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
Leslie Bingham
All Responded
2018-0228 17 Jul 2018 South Yorkshire (West)
Sheffield City Council
Concerns summary (AI summary) Pedestrians approaching a road from one direction may be misled by a green light intended for pedestrians crossing from a different direction.
Action Planned (AI summary) Sheffield City Council plans to install a length of barrier rail around the corner of the junction within 10 weeks to deter pedestrians from crossing in the wrong location and guide them to the designated crossing point.
Sheila Ridgway
Historic (No Identified Response)
2018-0229-wp26291 16 Jul 2018 Manchester (City)
Care Quality Commission Manchester University NHS Trust NHS England +2 more
Concerns summary (AI summary) A lack of systemic communication between specialty consultants prevents identifying and documenting potential ongoing risks when patients receive simultaneous treatments from different departments.
Tyrone Evans
Partially Responded
2018-0227 16 Jul 2018 Coventry
Department for Transport Driver and Vehicle Licensing Agency
Concerns summary (AI summary) There is no legal requirement for quad bike riders to wear crash helmets, even on road-adapted vehicles, despite evidence suggesting a helmet could prevent fatal head injuries.
Noted (AI summary) The Department for Transport acknowledges the coroner's concerns regarding quad bike safety and helmet use but states there are no immediate plans to make helmet use compulsory, though the position is under review. They note changes to casualty statistics are made as part of quinquennial reviews.
Adam Carter
All Responded
2018-0226 12 Jul 2018 Blackpool & Fylde
Lancashire Care NHS Trust
Concerns summary (AI summary) Poor record-keeping for a detained mental health patient meant risks, leave rationale, and assessments were undocumented, hindering informed decision-making and continuity of care for staff.
Action Planned (AI summary) Lancashire Care NHS Trust will prompt nursing teams to fully consider patient risks prior to leave, consider a minor amendment to the Leave Policy by 28 September 2018, pilot leave diaries in secure services, and the Clinical Director will write to consultants and ward managers about these actions by 14 September 2018. The impact of these actions will be included in a clinical audit in January 2019.
Rita Giles
Historic (No Identified Response)
2018-0224 11 Jul 2018 Brighton & Hove
Brighton and Sussex University Hospital… NHS England Clinical Commissioning Group +1 more
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.
Bartholomew Coleman
All Responded
2018-0250 10 Jul 2018 Dorset
Network Rail
Concerns summary (AI summary) The railway line is easily accessible from a bridge with a low wall, showing signs of frequent public use and alcohol consumption, without adequate warning of danger.
Action Planned (AI summary) Network Rail is planning to apply mitigation measures (wire mesh panels with base plated fence posts fixed to the top of the parapet walls) to further deter access to the track below, with an anticipated completion date of the end of September 2018. They will also erect a warning sign of the dangers presented.
Eugeniusz Niedziolko
Historic (No Identified Response)
10 Jul 2018 Wiltshire and Swindon
Dyfed & Powys Police Wiltshire Police College of Policing +4 more
Concerns summary (AI summary) Police lacked appropriate options for managing a heavily intoxicated individual, leading to them being left alone in a public lavatory on a cold night, resulting in death.
Doris McCarthy
Historic (No Identified Response)
2018-0222 9 Jul 2018 London (South)
Baycroft Care Homes Senior Villages
Concerns summary (AI summary) Concerns persist about sensor system outages failing to alert staff to falls and inadequate safeguards for residents prone to sliding in chairs.
Robert Power
All Responded
2018-0221 9 Jul 2018 Gloucestershire
North Bristol NHS Trust
Concerns summary (AI summary) A patient was "lost to follow-up" for eight years after an incorrect diagnosis, highlighting a risk of future deaths if outpatient care is not consistently maintained.
Noted (AI summary) The Trust acknowledges receipt of the coroner's letter and confirms that the Trust now works under different systems than in 2008 with processes to arrange follow-up appointments; they have no further submissions to assist the coroner.
Jacob Sulaiman
All Responded
2018-0252 6 Jul 2018 London (Inner) North
London Borough of Camden
Concerns summary (AI summary) Incomplete information sharing between different care services meant response officers lacked a full picture of the patient's condition, potentially affecting assessment and management.
