2019
PFD Reports
Reports: 527
Areas: 66
70% response rate (above 63% average).
Christopher Innes
Partially Responded
2019-0124
10 Apr 2019
Kent (Central and South East)
Kent County Council
Regent Coaches in Whitstable, Kent
Concerns summary (AI summary)
An unmarked bus stop on a 50mph road without pedestrian facilities created a hazard for alighting passengers, exacerbated by overgrown vegetation and unclear management responsibility.
Action Planned
(AI summary)
KCC plans to install pedestrian crossing road warning signs by September 2019 and additional signs for the Mansfield Farm site. Vegetation clearance will be added to a cyclic programme if landowner agreement is obtained. They will recommend the re-installation of the Hail and Ride bus service following the installation of pedestrian crossing signs and the removal of vegetation.
Aidan Ridley
All Responded
2019-0173
9 Apr 2019
Wiltshire and Swindon
Wiltshire Police
Concerns summary (AI summary)
Inadequate police call handler training led to incorrect advice not to move a patient and failure to involve ambulance services, compounded by underutilization of a new 3-way call system.
Action Taken
(AI summary)
Wiltshire Police states that staff briefings have been sent out reminding 999 call handlers to use the three-way call process when needed. They also state that further revisions of the relevant Force procedure on managing calls have now taken place.
Freda Mason
Partially Responded
2019-0126A
9 Apr 2019
Lancaster & Blackburn with Darwen
Lancashire County Council
The Chief Coroner
Concerns summary (AI summary)
The council's reactive bus shelter maintenance system, relying only on public complaints, lacks a proactive inspection regime, leading to delays in identifying and repairing safety issues.
Action Planned
(AI summary)
The organisation will instruct staff visiting bus shelters to inspect and report damage, write to bus operators requesting they report damage, introduce a more prominent 'Report It' notice for the public, and write to district councils and advertising agencies to suggest they consider their own arrangements for reporting damage.
Anthony Buckingham
All Responded
2019-0123
9 Apr 2019
Suffolk
Norfolk and Suffolk NHS Trust
Concerns summary (AI summary)
The death could have been prevented by daily mental health team visits, formal mental health act assessment, next of kin involvement, and practice nurse input.
Action Taken
(AI summary)
The Trust's suicide prevention lead has hosted two events bringing together non-statutory and statutory agencies, service users and Trust services in order to open channels of communication and raise awareness what each other provides. The Trust is strengthening its clinical and service leadership to ensure have the necessary breadth of skills and resource to lead safe and effective services.
George Twiddy
Partially Responded
2019-0150
8 Apr 2019
Portsmouth and South East Hampshire
Hampshire County Council
southern Health NHS Trust
Concerns summary (AI summary)
Poor inter-agency communication and unclear responsibilities between mental health services led to delays in providing immediate assistance during a patient's crisis.
Action Planned
(AI summary)
Hampshire County Council (HCC) & Southern Health Foundation Trust (SHFT) will implement a s140 Policy, opportunities to attend inter – agency training, strategic development plans to deliver integrated pathways, mental health act information digital information and leaflet, and collaborative working with AMHPs & AMHT.
Ronald Clark
Partially Responded
2019-0151
8 Apr 2019
Portsmouth and South East Hampshire
Medicines and Healthcare products Regul…
NHS Improvement
Concerns summary (AI summary)
Stents supplied in identical packaging with only small labels pose a risk of using incorrect sizes during medical procedures.
Action Planned
(AI summary)
The National Patient Safety Team is reviewing the National Safety Standards for Invasive Procedures (NatSIPPs) and the NatSIPP on prosthesis verification is being updated to reflect developments in implant selection and verification processes, including the potential for future scanning for all prothesis/implants.
Tina Tait
Historic (No Identified Response)
2019-0129
8 Apr 2019
Blackpool & Fylde
Blackpool Teaching Hospitals NHS Trust
Concerns summary (AI summary)
Persistent issues with poor and illegible clinical record-keeping within the hospital compromise incident reviews and patient care, impeding crucial learning from deaths.
Yong Hong
Historic (No Identified Response)
2019-0130
5 Apr 2019
London (South)
Bondcare, Clarendon Care Home
Care Quality Commission
Croydon County Council
+1 more
Concerns summary (AI summary)
The observation regime advised by the GP was not implemented, and no interpreter was sought to assist with assessment of his needs. Also, no risk assessment was carried out prior to making the decision to return his call bell.
