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)
Clear 294 results
Ellie Long
All Responded
2019-0090A 18 Mar 2019 Norfolk
Norfolk & Suffolk NHS Trust
Concerns summary (AI summary) The coroner highlights failures in record keeping and communication with external agencies, specifically that records were not properly recorded, handwritten notes were not reflected in electronic records and updating information was not sent to the GP or school.
Action Planned (AI summary) Norfolk and Suffolk NHS Trust details actions planned including; instructing all clinical services to review their working practice in respect of record keeping and communication with partner agencies and a learning session to be delivered by the Head of Patient Safety and Safeguarding and the Legal Services Manager.
Katharine Dowling
All Responded
2019-0089 14 Mar 2019 Cheshire
NHS England
Concerns summary (AI summary) Critical gaps exist in national guidance and consistent support for autistic patients with co-existing mental health conditions. Limited ASD-appropriate environments and inadequate, unmonitored staff training increase patient risk in psychiatric wards.
Action Planned (AI summary) NHS England is planning to address consistency of care for patients with ASD and co-existing mental health diagnoses by developing clear guidance for clinicians and ward staff, expanding ASD support services, increasing alternative forms of crisis provision, and developing a Core Capabilities Framework for Supporting Autistic People.
Mohammed Hussain
All Responded
2019-0122 13 Mar 2019 Bedfordshire & Luton
East London NHS Trust
Concerns summary (AI summary) Mental health assessments were flawed due to staff misunderstanding training and poor information sharing between staff and care providers. Despite further training, staff lacked insight into their actions.
Action Taken (AI summary) Further training on risk assessment and suicide prevention is being delivered to staff in Bedfordshire crisis services. A new Clinical Director for Crisis Pathway and Liaison has been appointed to review the crisis pathway, and the Trust is working with external experts to develop a new risk assessment tool for wider rollout; suicide prevention training is also being reviewed and refreshed.
Tamsin Grundy
All Responded
2019-0088 13 Mar 2019 Norfolk
Norfolk & Suffolk NHS Trust
Concerns summary (AI summary) A lack of continuity of care, with the patient seeing many different staff members, adversely impacted her mental health. Despite being noted, no definitive action was taken to address this issue.
Action Planned (AI summary) The CRHT team is using a national fidelity scale, including a point on therapeutic relationships, to reflect on practices and identify areas for improvement, matching clinicians with individuals where a positive relationship has developed; this scale is being used more widely across the Trust.
Marjorie Gartside
All Responded
2019-0091 12 Mar 2019 Manchester (North)
Pennine Acute Hospital NHS Trust
Concerns summary (AI summary) The hospital provided inaccurate discharge information and had unsafe discharge processes, leading to a lack of handover and critical medication not being sent with the patient.
Action Taken (AI summary) The NCMEO22 Pennine Acute Hospitals NHS Trust Standard Operating Procedure for Discharge from Hospital and Supporting Choice has been re-circulated to staff. Staff have been reminded to check for cannulas pre-discharge, and this issue has been raised within the division to ensure learning, with the response being circulated across the NCA for group learning.
Peter Carroll
All Responded
2019-0162 11 Mar 2019 Manchester (City)
MFT
Concerns summary (AI summary) A critical 6-month delay in reporting prevented a curable treatment option, likely altering the outcome, and there was a lack of leading physician sign-off on reports.
Action Taken (AI summary) The Department of Histopathology has implemented measures to redirect cases outside a pathologist's area of expertise, list all confirmed cancer cases for discussion at multidisciplinary team meetings, and directly email reports to the responsible clinician when there are delays. The MFT Chameleon Electronic Patient Record system has been improved to include operation notes, and a fully electronic paperless system of reporting test results, facilitating electronic results acknowledgement and tracking of clinician performance in reviewing results is being introduced.
John Richardson
All Responded
2019-0084 8 Mar 2019 West Sussex
Sussex NHS Trust
Concerns summary (AI summary) Confusion among staff regarding voluntary patients' leave status highlighted the absence of a specific leave policy for voluntary patients, unlike those sectioned under the Mental Health Act.
Action Taken (AI summary) Guidance regarding voluntary patients leaving the wards has been included in the new Acute Care Operational Policy.
Simon Robinson
All Responded
2019-0176 7 Mar 2019 Oxfordshire
Thames Valley Police
Concerns summary (AI summary) The current partnership agreement inadequately addresses mental health crises in private places, creating a gap in effective agency response where police powers are limited despite their primary responsibility.
Action Planned (AI summary) Thames Valley Police reviewed their Interagency Partnership Agreement and proposed amendments to clarify police response to mental health crises, with a consultation of amendments expected by April 30, 2019. The police intend to immediately instigate amendments 1, 2, 4, and 7 relating to operational guidance.