Action Planned (AI summary) The London Borough of Camden is migrating records to a new IT system for Careline, to be in place by the end of 2018, including a checklist for referring to emergency services with full patient history; a referral has been made to the SAR panel for review, and the Careline service has contacted LAS to discuss better information sharing.
David Chandler
All Responded
2018-0215 5 Jul 2018 Northamptonshire
Carlsberg Supply Co Ltd
Concerns summary (AI summary) An outdated and unreviewed isolation procedure from previous work led to an unsafe standard for new tasks, exacerbated by a lack of clear responsibility between contractors for safe isolation.
Disputed (AI summary) Carlsberg disputes several of the coroner's concerns, arguing that isolations were adequate, the permit to work system is fit for purpose, and there was no confusion about isolation levels; they state that competence of individuals with responsibility for completing PTWs has been reviewed.
Kathleen Allen
All Responded
2018-0213 4 Jul 2018 Birmingham and Solihull
University Hospitals Birmingham NHS Tru…
Concerns summary (AI summary) Inconsistent application and understanding of MEWS escalation pathways in the A&E department, with conflicting staff guidance, created a risk of inconsistent patient monitoring and delayed escalation.
Action Taken (AI summary) The Trust has deployed an ED-specific MEWS Observation Chart for use in the BHH and Good Hope EDs, and the Solihull Minor Injuries Unit; the ED directorate has circulated an email to Divisional Directors across HGS sites disseminating the ED MEWS SOP; the nurse responsible for the care of Mrs Allen has received a period of supervised practice and completed targeted objectives.
Yunis Hadi
All Responded
2018-0209 30 Jun 2018 London Inner (South)
London Borough of Lambeth South London Islamic Centre The Chief Coroner +1 more
Concerns summary (AI summary) A lack of formal first aid training, including choking response, for volunteers, absence of emergency medical equipment, and insufficient oversight for child safeguarding were identified.
Action Planned (AI summary) Lambeth Council has offered safeguarding training to the South Lambeth Islamic Centre, scheduled for September 19th, and shared a model safeguarding policy for schools; the Council's Food, Health and Safety Manager will follow up on the actions via a visit.
Charles Rashan
All Responded
2018-0210 29 Jun 2018 London Inner (North)
Metropolitan Police Service
Concerns summary (AI summary) Police training should emphasize recognizing that struggling to resist arrest can be a struggle to breathe or silent choking, and highlight the need to manage public intervention.
Action Taken (AI summary) The MPS has recommended changes to the Personal Safety Manual, Module 12 'Management of Persons Suspected of Concealing Items in Mouth', now requiring that where possible the subjects head should be tilted forward; the MPS continues to review and refine existing first aid techniques.
Lindsey Tyrrell
Historic (No Identified Response)
2018-0208 29 Jun 2018 Manchester (City)
Department of Health and Social Care NHS England
Concerns summary (AI summary) Routine testing for toxoplasmosis was not performed on stem cell transplant patients with infection signs, and local learning needs nationwide sharing.
Ashley Notson
Historic (No Identified Response)
2018-0207 29 Jun 2018 Suffolk
Care Quality Commission Department of Health and Social Care
Concerns summary (AI summary) There is no legal requirement for care home carers to have first aid training or to carry mobile phones, posing a risk in emergency situations.
Daphne Penn
Historic (No Identified Response)
2018-0206 29 Jun 2018 Suffolk
Newmarket Community Hospital Rookery Medical Centre West Suffolk Hospital
Concerns summary (AI summary) Inadequate communication of steroid risks and family concerns, alongside prescribing errors, led to an inadvertent rapid steroid dose reduction without sufficient clinical oversight.
Stephen Whitehead
All Responded
2018-0293 28 Jun 2018 Manchester (North)
British Society of Gastroenterology Department of Health and Social Care
Concerns summary (AI summary) The absence of a national registry for biliary stents creates a risk of "forgotten stents," while national guidelines lack a clear definition of "short-term" use.
