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
Lucy Lee
Historic (No Identified Response)
2019-0509 15 Jul 2019 Surrey
British Medical Association Department of Health and Social Care Surrey Police +2 more
Concerns summary (AI summary) A lack of mandatory national training for Firearms Enquiry Officers and systemic flaws in assessing medical fitness of shotgun certificate applicants, including undeclared conditions and inadequate FEO skills, create risks.
Christine Lee
Historic (No Identified Response)
2019-0509-wp27242 15 Jul 2019 Surrey
British Medical Association Department of Health and Social Care Surrey Police +2 more
Concerns summary (AI summary) The absence of mandatory national training for Firearms Enquiry Officers risks incorrect certification decisions. Additionally, the medical assessment system for shotgun certificates is flawed, with officers lacking skills to evaluate complex health conditions.
Rosa King
Partially Responded
2019-0239 12 Jul 2019 Cambridgeshire and Peterborough
Cambridgeshire Constabulary Department for Environment, Food and Ru… Hamerton Zoological Park +3 more
Concerns summary (AI summary) Hamerton Zoo lacks onsite conventional firearms and sufficient trained staff to manage an escaped tiger, compounded by unclear national guidance on firearm requirements for zoos, increasing risk to human life.
Action Planned (AI summary) Defra is revising the Secretary of State’s Standards of Modern Zoo Practice (SSSMZP) with expected consultation over the summer and publication by the end of 2020, to address concerns and place clear, legally enforceable obligations on zoos. Defra has undertaken a targeted consultation on draft new Standards of Modern Zoo Practice for Great Britain, addressing the need for clearer guidance and robust inspection processes. The new standards will come into effect on 23 May 2027 and will require zoos to have documented safe systems of work and regular staff training for those working with Category 1A, Category 1 or Category 2 listed animals.
John Shackley
All Responded
2019-0238 12 Jul 2019 Berkshire
Highways Authority
Concerns summary (AI summary) The lack of a footpath, street lighting, and poor visibility on the A329 near a hotel forces pedestrians to cross a dangerous, unlit road.
Action Planned (AI summary) • The Royal Borough of Windsor and Maidenhead met with the Police on 7th August 2018 to review the circumstances around the crash. • The Highway Authority will monitor and review pedestrian activity in the area. • There is existing street lighting on the road corresponding.
Jason Imi
All Responded
2019-0238-wp26735 12 Jul 2019 Berkshire
Highways Authority
Concerns summary (AI summary) The absence of a footpath and street lighting near a hotel entrance on a main road forces pedestrians to cross in darkness with poor visibility, creating a significant risk of collision.
Action Taken (AI summary) • The Highways Authority met with the Police on 7th August 2018 to review the circumstances around the crash. • The Highways Authority will monitor and review pedestrian activity in the area. • There is existing street lighting on the road.
David Jukes
All Responded
2019-0329 12 Jul 2019 Birmingham and Solihull
Birmingham and Solihull Clinical Commis… Birmingham and Solihull Mental Health N… Black Country Partnership NHS Foundatio… +2 more
Concerns summary (AI summary) Critical information was withheld from mental health assessors in custody, and communication breakdowns meant existing mental health teams failed to assess the patient, despite being notified, creating significant risk.
Disputed (AI summary) NHS England and NHS Improvement will hold a national event by the end of March 2020 to discuss information sharing issues with liaison and diversion practitioners, NHS Commissioners, and police representatives. They are also working with West Midland Police regarding their new IT system. Staffordshire Police argues that adequate information *was* available on the custody record and that the Liaison and Diversion practitioner could have requested further information from custody staff, therefore no action is required. Birmingham and Solihull Mental Health NHS Trust has increased resources to all Home Treatment Teams, launched two Quality Improvement Projects and is recruiting additional staff to improve services. Black Country Partnership NHS Trust has taken several actions, including reviewing the L&D process, providing additional training to staff, and improving access to mental health databases, including rolling out staff access to the Spine. NHS Birmingham and Solihull CCG highlights increased investment into mental health services including crisis cafes and crisis houses to improve accessibility and experience of those in crisis and reduce the impact of crisis on other agencies across the region.
Robert Rostron
All Responded
2019-0237 11 Jul 2019 Manchester (West)
HC-One
Concerns summary (AI summary) Critical over-reliance on inadequately inducted agency nurses as senior staff led to unfamiliarity with essential policies, records, and patient care plans, resulting in medication errors.
Action Taken (AI summary) HC-One has implemented actions including requiring two colleagues to support all insulin administrations, creating a Home Improvement Plan for insulin administration safety, and revising the agency procedure to include robust checks. They also use an agency procedure since 2016 which is being revised and have implemented agency profiles to be held within the quality assurance system.
Lindsey Bailey
All Responded
2019-0235 11 Jul 2019 Staffordshire (South)
Midlands Partnership NHS Trust
Concerns summary (AI summary) Despite the patient's consent and capacity, there was a significant failure to share relevant information with her parents, potentially hindering her treatment and care.