Alice Dixon
Historic (No Identified Response)
2019-0132
5 Apr 2019
Surrey
Ashford and St Peter’s Hospitals NHS Tr…
Concerns summary (AI summary)
A vulnerable patient received inadequate assistance during the consent process for a scan, resulting in an unclear consent form and unaddressed communication/hearing difficulties.
Raymond Knight
Historic (No Identified Response)
2019-0120
5 Apr 2019
Essex
Essex Police
Concerns summary (AI summary)
Police station CCTV cameras do not cover individual holding cells, creating a critical gap in monitoring and photographic records of prisoners.
Jennifer Handy
All Responded
2019-0121
5 Apr 2019
South Wales Central
Cwm Taf Health Board
General Medical Council
Concerns summary (AI summary)
The inability to trace a doctor who left the UK after treating a patient compromised the investigation and prevented the clinician from learning from issues raised.
Noted
(AI summary)
The Health Board now contacts the Assistant Medical Director for Professional Regulation and Standards to check for ongoing GMC concerns when a doctor leaves. The GMC states that its statutory powers only extend to doctors registered with the GMC, the Medical Act makes provision to erase doctors who fail to maintain an effective registered address, international regulators have data sharing practices, and information about a doctor's fitness to practise history can be publicly accessed on the online register, LRMP, therefore no further action is required.
Lesley Armstrong
All Responded
2019-0136
4 Apr 2019
North Northumberland
Northumbria Police
Concerns summary (AI summary)
Northumbria Police failed to communicate the discontinuation of an investigation, hindering the employer's ability to inform the employee and the Safeguarding Board from progressing their duties.
Disputed
(AI summary)
Northumbria Police argues that it already has a system for reminding officers to inform suspects of the outcome of police investigations, that decisions to disclose information to employers can only be made on a case-by-case basis, and that providing information to employers as a 'fail safe' mechanism would be unlawful without the employee's consent, therefore no further action is deemed necessary.
Julia Peto
All Responded
2019-0119
4 Apr 2019
London Inner (South)
Department for Transport
Concerns summary (AI summary)
Many two-stage pedestrian crossings nationally may lack louvres to prevent 'see-through' confusion from green signals and proper road markings to warn pedestrians of traffic direction.
Noted
(AI summary)
The Department for Transport states it is updating the Traffic Signs Regulations and General Directions (TSRGD), including Chapter 5 on pedestrian crossings, with updated advice on the design of pedestrian facilities, therefore no further action is considered necessary.
Aryan Akhgar
All Responded
2019-0115
3 Apr 2019
South Yorkshire (West)
Sheffield Children’s Hospital
Sheffield Clinical Commissioning Group
Concerns summary (AI summary)
A critical gap exists in urgent mental health services for 16 and 17-year-olds in Sheffield, with necessary additional resources for CAMHS lacking guaranteed funding.
Action Planned
(AI summary)
Sheffield Children's and Sheffield Health and Social Care Trusts have jointly approved an addendum to the Transitions Policy, implemented a review process overseen by Associate/Directors for young people accessing care, and provided 'read only' access to electronic patient records for CAMHS activity to Sheffield Health and Social Care staff. The CCG approved a business case for a Home Intensive Treatment Team (HITT) on May 7th, 2019, with phased implementation planned from autumn 2019, and has begun recruiting nursing staff.
Ronald Lowe
All Responded
2019-0113
3 Apr 2019
Birmingham and Solihull
University Hospitals Birmingham NHS Tru…
Concerns summary (AI summary)
A hospital's system for ensuring radiographers had read and signed standard operating procedures was not robust, increasing the risk of dangerous practice due to incorrect understanding of duties.
Action Taken
(AI summary)
The Trust conducted a review of outpatient CTPA studies, created a central register for radiographer training across multiple sites, and reviews staff training during annual appraisals.
Terence Thornton
Partially Responded
2019-0114
3 Apr 2019
Plymouth Torbay and South Devon
Derriford Hospital
University Hospitals Plymouth NHS Trust
Concerns summary (AI summary)
Severe staffing shortages of radiology clinicians at Derriford Hospital are creating dangerous work pressures and increasing the risk of medical errors and fatalities.
