repeated use of psychoactive substances. By April 2019, Forward Trust will have access to SystmOne to improve communication with prison and healthcare staff.
Nigel Handscomb
Historic (No Identified Response)
2018-0278 1 Aug 2018 London Inner (South)
Eden Park Surgery
Concerns summary (AI summary) Incomplete and inaccurate GP consultation notes, made several hours after the fact, failed to record critical patient information, including examination findings and medication adherence, alongside unrecorded verbal instructions.
Cuthbert Hingert
Historic (No Identified Response)
2018-0280 1 Aug 2018 Isle of Wight
Isle of Wight NHS Trust
Concerns summary (AI summary) Significant medication errors, including duplicate prescribing and incorrect dosages, occurred due to clinicians failing to check databases and insufficient training. A nurse also failed to report these errors according to protocol.
Richard Barrett
All Responded
2018-0249 30 Jul 2018 South Wales Central
Cardiff and Vale University Health Board Minister for Health Welsh Ambulance Service Trust
Concerns summary (AI summary) Seriously underestimated ambulance demand and unrealistic A&E turnaround targets led to severe ambulance shortages. Unreliable welfare call systems and failure to involve police for checks further delayed critical intervention.
Action Planned (AI summary) The Welsh Ambulance Services NHS Trust and Cardiff and Vale University Health Board confirmed the continued actions of reminding CCC Clinical Leads to address Protocol 23 cases promptly, approach the Police to extend the MOU to include overdose cases, expand the clinical desks, rolling out the APP model across Wales and implementing a Level 1 response to people who have fallen and are not injured. The Welsh Ambulance Services NHS Trust (WAST) is considering options to increase capacity on its clinical support desk and exploring options for third sector organisations to support delivery of welfare checks. The Cabinet Secretary has commissioned a review of the ‘Amber’ category.
Stanford Bell
All Responded
30 Jul 2018 West Yorkshire (West)
Airedale NHS Foundation Trust Riverview Nursing Home
Concerns summary (AI summary) Concerns exist over Airedale Hospital's discharge procedures for head injury patients lacking discharge papers and Riverview Care Home's referral procedures for patients experiencing post-trauma seizures.
2 responses from Stanford Bell Response2, Stanford Bell
Natalie Billingham
Historic (No Identified Response)
2018-0274 27 Jul 2018 Black Country
Care Quality Commission Russell Hall Hospital
Concerns summary (AI summary) Inadequate communication, delayed assessment of blood results, and missed opportunities for early antibiotic administration led to a failure in recognising the development of sepsis.
Glynn Storey
All Responded
2018-0246 27 Jul 2018 County Durham and Darlington
Construction Industry Council
Concerns summary (AI summary) Confusion regarding responsibility for ensuring windows meet building standards between building control and builders created a false sense of compliance.
Noted (AI summary) CICAIR clarifies the responsibilities of Approved Inspectors versus builders in ensuring buildings meet safety standards, emphasizing that Approved Inspectors provide a spot-checking process and cannot guarantee compliance. It references existing guidance and complaint procedures.
Astonn Mitchell-Male
Historic (No Identified Response)
2018-0248 26 Jul 2018 Manchester (North)
Pennine Care NHS Trust
Concerns summary (AI summary) The Trust lacks a policy for patient medication monitoring and triangulation of information in community settings, compounded by poor and non-existent record keeping, undermining patient safety.
Daniel Young
All Responded
2018-0240 26 Jul 2018 London (Inner) West
Department for Health
Concerns summary (AI summary) GP surgeries lack routine monitoring for psychiatric patients collecting antipsychotic medication, increasing the risk of relapse and harm to themselves or others.
Action Planned (AI summary) NHS England is developing a framework for community mental health services to improve joint working between primary and secondary services. They will also write to GP practices about monitoring antipsychotic medication prescriptions and explore alerts within primary care clinical systems.