Matthew Bilby
All Responded
2019-0112 7 Mar 2019 Lincolnshire
Department for Transport Lincolnshire County Council
Concerns summary (AI summary) A dangerous and confusing staggered junction, identified as an accident blackspot with multiple fatalities, poses an ongoing risk to road users due to its layout and lack of traffic calming measures.
Noted (AI summary) The Department for Transport states that responsibility for traffic management on local roads rests with the local highway authority, and their role is to provide overarching strategy, policy, and guidance. They provide links to relevant guidance documents. The council states that there is currently no funding available for a roundabout project. Average speed cameras have reduced speeding offences, and the junction has been re-assessed with a lower priority ranking.
Kristopher McDowell
All Responded
2019-0083 7 Mar 2019 North Wales (East and Central)
Canal and River Trust
Concerns summary (AI summary) The report raises concerns about the wide spacing on the aqueduct parapet, posing a fall risk, and the subjective nature of the testing process for upright embedment, potentially leading to inconsistent assessments of deterioration.
Action Planned (AI summary) The Trust has started an investigation of physical options to address gaps in the parapet and will submit a final design for approval after an informal public consultation.
Chand Ali
All Responded
2019-0085 7 Mar 2019
Barts Health NHS Trust
Concerns summary (AI summary) Cyclizine, cautioned for severe heart failure, is routinely administered without individual risk assessment or monitoring of adverse outcomes. There has been no review of alternative antiemetics.
Noted (AI summary) The Trust reviewed the evidence for the caution in the British National Formulary regarding cyclizine use in heart failure patients and found the evidence limited. They will warn teams of the risks, but cyclizine may still be used when assessed as the best option.
Michael Henderson
All Responded
2019-0037A 6 Mar 2019 Cumbria
Cumbria County Council (Highways Depart…
Concerns summary (AI summary) A road with unusual features, despite appropriate signage, facilitates excessive speeding and has a history of multiple fatal collisions. Traffic calming measures are needed to reduce future risks.
Action Planned (AI summary) Cumbria County Council will undertake a traffic speed survey and further investigations to determine if traffic calming measures are required on New Road. Cumbria County Council plans to replace lighting columns and enhance the gateway on New Road as part of a major development project, aiming to positively impact driver behavior.
Jack May
All Responded
2019-0078 1 Mar 2019 South Wales Central
Cardiff University
Concerns summary (AI summary) Inadequate university mental health services, characterized by long waits and limited appointments, combined with patchy, poorly trained pastoral support from personal tutors, allowed students to "slip through the net."
Noted (AI summary) Cardiff University acknowledges the coroner's concerns and provides a detailed explanation of its student support services, personal tutoring policies, and local pastoral care. They state they are not complacent and are putting resources in place, and working with partners, to help meet increased demand.
Hoshi Naylor
All Responded
2019-0076 27 Feb 2019 West Yorkshire (East)
Leeds City Council
Concerns summary (AI summary) The absence of facilitated pedestrian crossing points and sparse crossing infrastructure in a busy area, combined with poor street lighting, creates a significant hazard for pedestrians.
Action Planned (AI summary) Leeds City Council will widen the carriageway to construct a pedestrian refuge and provide lighting within the grassed area to illuminate the route, subject to funding approval.
Shane Gray
All Responded
2019-0075 27 Feb 2019 West Sussex
Park Holiday UK Limited
Concerns summary (AI summary) Inadequate, text-only signage and a lack of physical barriers create a significant drowning risk in an area of the lake frequented by families. Contractors were also not sufficiently informed of the rules.
Disputed (AI summary) Park Holidays UK outlines existing signage and a risk assessment, argues that the responsibility for swimming in the lake rests with the individual, and states that measures taken are reasonable and appropriate, and were reviewed by the Senior Environmental Health Officer from Chichester District Council. They do not agree that anything more can practically be done.
Janie McFadyen
All Responded
2019-0474 27 Feb 2019 Manchester (City)
Head of Safeguarding
Concerns summary (AI summary) No specific concerns were detailed in the provided text.
Action Planned (AI summary) Victory Outreach Manchester has reviewed its policies and procedures, and implemented changes to comply with current regulations, including improvements to communication and reporting channels. They have also experienced a similar incident and demonstrated how the new procedures worked. The Charity Commission has provided regulatory advice to Victory Outreach Manchester and requires that implemented changes are embedded. A program of diversified training is to be agreed and delivered, charges are to be reviewed annually, and the charity is to clarify when it will accompany residents to their GP.
Lyn Morgan
All Responded
2019-0080 26 Feb 2019 Swansea Neath & Port Talbot
Welsh Government
Concerns summary (AI summary) A road barrier failed to redirect a lorry as designed, causing it to re-enter the carriageway. Given the heavy vehicle use, there's a risk of similar incidents occurring again.