Action Planned (AI summary) Midland Partnership NHS Trust is improving carer engagement by developing a Carer Engagement Standard Operating Procedure for Crisis Response Home Treatment Services, introducing a bespoke training programme for staff and is developing a letter for service users which outlines the importance of family involvement.
Carl Sargeant
All Responded
2019-0236 11 Jul 2019 North Wales (East and Central)
Welsh Government
Concerns summary (AI summary) The report highlights a need to provide appropriate support channels for high-profile individuals removed from government roles, regardless of mental vulnerabilities or the reason for their removal.
Action Planned (AI summary) The First Minister of Wales has consulted with current and former ministers and the family of the deceased to make changes to the process for ministers leaving the Cabinet. A new section will be added to the Welsh Government Ministerial Code to ensure the well-being of ministers is taken into account during reshuffles and that they are aware of available support services.
Allan Davies
All Responded
2019-0291 9 Jul 2019 Birmingham and Solihull
NHS Digital NHS England
Concerns summary (AI summary) The NHS Pathways triage system for overdose patients is too generic, failing to assess specific drug risks for sudden collapse, potentially categorizing high-risk cases incorrectly and endangering lives.
Action Taken (AI summary) NHS England highlighted the issue of triaging overdose cases to ambulance services and asked them to ensure robust clinical oversight is in place for self-harm and suicidal patients. A new diagnostic code (Dx0124) is being introduced in 'NHS Pathways Release 18' to raise visibility to clinicians, with widespread deployment planned for October 2019 after beta testing. NHS Digital (NHS Pathways) is deploying Release 18 which includes a new disposition code (Dx0124) to highlight potential overdose/suicide cases. They also reference a letter from NHS England to Ambulance Services about oversight of self-harm patients.
Leroy Medford
Partially Responded
2019-0233 9 Jul 2019 Berkside
College of Policing National Police Chiefs’ Council Thames Valley Police
Concerns summary (AI summary) The coroner expresses concern that officers were unaware of a requirement in the Drugs SOP for an officer to be within the cell with a detained person, and recommends a national review of how training is delivered and monitored within the police service.
Action Planned (AI summary) Thames Valley Police have initiated a quarterly Drug Concealment Working Group and are refreshing guidance for superintendents on managing drugs concealment cases (target Nov 2019). They are developing healthcare pathways and simpler guidance, accessible on officer's mobile phones. Special Points of Contact (SPOCs) have been introduced to improve communication of new guidance. The NPCC is closely involved in the College of Policing’s work on a national strategy for police learning, which may address concerns around training. The NPCC has shared the coroner's report with chief constables, encouraging them to review training delivery within their own forces.
Keith Battman
All Responded
2019-0231 5 Jul 2019 West Sussex
West Sussex County Council
Concerns summary (AI summary) Insufficient road safety features, including inadequate chevrons, faded road markings, and lack of vehicle-activated warning signs, contribute to a dangerous sharp bend.
Action Taken (AI summary) West Sussex County Council has replaced small chevrons with a larger yellow-bordered chevron at the collision site. They plan to install a vehicle-activated flashing bend warning sign, and will remark 'SLOW' markings and junction markings by the end of August.
Alexander Boamah
All Responded
2019-0232 5 Jul 2019 London Inner (North)
Department for Work and Pensions
Concerns summary (AI summary) A lack of process for clinicians to alert DWP about vulnerable individuals receiving large funds, particularly those without capacity, puts them at high risk of illicit substance misuse.
Action Planned (AI summary) The DWP is currently reviewing its safeguarding policy and guidance with the aim of strengthening existing procedures. The review will consider communication channels between the Department and treating clinicians and is scheduled to provide a revised policy and guidance in September 2019.
Miriam Tighe
Historic (No Identified Response)
2019-0234 4 Jul 2019 Manchester (West)
Edge Hill Residential Home Oldham Clinical Commissioning Group Pennine Care NHS Trust +1 more
Concerns summary (AI summary) Lack of communication and awareness between GPs and psychiatrists led to unsafe, duplicate prescribing and over-sedation of a care home resident with conflicting medications.
Jennifer Withey
All Responded
2019-0225 3 Jul 2019 Cornwall and the Isles of Scilly
NHS England NHS Pathways
Concerns summary (AI summary) The 111 call system lacks automated red flags for critical symptoms like sepsis, and fragmented response pathways between organizations create unnecessary delays in urgent patient care.
Action Taken (AI summary) NHS Digital updated NHS Pathways (Release 15, deployed May 2018) to better identify critically ill patients at risk of sepsis, including the qSOFA assessment, compliant with NICE guidance NG51. This includes questions about functional impairment, with positive answers leading to emergency ambulance dispatch. NHS England confirms they liaised with NHS Digital and NHS Pathways. NHS England updated standards by which Out-of-hours organisations are measured with IUC KPIs in October 2018, and have been collecting data to measure and monitor KPIs since January 2019.
