2019
PFD Reports
Reports: 527
Areas: 66
70% response rate (above 63% average).
Sebastian Hibberd
Partially Responded
2019-0193
11 Jun 2019
Plymouth, Torbay and South Devon
NHS Digital
NHS England
Concerns summary (AI summary)
NHS Pathways for 111 call handlers failed to adequately recognize acutely unwell children due to missing questions (e.g., cold hands/feet) and inappropriately high thresholds for symptoms like green vomit.
Noted
(AI summary)
NHS Digital explains the rationale behind the NHS Pathways questions related to colds, hands and feet, green vomit, and pain assessment in children, defending the current design based on available data and clinical expertise.
Glenys Button
Partially Responded
2019-0192
10 Jun 2019
South Wales Central
Cardiff and Vale University Health Board
Cwm Taf Morgannwg University Health Boa…
Hwyel Dda University Health Board
+3 more
Concerns summary (AI summary)
Inefficient and outdated neurosurgical referral systems, relying on switchboards and bleeps, cause delays and miscommunications, with no backup for busy on-call doctors. Modern digital solutions are available but not utilized.
Action Planned
(AI summary)
An e-referral system is being piloted, with an evaluation to follow three months after the pilot starts; however, networking issues have delayed the pilot's extension. In the interim, additional measures and email communication have been implemented to avoid delays in urgent referrals.
Beverley Shaw
All Responded
2019-0191
10 Jun 2019
Manchester (North)
Hopwood House Medical Practice
NHS Oldham Clinical Commissioning Group
Turning Point
Concerns summary (AI summary)
Critical communication failures between Turning Point and the GP regarding butane gas misuse and medication reviews occurred. Incomplete medical record transfers between substance misuse services also posed risks.
Action Planned
(AI summary)
Oldham CCG is co-ordinating a learning event with Hopwood House Medical Centre and the Oldham Turning Point team to facilitate reflection and agree on actions to improve working relationships. Turning Point conducted a review of GP communication across its substance misuse services and has implemented improvements including changes to prescriber templates, communication frequency, record keeping, and audit processes. These changes have been made across all community substance misuse services. Hopwood House Medical Practice has implemented a DNA policy to discuss patients who do not attend appointments and is considering referring such patients to a Focus Care worker. The practice will also highlight methadone use on patient medication lists.
Richard Hallett
All Responded
2019-0189
6 Jun 2019
Dorset
Duchy of Cornwall
Concerns summary (AI summary)
A lack of road markings at junctions and permitted parking obstructing sightlines created dangerous driving conditions, leading to confusion about right of way and reduced visibility.
Action Planned
(AI summary)
The Duchy of Cornwall will install two additional parking bollards on each approach to the junction on Lower Blakemere Road, to deter parking in the immediate vicinity. They have submitted the proposals to Dorset Council Highways Department for approval with a longstop of 31 October 2019.
David Bird
Historic (No Identified Response)
2019-0188
3 Jun 2019
Bedfordshire & Luton
Bedfordshire Police
Concerns summary (AI summary)
Custody officers received inadequate training in interpreting detainee behavior, leading to misjudgments of vulnerability. There were also failures to ensure vulnerable detainees saw a Health Care Practitioner before release, despite identified risks.
Matthew Jones
All Responded
2019-0187
3 Jun 2019
Bedfordshire & Luton
Department of Health and Social Care
Concerns summary (AI summary)
A lack of appropriate training for mental health clinicians resulted in poor understanding of non-compliance risks with treatment orders and inadequate multi-agency coordination. Housing was also overlooked in discharge planning.
Noted
(AI summary)
The Department of Health and Social Care acknowledges the concerns around coordinated, multi-agency working for patients on Community Treatment Orders, and refers to existing NICE and Mental Health Act guidance. No specific actions are described beyond signposting existing resources.
Jeanette Robinson
All Responded
2019-0185
3 Jun 2019
Cornwall and the Isles of Scilly
Cornwall Council
Medicines and Healthcare products Regul…
Concerns summary (AI summary)
The coroner raises concerns about the lack of an alarm on a Nimbus 3 air mattress, which deflated when its power cable was dislodged, contributing to the patient's death.
Noted
(AI summary)
Cornwall Council has replaced all Nimbus mattress systems in the community with Elite systems. All Nimbus stock has been destroyed. The council states that the previous service records indicate that there is no evidence to suggest that alarm failure was an issue on the Nimbus system. The MHRA explains CE marking and post-market surveillance processes for medical devices like mattresses, noting that the incident was not reported to them. They state that without a serial number to identify the mattress, a report may be inconclusive and there is no further action that MHRA can take.
Kathleen Smith
All Responded
2019-0184
3 Jun 2019
North Wales (East and Central)
Coed Duon Care Home
Concerns summary (AI summary)
Care home staff lacked sufficient training in first aid for choking, assisting residents, and preparing appropriate foods for those with swallowing difficulties, compounded by inadequate management oversight.
Action Taken
(AI summary)
Coed Duon Care Home has implemented several changes, including SALT training for staff, designation of two Dysphagia champions, creation of a diets and fluids consistency file for each resident in the kitchen, and clearer documentation of meals served.