Herbert Francis
Partially Responded
2018-0242 26 Jul 2018 Carmarthenshire and Pembrokeshire
Economy and Transport Department for Transport
Concerns summary (AI summary) The junction lacks adequate road markings, early warning signs, and properly positioned speed limit signs. Filter lanes are too short, and there's no westbound filter, increasing road safety risks.
Action Planned (AI summary) The Welsh Government will consider the concerns raised in the report as a priority as part of the ongoing three-year speed limit review looking at road safety issues. Preliminary investigations have begun to develop further overtaking opportunities & safety improvements along the length of the A40 including improvements at Redstone Cross.
Paul Allan
All Responded
2018-0251 25 Jul 2018 London (Inner) West
Pennine Care HNS Foundation Trust Rochdale Community Mental Health Team Pennine Acute Hospitals NHS Trust
Concerns summary (AI summary) The Community Mental Health Team inappropriately discharged a patient instead of transferring care, and failed to consult required alcohol advisory services, leading to a gap in mental health support.
Action Planned (AI summary) The Trust will circulate a reminder to all staff regarding the CPA policy and how to access it. Pennine Care NHS is a signatory to the Greater Manchester Strategic suicide prevention strategy and will work collaboratively to bring the NCISH recommendations to practice.
Robert Wrinch
Historic (No Identified Response)
2018-0244 25 Jul 2018 Manchester (South)
Department for Health Greater Manchester Strategic Health Gro… Royal College of Pathologists +1 more
Concerns summary (AI summary) The pathology department lacked systems for tracking samples and documenting clinician communications, causing delays and unclear chronologies. Incompatible IT systems between trusts and national pathologist shortages also contributed to backlogs.
Jane Parker
Historic (No Identified Response)
2018-0243 25 Jul 2018 Manchester (South)
Care Quality Commission Minister of State for Care
Concerns summary (AI summary) Care home staff had poor understanding of modified diets and lacked systems for correct food preparation and marking. There was also limited understanding of escalating choking episodes to speech and language therapy.
Aniyah Winston
Partially Responded
2018-0241 25 Jul 2018 Manchester (South)
Department for Health the Healthcare Safety Investigation Bra…
Concerns summary (AI summary) Undetected breech births are common due to lack of routine pre-delivery scans, and staff felt uncomfortable challenging a clinician's decision to administer Syntocinon, highlighting systemic issues in challenging inappropriate care.
Action Taken (AI summary) The response clarifies that NICE guidelines already address fetal malpresentation assessment and that routine third-trimester scans are not recommended due to lack of evidence. The Department also highlights the Maternity Safety Strategy and the distribution of the £8.1 million Maternity Safety Training Fund to NHS trusts for multi-disciplinary team training.
Taiyah-Grace Peebles
All Responded
2018-0239 24 Jul 2018 North East Kent
Network Rail
Concerns summary (AI summary) Many railway platforms lack barriers to prevent accidental contact with live rails, which pose a significant electrocution risk compared to safer overhead power systems used elsewhere.
Action Taken (AI summary) Platform-end gates have been installed at 30 locations in Kent and Sussex. £800,000 of work is due to be completed by April 2019 to improve fencing at higher risk areas.
Kathleen Bamforth
All Responded
2018-0247 20 Jul 2018 West Yorkshire (West)
Department for Health
Concerns summary (AI summary) Concerns exist regarding current practice guidelines for clomipramine prescription, specifically the merits of routine blood screens for patients on long-term use.
Noted (AI summary) The Department of Health acknowledges the concerns and provides information on NICE guidelines and SmPC recommendations for clomipramine and tramadol. The MHRA is seeking advice from experts on routine blood screens during long-term clomipramine use and requests a copy of the coroner's report.
Ruth Perkins
Historic (No Identified Response)
2018-0236 20 Jul 2018 Coventry
Department for Health
Concerns summary (AI summary) A high-risk patient was discharged to a care home with insufficient staffing levels for her needs, particularly lacking 1:1 care, significantly increasing her risk of falls.