Action Taken
(AI summary)
Following an incident, the Consultant Neuroradiologist submitted the case for review, it was discussed at a departmental discrepancy meeting and lessons were shared with the Radiology team.
Stuart Clark
All Responded
2019-0125A
2 Apr 2019
Exeter and Greater Devon
Royal Devon and Exeter NHS Trust
Concerns summary (AI summary)
A patient's disclosure of suicide risk was not properly assessed or escalated to senior staff, and relevant information was not immediately available in medical records.
Action Planned
(AI summary)
The Trust will reinforce individual responsibility for patient safety and suicide prevention and is running a 'Care Matters' professional leadership forum in June 2019 to reiterate the importance of escalating concerns.
Tarek Chowdhury
Historic (No Identified Response)
2019-0131
2 Apr 2019
London (West)
HM Prison & Probation Service
Home Office
NHS England
Concerns summary (AI summary)
There is a failure to share critical prisoner information between HMPPS and immigration detention facilities, alongside issues with the SystmOne records system's functionality and staff training.
Elsa Reid
Historic (No Identified Response)
2019-0139
2 Apr 2019
Black Country
New Cross Hospital NHS Trust
Wolverhampton City Council
Concerns summary (AI summary)
Inadequate communication between the hospital and occupational therapist delayed mobility intervention, leading to a minimal exercise regime and increased risk of patient complications.
Ozan Allen
All Responded
2019-0197
1 Apr 2019
London Inner (North)
Transport for London
Concerns summary (AI summary)
A busy crossroads junction lacks pedestrian guard railings, has impaired visibility, and features staggered crossings often misused by pedestrians, contributing to a high rate of collisions.
Action Planned
(AI summary)
TfL is considering adjustments to the junction design and plans to publish a consultation report by October 2019, with construction potentially starting in winter 2019/20. They are also proposing a reduced speed limit of 20mph and investigating measures on the A11 Mile End Road approaches, with completion planned by 2024.
Andrew Clegg
Partially Responded
2019-0108
1 Apr 2019
Wilshire and Swindon
Care Quality Commission
Royal Institute of British Architects
Concerns summary (AI summary)
Care homes are rarely designed with water safety in mind, and CQC inspectors lack sufficient training to identify legionella risks in water systems.
Noted
(AI summary)
The CQC confirms that water safety is considered by its inspectors and that they check for Legionella risk assessments. The Construction Industry Council is pressing for all aspects of life safety to be included in building safety regulatory reform.
Alexander Green
All Responded
2019-0117
1 Apr 2019
Avon
Royal United Hospital
Concerns summary (AI summary)
Ineffective trust-wide handovers and a failure to challenge assumptions led to critical delays in diagnosing a head injury due to bias towards intoxication.
Action Taken
(AI summary)
The Trust has drafted a standard operating procedure for handovers, added an SBAR tool to the Paediatric proforma, developed a tool to safely exclude brain injury in intoxicated patients, and created a training tool with the South West Ambulance Service on "Confirmation Bias".
Marcie Tadman
Partially Responded
2019-0118
1 Apr 2019
Avon
Banes Clinical Commissioning Group
Royal United Hospital, Bath
Concerns summary (AI summary)
No specific matters of concern were detailed in the provided text.
Action Planned
(AI summary)
The Trust shared a briefing paper with its commissioners detailing what would be required to deliver paediatric critical care, including an additional evening ward round, and is aiming to deliver twice daily consultant ward rounds and paediatric high dependency care by Winter 2019.
Colin Bailey
Historic (No Identified Response)
2019-0106
29 Mar 2019
Manchester (South)
N.I.C.E
Concerns summary (AI summary)
National guidelines on head injury assessment do not universally recommend CT scans for patients on non-warfarin anticoagulants, despite clinical consensus for their necessity.
Ann Corfield
Historic (No Identified Response)
2019-0107
29 Mar 2019
Manchester (City)
Greater Manchester Mental Health NHS Tr…
Pennine Acute Hospitals NHS Trust
Concerns summary (AI summary)
Inadequate patient handover between hospitals led to critical medication information loss. Poor fluid balance chart completion, delayed prophylactic anticoagulation, and mental health unit staff untrained in IV fluid administration were significant issues.