Christopher Williams
All Responded
2019-0183
31 May 2019
Norfolk
East of England Ambulance Service
Concerns summary (AI summary)
The report highlights an ambulance arriving outside of Trust guidelines, a call handler's failure to escalate the patient's worsening condition and incorrect algorithm use, and a communication breakdown about an arranged hospital bed, potentially delaying treatment.
Action Taken
(AI summary)
East of England Ambulance Service NHS Trust has recruited 491 frontline staff and has a further 270 frontline offers of employment in process. They are also in communication with the CAD supplier to allow pertinent information to be transferred from the original call into the new call. As an interim arrangement dispatch staff will ensure pertinent information is transferred into the new call.
Joshua Blackham
All Responded
2019-0182
31 May 2019
Berkshire
Surrey Police
Concerns summary (AI summary)
Surrey Police lacked written policies for Welfare Officers, particularly regarding specialized training, effective communication with professional standards, and appropriate arrest locations for serving officers.
Action Taken
(AI summary)
Surrey Police will provide training and refreshed guidance for Welfare Officers and those who supervise them. Revised guidance has been created to include contacting the family of an officer suspended from duty, a secondary (back up) WO, and consideration about the location of the arrest of a serving officer.
Peter Moran
All Responded
2019-0181
30 May 2019
Stoke-on-Trent & North Staffordshire
AR1 Homecare Limited
Concerns summary (AI summary)
Carers failed to properly turn off a cooker before removing knobs for a fire-risk patient, and the knob removal method itself was inadequate to ensure appliance safety.
Action Taken
(AI summary)
The organisation provides staff training on fire awareness, uses risk assessment tools for client homes and staff induction, and has engaged a company for risk assessments and online fire training. They added a clause to their risk assessment that under no circumstances do they remove any knobs from appliances, and recommend the request of a Fire Officer to visit.
Geoffrey Duke
All Responded
2019-0256
30 May 2019
Stoke-on-Trent & North Staffordshire
Darwin medical Practice
University Hospitals Birmingham NHS Tru…
University Hospitals of Derby and Burton
Concerns summary (AI summary)
Repeatedly, clinicians failed to consider a pacemaker box change as the source of undiagnosed infections, and no clear referral process existed for patients experiencing post-pacemaker surgery complications, delaying diagnosis.
Noted
(AI summary)
The trust has developed a Cardiac Implantable Electronic Device Lead Infection Microbiology Hospital Guideline to aid in detection and treatment of Subacute Bacterial Endocarditis (SBE) related to cardiac rhythm devices and will link it to existing guidance for Pyrexia of Unknown Origin (PUO). The learning board has been shared and will be further supported at the Trust-wide Quality Summit and in a monthly 'Patient Safety Brief' newsletter. The Trust is undertaking a programme of education for acute physicians via grand rounds and a 'Lesson of the Month' email to raise awareness of pacemaker related endocarditis. They will also update patient information leaflets to include additional instructions regarding fever and device related endocarditis, aiming to complete this by November 2019. The practice discussed the case and reviewed the patient's medical record, concluding that the diagnosis was difficult to make in primary care due to the unusual nature of the infection and non-specific symptoms. They now recognise this as a possible cause of malaise in similar future scenarios.
Barbara Henderson
All Responded
2019-0180
30 May 2019
Milton Keynes
Highways England
Concerns summary (AI summary)
Road inspections conducted at speed failed to identify a critical drain problem, indicating an inadequate inspection process that needs urgent review.
Action Planned
(AI summary)
Highways England will issue a memorandum to all Areas highlighting the importance of inspection and defect rectification for recessed gullies. Area 8 will move to the new Asset Delivery approach on 1st October 2019.
Emily Inglis
Historic (No Identified Response)
2019-0177
30 May 2019
Camarthenshire and Pembrokeshire
Glangwili General Hospital
Hywel Dda University Health Board
Concerns summary (AI summary)
There was no overarching risk management plan for patient care, coupled with deficiencies in record-keeping, including outdated strategies and poor preservation of handover information.
Maia Strachan
Partially Responded
2019-0174
28 May 2019
Newcastle Upon Tyne
North Tyneside Hospital
Northumbria Health Trust
Concerns summary (AI summary)
The inability to store sequential scan data and provide sonographer alerts hindered comparison and further investigation, potentially delaying necessary changes to patient care plans.
Action Taken
(AI summary)
The Trust has reviewed current training around documentation standards and it is provided as part of the PROMPT annual training. An ongoing monthly audit of notes will occur, and a quarterly report will be generated. Additional training will be provided to midwives around bereavement and the medical examiner role is being reviewed.
Gloria Mekins
Partially Responded
2019-0171
28 May 2019
Teesside and Hartlepool
Care Quality Commission
Rossmere Park Care Home
Concerns summary (AI summary)
A Health Care Assistant failed to perform first aid during a choking incident, and confusion over a DNA CPR order caused delays. The care home also failed to investigate or identify these critical issues internally.