Noted (AI summary) The Department acknowledges the coroner's concerns but refers to the BSG's opinion that a national stent registry is not required and NICE's view that existing guidance remains appropriate. It also mentions the Pennine Acute Hospitals NHS Trust established an ERCP biliary stent oversight meeting, and that NHS Improvement has brought the concerns in the report to the GIRFT clinical lead for gastroenterology. The BSG is in discussion with JAG about adding a stent planning/recall database to key performance indicators and incorporating it into the ISREE programme, with a formal discussion planned for the BSG Endoscopy Committee in October. It also mentions that reduction in variation in practice is an objective of the Get It Right First Time (GiRFT) initiative.
John Worthington
Partially Responded
2018-0204 28 Jun 2018 Stoke-on-Trent & North Staffordshire
Audlem Medical Practice Royal Stoke University Hospital
Concerns summary (AI summary) A&E made a borderline decision not to investigate a significant head injury, and the GP failed to take full observations for persistent back pain, delaying a pneumonia diagnosis.
Action Taken (AI summary) The doctor involved has reflected on the case and will be more aware of documenting a full set of observations and considering x-rays for older patients after trauma. She is also completing an online course in record keeping and has reviewed GMC guidance; the importance of detailed reports to the Coroner has been discussed at a practice level.
Angela West
All Responded
2018-0212 27 Jun 2018 London Inner (North)
Barts Health NHS Trust
Concerns summary (AI summary) High-risk surgery scheduled before a weekend led to care under reduced staffing, compounded by placement on a general ward and missing fluid balance charts, indicating dehydration issues.
Action Taken (AI summary) The out of hour’s surgical cover has been enhanced to ensure daily review of acute inpatients seven days a week, the junior doctor’s induction programme now contains a section around clinical escalation, the numbers of overall doctors in the surgery department have increased and there is a good mixture of skills sets throughout shifts, and that this specific case has also been presented through the mortality and morbidity meetings within surgery and medicine and continuing to be provided to all clinical staff.
Dudley Brown
Partially Responded
2018-0211 27 Jun 2018 London Inner (North)
East London NHS Trust London Borough of Hackney
Concerns summary (AI summary) Misconceptions about Mental Health Act procedures, withdrawal of care without welfare checks, and delays due to weekend scheduling and information requirements hampered a mental health assessment.
Action Planned (AI summary) Hackney Council and East London Foundation Trust have formulated and are implementing a multi-agency action plan to ensure staff fluency with mental health assessment processes, review escalation pathways for service refusals, and review the AMHP referral risk assessment process; expected completion by 30th September 2018.
Angela Turner
All Responded
2018-0199 26 Jun 2018 Manchester (West)
Department of Health and Social Care
Concerns summary (AI summary) The response to an NHS 111 call was deemed wholly inadequate, raising concerns about emergency access to care.
Action Planned (AI summary) The Department of Health and Social Care acknowledges the concerns and states that the North West Ambulance Service NHS Trust (NWAS) is conducting a full investigation into the incident and concerns raised. It also references NHS England's Urgent and Emergency Care review and the introduction of new urgent treatment centres.
Margaret Evans
Historic (No Identified Response)
2018-0197 26 Jun 2018 North Wales (East and Central)
BCUHB HM Stanley Site Welsh Ambulance Services NHS Trust +1 more
Concerns summary (AI summary) Persistent issues with ambulance delays, emergency department overcrowding, and resource availability continue to pose significant risks to patient safety.
Sylvia Davies
Historic (No Identified Response)
2023-0415 25 Jun 2018 Inner North London
Coventry and Rugby Clinical Commissioni… Virgin care Coventry LLP
Concerns summary (AI summary) Virgin Care's delay in adopting new urgent care assessment standards and the failure to transcribe or retain crucial patient information provided by families create ongoing safety risks.
Lauren Sandell
Partially Responded
2018-0205 25 Jun 2018 London (East)
NHS England NHS London Public Health England
Concerns summary (AI summary) Confusion persists regarding responsibility for vaccinating children not covered by school programs, and the optional nature of GP vaccination services means there's no audit to identify or protect unvaccinated children.
Action Taken (AI summary) NHS England clarified the role of Child Health Information Services (CHIS) in call and recall processes for vaccinations and highlighted improvements made since 2016, including sharing guidance algorithms and conducting region-wide audits of call/recall systems.