William Watson
All Responded
2018-0237 19 Jul 2018 Cornwall & Isles of Scilly
Dorset Clinical Commissioning Group Kernow Clinical Commissioning Group
Concerns summary (AI summary) Ambulance services and patient transport face significant performance gaps due to insufficient funding, leading to critical delays in emergency, high dependency, and non-emergency transfers, risking avoidable deaths.
Action Planned (AI summary) NHS Kernow will be working with current providers to extend their current contracts, as the procurement process was not successful. The CCG will finalise future commissioning arrangements for one universal non-emergency patient transport service. Commissioners plan a total overall investment of £13.8m to support achievement of the ARP standards. SWASFT have provided a draft business case and performance standards are expected to be met by September 2020, with Category 2 in June 2021.
Jeroen Ensink
Historic (No Identified Response)
2018-0235 19 Jul 2018 London (Inner) North
Metropolitan Police Service
Concerns summary (AI summary) Police failures included not creating mental health alerts, inaccurate record-keeping regarding injuries and force, and failing to inform the forensic medical examiner of mental health concerns or family-reported history.
Ronald Harman
Historic (No Identified Response)
2018-0234 19 Jul 2018 Brighton & Hove
Brighton and Sussex University Hospital…
Concerns summary (AI summary) The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths without specifying particular issues.
Nigel Malloy
Partially Responded
2018-0232 19 Jul 2018 Southampton & New Forrest
Hampshire Hospitals NHS Foundation Trust South Staffordshire & Shropshire NHS Tr…
Concerns summary (AI summary) There was a critical lack of information sharing and coordinated treatment planning between the Alcohol Liaison service and other support services for a patient with severe alcohol dependence and repeated admissions.
Action Taken (AI summary) The Trust has a 24-hour referral service and pathway with Inclusion, leaflets about Inclusion Service, a weekly inreach service (now adhoc), regular telephone liaison, referrals to Mental Health Provider and a monthly High Intensity User Group. There are ongoing discussions to improve access to services.
Darren Neilson
All Responded
2018-0231 18 Jul 2018 Birmingham
BAE Systems Ltd MOD
Concerns summary (AI summary) The tank was able to fire without the BVA assembly being present, a hazard not adequately considered during production and manufacture. There was also no written process to check for the BVA assembly's presence or confirm when it should be removed and stored.
Action Taken (AI summary) Following the accident, a ban on all 120mm training ammunition natures was ordered and an Extraordinary Safety and Environmental Management Panel (SEMP) was convened. Three systemic issues relating to safety have been identified across DE&S and will be resolved. Following the incident in June 2017 the MoD and BAE Systems are developing a design solution to eliminate the risk of this happening again and to bring the current Challenger 2 gun up to date with the Standard. Progress on four solutions will be reviewed by the MoD Challenger 2 Safety and Environmental Management Panel in October 2018.
Matthew Hatfield
All Responded
2018-0231-wp26293 18 Jul 2018 Birmingham
BAE Systems Ltd MOD
Concerns summary (AI summary) Soldiers lacked clarity on gun safety drills, and the officer in charge lacked critical information on tank status. Risk assessments also failed to identify a design flaw allowing guns to fire without a vital safety assembly.
Disputed (AI summary) • Immediately following the tragic accident; ban on all 12Omm training ammunition natures was ordered by Defence General Munitions ("DGM"). • Once all live fire training on Challenger 2 ("CR2") tanks was halted, an Extraordinary Safety and Environmental Management Panel ("SEMP") was convened. • The SEMP held a series of four extraordinary meetings (20 June, 12 July, 24 July and August 2017) to investigate the incident.
Mohammed Ahmed
Historic (No Identified Response)
2018-0230 18 Jul 2018 Manchester (West)
Department for Health Manchester University NHS Trust RCOG
Ellie Knowles
Historic (No Identified Response)
2018-0202 18 Jul 2018 Newcastle Upon Tyne
Hoults Limited Shindig Events Limited
Concerns summary (AI summary) A venue maintains a license for high-risk events but lacks a robust internal protocol requiring consultation with police and council licensing officers before planning similar future events.