Action Taken
(AI summary)
The care centre disputes the coroner's assertion that staff believed the deceased was choking. Following a Lessons Learned Meeting, they implemented a protocol for staff to follow after a death and created a Health Concerns or Advice Sheet. They also revised their Choking Risk Assessment in consultation with the SALT team to make it more user-friendly.
Ahmed Motala
All Responded
2019-0168
25 May 2019
Gloucestershire
Gloucestershire County Council Highways…
Concerns summary (AI summary)
The poor condition of the cycle lane forces cyclists into traffic, creating a dangerous situation and risking future lives if not repaired.
Action Planned
(AI summary)
The council's Safety Inspection Team assessed the site and found no actionable safety defects, but noted the red surfacing is stripping away. Cole Avenue is in the resurfacing program for the financial year 20/21 and until then will continue to be inspected monthly with defects attended to.
Noah Lomax
All Responded
2019-0186
24 May 2019
South Yorkshire (West)
Sheffield Children’s NHS Trust
Concerns summary (AI summary)
The CAMHS/GP referral form is inadequate, resulting in insufficient information for risk assessment and delayed care; the Trust should reconsider redesigning the form.
Action Planned
(AI summary)
The CAMHS team has commenced a review of the referral form, and a draft form was sent to the Clinical Director for Mental Health commissioning at Sheffield Clinical Commissioning Group (SCCG) for comments. The reviewed and updated form and guidance will be distributed to all General Practitioners by 12 July 2019.
Barry Clow
All Responded
2019-0170
24 May 2019
Gloucestershire
Gloucestershire County Council
Concerns summary (AI summary)
Standing and running water on a stretch of the A424 poses a risk to motorists, particularly those unfamiliar with the road, and there are no warning signs in place.
Action Taken
(AI summary)
Despite not being aware of flooding as an issue at the location prior to the report, the council erected flood warning signs at the site.
Ray Westlake
All Responded
2019-0170-wp26664
24 May 2019
Gloucestershire
Gloucestershire County Council
Concerns summary (AI summary)
A stretch of road regularly experiences significant standing water and flooding, and the absence of warning signs for motorists creates a future risk of accidents.
1 response
from Gloucestershire Highways
Graham Smith
All Responded
2019-0167
23 May 2019
Leicester City and Leicestershire South
JRCALC
Concerns summary (AI summary)
The emergency call system lacks the capacity to link repeat calls for the same patient, preventing crucial safety-netting, senior review, and appropriate management of attendances.
Action Planned
(AI summary)
EMAS has issued bulletins to frontline staff and control centers clarifying procedures for safe discharge of lower acuity calls, mental capacity assessments for patients refusing transport, and CAT access to patient history and records. All staff have access to the EMAS Safeguarding Policy and procedures. AACE will request that JRCALC review UK ambulance service clinical practice guidelines relating to the management of patients that have misused alcohol, including alcohol withdrawal, its presentation and management, and will ensure that any recommendations are published.
Sasha Forster
Historic (No Identified Response)
2019-0169
23 May 2019
Hampshire (Central)
Department of Health and Social Care
Guildford and Waverley Clinical Commiss…
North East Hampshire and Farnham Clinic…
+1 more
Concerns summary (AI summary)
Staff lacked resources to collect a patient when leave was revoked, placing an unfair burden on the family and contributing to the patient taking a fatal overdose.
Tyereece Johnson
All Responded
2019-0166
23 May 2019
London Inner (West)
Metropolitan Police
Concerns summary (AI summary)
The approximate age of moped riders was not communicated to the police tactical team, omitting a relevant factor for risk assessment and decision-making.
Action Planned
(AI summary)
The MPS will review the roles and responsibilities of the police pursuits pod to ensure they are maximising information/intelligence opportunities. They will consider a mandatory checklist of indices at the start of a pursuit and ensure Pan London courses and refresher training include an input on information and intelligence gathering. This review will be completed by 31st October 2019.
Jonathan McCarthy
All Responded
2019-0179
22 May 2019
North West Kent
Maidstone & Tonbridge Wells NHS Trust
Concerns summary (AI summary)
The Trust failed to correctly monitor blood sugar and ketones, administered incorrect insulin, and provided inadequate nursing care with a failure to escalate concerns.
Action Taken
(AI summary)
The Trust has created a guideline for capillary blood glucose monitoring, implemented monthly training for staff, and introduced new blood glucose meters with enhanced data capture. The Trust has raised awareness through the Patient Safety Calendar, a launch of the Blood Monitoring Guideline and bespoke Training days for Nurses and Clinical Support Workers.
Richard Phillips
All Responded
2019-0165
20 May 2019
Dorset
Dorset Council Highways Department
Concerns summary (AI summary)
A known problem of water running and freezing on a road descent created hazardous icy conditions, contributing to a fatal collision and highlighting unresolved road safety issues.
Action Taken
(AI summary)
Dorset Council has resurfaced the section of the B3091 where the accident took place, adjusting the camber to improve ride quality and drainage. They will continue to inspect the section regularly and monitor the surface water situation over the winter period.