2019

PFD Reports
Reports: 527 Areas: 66

70% response rate (above 63% average).

Response Status
Responded 367 Historic 160
AI Classification
Action Taken 43%
Action Planned 38%
Noted 17%
Disputed 2%
Based on 507 classified responses
Top Categories
Hospital Death (Clinical Procedure… (216) Mental Health related deaths (64) Suicide (from 2015) (57) Alcohol, drug and medication relat… (53) Road (Highways Safety) related dea… (50)
527 results
Joanna Orpin
All Responded
2019-0457 31 Dec 2019 Isle of Wight
Isle of Wight Council National Trust on the Isle of Wight
Concerns summary (AI summary) Samaritans signs, previously present at Culver Cliff, have been removed, despite numerous individuals being found in mental distress there monthly and repeated recommendations for their reinstallation being ignored.
Action Planned (AI summary) The National Trust is engaging with Public Health, the Suicide Prevention & Intervention team, and the IOW Samaritans to discuss suicide prevention on their land. They will conduct an internal review of suicide prevention measures after these meetings.
Jacob Bates
All Responded
2019-0456 31 Dec 2019 Derby & Derbyshire
Department for Education
Concerns summary (AI summary) Vulnerable 16-18 year olds are placed in unregulated care settings lacking statutory oversight, leaving local authorities unable to adequately assess provider competency or safety due to resource constraints.
Action Planned (AI summary) The Department for Education launched a consultation on proposals to ensure unregulated provision is used appropriately, including introducing new national standards and enforcement mechanisms, with the consultation open until April 8, 2020.
Maureen Waterfall
Historic (No Identified Response)
2019-0455 30 Dec 2019 Manchester (South)
Department of Health and Social Care Greater Manchester Mental Health and So… National Institute for Health and Care …
Concerns summary (AI summary) There is no licensed antidote for Edoxaban anticoagulant, increasing risks for head injury patients. Concerns were raised about the lack of national guidance on antidote administration targets and storage, especially for non-tertiary hospitals.
Enid Baber
Historic (No Identified Response)
2020-0120 27 Dec 2019 Nottinghamshire and Nottingham
Nottinghamshire County Council
Concerns summary (AI summary) Nottinghamshire County Council failed to routinely assess for deprivation of liberty in community settings, and staff lacked training in this complex area, potentially leaving vulnerable individuals without adequate human rights safeguards.
Julie Taylor
All Responded
2019-0454 24 Dec 2019 Manchester (South)
Department of Health and Social Care
Concerns summary (AI summary) The hospital failed to implement a reasonable adjustment care plan and conduct best interests meetings for a patient with learning disabilities. There was also poor inter-agency communication and a severe lack of specialist acute learning disability beds.
Noted (AI summary) Stockport NHS Foundation Trust has achieved a 90% delivery rate for discharge summaries within 48 hours, and aims to reach 95%. Learning from the case will be presented to the Greater Manchester Quality Board and shared with commissioners. The Department of Health and Social Care acknowledges the failings and concerns identified in the report and refers to the response from the Greater Manchester Health and Social Care Partnership. It notes the JCVI's consideration of varicella infection risk in children with Down's syndrome.
Ifeoma Onwuka
Historic (No Identified Response)
2019-0453 24 Dec 2019 Norfolk
GMC James Paget University Hospital NHS Tru…
Concerns summary (AI summary) An on-call consultant lacked confidence for emergency surgery, showed poor leadership, and failed to investigate the cause of a patient's DIC, potentially putting pregnant women at risk.
Keith Whetton
All Responded
2019-0452 24 Dec 2019 Staffordshire (South)
Hunters Lodge Care Home
Concerns summary (AI summary) The care home failed to seek prompt medical attention after a resident's fall and did not inform family members in a timely manner.
Action Taken (AI summary) Following a review of the coroner's report, staff have been supervised and completed falls training. The falls policy has been updated, and staffing levels have been increased to improve observation and patient safety.