John Doyle
Partially Responded
2019-0226 3 Jul 2019 London (East)
Goodmayes Hospital North East London NHS Trust
Concerns summary (AI summary) Inadequate and outdated training for occupational therapists on emergency Telecare equipment, including ordering processes and compatibility, poses a risk due to rapidly changing technology.
Action Planned (AI summary) North East London NHS Foundation Trust (NELFT) has provided an action plan to address issues identified in the Regulation 28 report, and established a working group around pendant alarms.
Ezra Boulton
Partially Responded
2019-0222 1 Jul 2019 Portsmouth and South East Hampshire
Midwifery and Maternity Portsmouth Hosp… Portsmouth Hospitals NHS Trust
Concerns summary (AI summary) Critical issues include a lack of continuity in antenatal care, insufficient safe-sleeping advice provided post-natally, and midwives' unawareness of criminal implications of infant overlay with alcohol/drugs.
Action Taken (AI summary) Portsmouth Hospitals NHS Trust has emailed all midwives and neonatal nursing, medical and support staff to alert them to the definition of the criminal offence of "overlay".
Andrew McCall
All Responded
2019-0228 1 Jul 2019 Stoke-on-Trent & North Staffordshire
NHS England
Concerns summary (AI summary) A critical lack of verification for patients' methadone prescriptions by GPs, who rely on self-declaration, led to potentially harmful prescribing of other medications for drug-seeking behavior.
Action Planned (AI summary) NHS England will contact Addiction Dependency Solutions to review processes for collecting/verifying GP data and information sharing. They will also write to all Staffordshire GP practices to highlight risks and ask them to alert the clinic if they receive information relating to a patient not registered at the practice.
Peter Lawrence
All Responded
2019-0245 1 Jul 2019 Black Country
Walsall Mental Health Partnership Walsall Metropolitan Borough Council
Concerns summary (AI summary) Inadequate joint multi-disciplinary care planning and excessive reliance on a tribunal decision led to delayed responses to relapse indicators and insufficient follow-up for a patient with a history of disengagement.
Action Planned (AI summary) The Trust, in conjunction with Walsall Council, has formulated a joint action plan to ensure that policies and procedures relating to multidisciplinary/agency care plans and risk assessments meet the needs of community patients with complex needs.
Feni Lee
Partially Responded
2019-0224 28 Jun 2019 London Inner (South)
Erith Health Centre, 50 Pier Rd, Erith,… Bexley Medical Group
Concerns summary (AI summary) An inadequate medication review failed to address unlicensed drug use and a vulnerable patient's needs, compounded by severe delays in internal post redirection between GP practices for critical hospital correspondence.
Action Taken (AI summary) The practice has started implementing a plan to carry out medication reviews in all patients who have not had a review for over 12 months. The practice has discussed the report with Riverside Medical Practice and they have agreed to send letters via email and in person.
Thomas Reid
Historic (No Identified Response)
2019-0229 28 Jun 2019 Derby and Derbyshire
Derbyshire County Council
Concerns summary (AI summary) Insufficient and easily obscured advanced warning signage for a dangerous junction with a history of serious incidents poses an ongoing risk, despite awareness of the need for improvements.
Heather Birchall
Historic (No Identified Response)
2019-0223 28 Jun 2019 Wiltshire and Swindon
Department of Health and Social Care
Concerns summary (AI summary) Healthcare professionals assessing detained persons lack full access to mental health records, especially out-of-hours, due to confidentiality issues, hindering informed decisions for appropriate care.
Macy Fletcher
Historic (No Identified Response)
2019-0227 27 Jun 2019 Manchester (North)
Ministry of Housing, Communities and Lo…
Concerns summary (AI summary) A critical lack of national oversight and guidance for private landlords on updated blind cord safety regulations means many are unaware of risks from older blinds, leading to child strangulation deaths.
Edir DA Costa
All Responded
2019-0211 27 Jun 2019 London (East)
Metropolitan Police
Concerns summary (AI summary) Many police officers are not up-to-date with mandatory Emergency Life Support training, and monitoring compliance is difficult, leading to critical delays in commencing CPR.
Action Taken (AI summary) The Metropolitan Police have reduced the number of officers who need mandatory Emergency Life Support training. They have also circulated a reminder to all staff via a weekly MetCC Operational Update bulletin regarding policy compliance and will emphasise this policy in MetCC initial call handler training and Personal Development Days in October 2019.
Frank Stockton
Historic (No Identified Response)
2019-0466 27 Jun 2019 Blackpool & Fylde
Blackpool Teaching Hospital Glenroyd Medical Practice
Concerns summary (AI summary) Clinicians may lack awareness of the fatal risks of epistaxis, particularly in vulnerable patients on oxygen or Warfarin, and failed to recognize its significance in clinical records.