Noted (AI summary) The Welsh Government acknowledges the concerns raised about safety barriers. While noting the barriers met standards at the time of the incident, they commit to applying national standards, working with National Highways, adopting policy changes, and monitoring incidents.
Danyon Chesters
All Responded
2019-0079 26 Feb 2019 Manchester (South)
Department of Health and Social Care
Concerns summary (AI summary) Significant delays in accessing NHS mental health services led to fragmented private care, lack of information sharing between professionals, and private therapists not reviewing medication, impacting the deceased's treatment.
Noted (AI summary) The Department acknowledges the concerns raised and explains the NHS's role in commissioning services and targets for psychological therapies. They reference guidance for therapists on managing client confidentiality and risk, emphasizing the importance of acting within their expertise and seeking advice when necessary. They highlight government initiatives for suicide prevention.
Kathleen McGeary
All Responded
2019-0081 26 Feb 2019 Nottinghamshire
Doncaster and Bassetlaw Teaching Hospit…
Concerns summary (AI summary) The coroner notes a lack of comprehensive assessment, investigation, diagnosis, and treatment for the vulnerable patient before discharge, unclear responsibility for discharge decisions, an inadequate electronic discharge summary, and the patient leaving without prescribed antibiotics, as well as a culture of acceptance of these failings.
Action Taken (AI summary) The Trust has implemented a discharge checklist and is working to finalise a standard operating procedure after an audit showed only 86% of discharges had a summary. They also issued an apology for a failing in administering antibiotics prior to discharge. They plan to implement an electronic discharge summary within 3 months.
Nathan Mooney
All Responded
2019-0072 26 Feb 2019 Manchester (South)
Department of Health and Social Care
Concerns summary (AI summary) The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were not provided in the text.
Action Planned (AI summary) Health Education England acknowledges the challenges of recruiting and retaining doctors. They mention a commitment to increasing medical school places and the development of a workforce implementation plan to address staffing and culture in the NHS.
John Thorp
All Responded
2019-0067 26 Feb 2019 London (West)
London North West University NHS Trust
Concerns summary (AI summary) Inconsistent prescription practices for TED stockings, coupled with inadequate documentation for nursing administration, increased the risk of thromboembolic formation due to stockings potentially not being given as prescribed.
Action Taken (AI summary) The Trust has introduced a new, standardised prescription chart with a section for TED stockings, including a venous thromboembolism risk assessment. Nurses must sign and date the chart daily to confirm they have checked the fitting and skin integrity. Memos were sent to staff and the information circulated Trust-wide via newsletters and screen savers.
Keith Heatley
All Responded
2019-0478 26 Feb 2019 South Wales Central
ABMU Health Board
Concerns summary (AI summary) There was a lack of documented multidisciplinary decision-making and policy guidance regarding leave for informal patients, coupled with inconsistent recording of MDT meetings and no clinical review before high-risk patient leave.
Action Taken (AI summary) The health board implemented a checklist to ensure multidisciplinary team members, including the Community Mental Health Team and family, can express their views on patient leave. They also appointed a ward clerk, developed a carers' forum, implemented a risk assessment model (WARNN), created a Patient Experience Group (PEG), involved carers in 15-step reviews, and arranged a learning event.
Steven Key
All Responded
2019-0102 25 Feb 2019 Cumbria
Network Rail
Concerns summary (AI summary) Inadequate low fencing at the railway line allowed easy access, posing a significant risk of death or injury from high-speed trains to both adults and children, despite a clear duty to prevent access.
Action Taken (AI summary) Network Rail has installed additional meshing and netting at the location. They will investigate whether affixing a mesh to the galvanised iron tubular hand rail safety rail at the top of the bridge could make this area more secure.
Brenda Gowan
All Responded
2019-0064 25 Feb 2019 London (East)
Royal London Hospital
Concerns summary (AI summary) Inadequate discharge planning for a stroke patient included insufficient social care, disregarded family concerns, unassessed falls risk, lack of community support, and unprovided essential safety equipment.
Action Planned (AI summary) The Trust will document care planning meetings, offer experiential training for carers including an overnight stay, and include carer guidelines in the discharge information. These changes will be reviewed within the monthly stroke governance meeting.
John Pearce
All Responded
2019-0068 25 Feb 2019 London Inner (North)
Central and North West London NHS Trust
Concerns summary (AI summary) The District Nursing Team failed to urgently refer a patient with a severely worsening knee wound, visible over two months of regular visits, leading to significant delays in hospital admission.
Action Taken (AI summary) The Trust acknowledged failures in care and has re-trained staff in wound management, including the use of the NEWS2 tool for deteriorating patients. They will also conduct a 3-month action plan to ensure improvements are embedded, including improved communication and escalation procedures with specialist services and GPs.