Kieran Hubbard
Historic (No Identified Response)
2019-0451 23 Dec 2019 Manchester (City)
Manchester Mental Health NHS Trust Pennine Care Mental Health Trust
Concerns summary (AI summary) Mental health trusts failed to expedite securing an inpatient bed and communicate effectively about placement requirements for a suicidal patient. There was also no clear guidance for advising patients in crisis about driving restrictions.
Adam Wilcox
Historic (No Identified Response)
2019-0492 23 Dec 2019 Hampshire (Central)
Hampshire County Council Southampton County Council
Concerns summary (AI summary) A busy main road lacks safe pedestrian and cycle crossings, forcing individuals to navigate dangerous sections where pathways end, significantly increasing the risk of serious collisions.
Tomasz Nowasad
All Responded
2019-0445 20 Dec 2019 Manchester (City)
Greater Manchester mental Health NHS Tr… HM Prison and Probation Service
Concerns summary (AI summary) There was an over-reliance on prisoners' self-declarations regarding self-harm risk, and insufficient consideration of all risk factors or the "big picture" during ACCT reviews and discharge. Risk assessment rationales were also not consistently documented.
Action Planned (AI summary) NHS England published guidelines and supporting documents for Health and Justice Clinical Reviewers in Sept 2018 and has published an amended specification for the provision of mental health services in prison. Additional resources were provided to HMP Manchester for mental health staffing. HM Prison and Probation Service are rolling out improvements to the ACCT process and are increasing the numbers of safer cells available to governors, including at HMP Manchester.
David Fowler
All Responded
2019-0450 20 Dec 2019 Manchester (West)
TRU
Concerns summary (AI summary) The patient's family was not informed or invited to an MDT meeting before his Mental Health Act section was lifted. Staff lacked clarity on who was responsible for family communication, and no formal policy was in place.
Action Taken (AI summary) The TRU revised policies and procedures for critical decision-making, multidisciplinary team communications, mental capacity assessments, care coordination, communication with family and statutory services, and aftercare/discharge planning. The Responsible Clinician made a referral to the General Medical Council and undertook further professional development.
Matthews Rogers
Historic (No Identified Response)
2019-0448 20 Dec 2019 Blackpool & Fylde
Blackpool Victoria Hospital
Concerns summary (AI summary) Patient observations were not monitored hourly as required for a high NEWS score, likely due to nurse understaffing and high patient numbers, indicating an omission in care.
Keith Hill
All Responded
2019-0446 20 Dec 2019 London Inner (North)
Barts Health
Concerns summary (AI summary) Poor communication between specialists, inadequate medical record-keeping, and insufficient senior support for junior pharmacists resulted in crucial medication decisions not being documented or administered.
Action Taken (AI summary) The Trust reviewed decision-making between teams, reinforced documentation of significant decisions, reiterated consultant support availability to junior doctors, and instituted a rota for senior pharmacist support out-of-hours.
Samantha Brousas
All Responded
2019-0443 20 Dec 2019 North Wales (East and Central)
Welsh Ambulance Service NHS Trust
Concerns summary (AI summary) Paramedics failed to pre-alert the hospital about suspected sepsis due to discretionary policy. They also could not administer vital antibiotics, and did not escalate concerns about patient condition or admission delays.
Action Taken (AI summary) The Trust implemented pre-alert guidance in Dec 2018 developed with clinical directors and the Royal College of Emergency Medicine, reinforced sepsis guidelines in mandatory training, and is designing an escalation process for ambulance crews when concerns aren't addressed in the Emergency Department.
Colin Beaumont
All Responded
2019-0449 19 Dec 2019 Warwickshire
Warwick Hospital
Concerns summary (AI summary) A nasogastric tube was misplaced twice in the same patient, resulting in a pneumothorax that directly contributed to their death.
Action Planned (AI summary) The Trust will amend its Nasogastric Tube Insertion policy to mandate review of alternative feeding options after two unsuccessful attempts, will arrange a Grand Round discussion on balancing clinical risks and communication with patients regarding treatment futility, scheduled within the next six months.
Doris Clark
Historic (No Identified Response)
2019-0444 19 Dec 2019 London (East)
Barking, Havering & Redbridge Universit… London Ambulance Service
Concerns summary (AI summary) A hospital doctor was unaware of morphine administered by paramedics due to inconsistent unit notation (mls vs. mgs), risking opiate overdose. Lack of standardised units between services creates a significant safety concern.
Suzanne Roberts
Historic (No Identified Response)
2019-0441 18 Dec 2019 West Sussex
NHS England
Concerns summary (AI summary) The hospital's patient record management was "sub-optimal" and fragmented across multiple systems, leading to ineffective cross-department communication and potential future deaths. Mandatory rules and data quality assurance were lacking.
Katherine Stamp
Historic (No Identified Response)
2019-0437 18 Dec 2019 West Sussex
NHS England
Concerns summary (AI summary) The serious side effects of clozapine, particularly regarding smoking and pneumonia, are under-appreciated by prescribers and not sufficiently detailed in national guidance.
Jamie Finlay
All Responded
2019-0510 17 Dec 2019 Suffolk
Transport and Rural Affairs at Suffolk …
Concerns summary (AI summary) The filter lane and junction design fails to prevent drivers from incorrectly turning onto the wrong side of bollards, posing a road safety risk.
Action Planned (AI summary) Suffolk County Council will review the junction design and layout to identify engineering solutions to reduce the opportunity for drivers to turn right in advance of the centre island, and will continue to monitor collisions across the county.
Barry Liffen
All Responded
2019-0400 17 Dec 2019 London Inner (West)
Glebelands Care Team
Concerns summary (AI summary) A concern was raised regarding the lack of clinical assessment for frail persons resident at Glebelands following falls.
Action Planned (AI summary) • All home managers will be reviewing falls on the PCS (Person Centered Software) system on a weekly basis to ensure that falls are monitored more frequently. • Managers will add notes to the falls log for the week and to the support plans of those residents involved. • Any resident who has more than two falls within a two week period, a review will be arranged with their GP or CPN.
Eugeniusz Malek
Historic (No Identified Response)
2019-0439 17 Dec 2019 London Inner (West)
Health and Safety Executive
Concerns summary (AI summary) The absence of regulations for capping scaffolding poles in areas where workers may fall created a hazard, contributing to fatal injuries from uncapped poles.
Constance Robinson
Historic (No Identified Response)
2019-0436 17 Dec 2019 Manchester (West)
Greater Manchester Stroke Operational D… Salford Royal Hospital
Concerns summary (AI summary) Limited 24/7 hyper acute stroke unit availability in Greater Manchester led to extended ambulance travel and delayed urgent medical assessment, impacting patient care, especially overnight.
Mark Anderson
Historic (No Identified Response)
2019-0435 17 Dec 2019 South Wales Central
Cardiff Council
Concerns summary (AI summary) Motorcyclists using Trelai Park as an unfettered racing area pose a significant safety risk to the general public, particularly children and the elderly.
Lewis Mendelson
All Responded
2019-0434 17 Dec 2019 Manchester (South)
Department of Health and Social Care Stockport Borough Council
Concerns summary (AI summary) Local authority backlogs and staff shortages led to a lack of DoLS and care reviews. Hospital care lacked best interests meetings, IMCA involvement, and caused distress with unbeneficial procedures, including End of Life Care decisions without proper assessment.
Action Planned (AI summary) Stockport Council is creating a dedicated review team to address the backlog of annual reviews in the Learning Disabilities Service, to be funded throughout the financial year 2020/21. The Department of Health and Pensions notes that mandatory learning disability and autism training for health and care staff is being developed and tested during 2020/2021 and will be rolled out in the future.
Terence James
All Responded
2019-0430 17 Dec 2019 Kent (Central and South East)
Charing Healthcare
Concerns summary (AI summary) The care home failed to promptly inform medical professionals about falls, adequately handover patient history, or escalate concerns about a patient's deteriorating condition.
Action Taken (AI summary) The organisation has conducted team meetings and supervision sessions and is introducing a specific audit relating to the handover process from 29 January 2020. They have reviewed and updated robust systems and ensured they are in place.