2019

PFD Reports
Reports: 527 Areas: 66

70% response rate (above 63% average).

Responses identified
Responses identified 367 Historic 160
AI Classification
Action Taken 43%
Action Planned 38%
Noted 16%
Disputed 3%
Based on 508 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
Tony Goodridge
0/1 responses identified
2019-0172 28 Mar 2019 London Inner (North)
London Borough of Camden
Concerns summary (AI summary) The property lacked a smoke alarm. Emergency services faced difficulty accessing the property due to parked vehicles, hindering response.
Wayne Rodgers
1/5 responses identified
2019-0105 28 Mar 2019 Isle of Wight
Cowes Week Limited Emergency Preparedness, Resilience and … Resilience and Response, Isle of Wight … +2 more
Concerns summary (AI summary) Ambulance services are overstretched, and major event safety planning is insufficient. Deficiencies include lack of on-site medical provision, inadequate crisis management, and unclear safety equipment requirements and racing abandonment criteria.
Action Planned (AI summary) Cowes Week Limited is discussing additional ambulance support, reviewing AED placement, reinforcing the necessity of having a sharp knife on board, and reviewing criteria for abandoning racing. The organisation will have independent radio operators to monitor safety communications and will address continuous spinnaker sheets in their safety booklet.
Justin Brown
0/1 responses identified
2019-0103 27 Mar 2019 Suffolk
Suffolk County Council
Concerns summary (AI summary) Hospital discharge processes failed to ensure confirmed addiction support. A lack of agreed protocols and collaboration with drug services meant referrals were not effectively monitored for vulnerable patients.
Donna Williamson
1/5 responses identified
2019-0111 27 Mar 2019 London Inner (South)
Department of Health and Social Care Home Office Local Government Association +2 more
Concerns summary (AI summary) The report identifies failures in repairing and securing a door, informing the victim of the suspect's release on bail, and the MARAC process's inability to protect chaotic, non-engaging individuals, alongside concerns about GPs' knowledge of disclosing confidential information.
Noted (AI summary) The Royal College of General Practitioners highlights existing guidance on information sharing and safeguarding, and the LGA has highlighted the importance of learning from Domestic Homicide Reviews at a national level. The LGA is seeking further information on the legal duty to repair doors of private rented accommodation.
Nora Bruton
1/1 responses identified
2019-0090 25 Mar 2019 Birmingham and Solihull
Birmingham & Solihull Mental Heath NHS …
Concerns summary (AI summary) Inadequate dissemination of substance abuse risk assessment training and a failed review of crisis call communication protocols led to safety gaps. The protracted review of the Home Treatment Team model also raises concerns.
Action Taken (AI summary) Birmingham and Solihull Mental Health NHS Trust has developed a dedicated crisis email address for Home Treatment Teams with dedicated support to manage the system. They have also increased the capacity of the out of hours service by putting a senior clinician (Band 7) on duty each evening and have increased the capacity of their Home Treatment Teams and are now ‘over-recruited’ to medical positions.
Christopher Gibbs
1/2 responses identified
2019-0100 25 Mar 2019 Dorset
Bournemouth Borough Council Dorset County Council
Concerns summary (AI summary) The A338, a 10-mile arterial route with consistent speed limits and no exits, presents inherent risks due to its design of straight sections and open sweeping bends.
Disputed (AI summary) Dorset County Council does not support installing cycling warning signs on the A338, stating it's not the prescribed use and could generate a false sense of security. They promote safer parallel routes and BCP Council is working on cycle facilities along sections of Wallisdown Rd.
Mark Kubiak
0/1 responses identified
2019-0098 22 Mar 2019 Milton Keynes
Thames Valley and Wessex Operational De…
Concerns summary (AI summary) The patient transfer checklist failed to require essential oxygen supply checks and tug tests. This systemic flaw meant oxygen flow failure went unnoticed during transfer, risking patient safety.
Brian Havard
0/1 responses identified
2019-0101 22 Mar 2019 Norfolk
Norfolk and Norwich University Hospital
Concerns summary (AI summary) Critical ambulance records were not accessed or read by doctors, and senior medical staff lacked professional curiosity. Poor record-keeping and an inadequate system for junior doctor case review by seniors were identified.
Bram Radcliffe
0/2 responses identified
2019-0110 22 Mar 2019 West Yorjshire (West)
Ministry of Housing, Communities and Lo… Stone Federation of GB
Concerns summary (AI summary) Dangerous, substandard fireplace surround installations are unregulated as they are not deemed "building work." There is no British Standard for fixing these components, only for their manufacture, creating a safety gap.
Bethany Tenquist
1/1 responses identified
2019-0178 21 Mar 2019 Brighton and Hove
Sussex Partnership NHS Trust
Concerns summary (AI summary) Flawed room checks and inadequate staff training led to dangerous items remaining accessible to vulnerable patients. This highlights critical deficiencies in self-harm prevention protocols.
Action Planned (AI summary) Sussex NHS Trust will improve communication pathways with the Police and improve guidance to staff regarding contacting the Police following serious incidents.
John Wright
2/2 responses identified
2019-0175 21 Mar 2019 Oxfordshire
Healthcare Care UK HM Prison and Probation Service
Concerns summary (AI summary) Critical self-harm risk information for incoming prisoners is poorly shared between external agencies, prison, and healthcare. Systemic gaps in IT and manual communication methods mean vital data is not consistently accessible to staff.
Action Taken (AI summary) HMPPS details actions taken including; NHS England Commissioners, Mountain Healthcare, and the liaison and diversion service have been informed of the process for contacting the prison healthcare team. The courts that serve HMP Bullingdon and the escort contractors (GEO Amey) have been reminded that safety concerns should be recorded on the Person Escort Record. Care UK provides details of actions taken including; Healthcare staff attending prison morning meetings, maintaining a register of staff who have completed SASH training and providing ASIST training to all patient-facing staff.
Pamela Sunter
0/1 responses identified
2019-0096 20 Mar 2019 South Yorkshire (West)
Cancer Alliance
Concerns summary (AI summary) Outdated "two week wait" forms remain on the system, causing confusion due to insufficient priority given to their removal. This hinders efficient clinical administration.
Christopher Bevan
0/3 responses identified
2019-0104 20 Mar 2019 Blackpool & Fylde
CORONER Holloway Assistant Coroner for Blackpoo… Iam Tim
Concerns summary (AI summary) Ladders were used unsafely on a slippery surface, unfooted, and improperly secured. This highlights a risk of unsafe work practices leading to falls and injury.
Mohammed Ahmed
1/2 responses identified
2019-0093 19 Mar 2019 Suffolk
Department of Health and Social Care NHS England
Concerns summary (AI summary) Combined use of Olanzapine and Spice caused a fatal allergic reaction, yet Olanzapine continued to be prescribed. Clinicians may lack national awareness of serious drug interactions and side effects with Olanzapine.
Noted (AI summary) The Department of Health acknowledges the concerns but states that the MHRA considers current warnings for olanzapine to be adequate and will keep the issue under scrutiny. NHS England will encourage medical directors to remind prescribers of the risks highlighted within the SPC when prescribing antipsychotic medication to people who are known users of synthetic cannabinoids.
Graham Tailby
1/1 responses identified
2019-0092 19 Mar 2019 Manchester (City)
Pennine Acute Hospitals NHS Trust
Concerns summary (AI summary) No specific concerns were detailed in the provided text.
Disputed (AI summary) Northern Care Alliance NHS Group states that the trolleys are not serviced by themselves and the staff member who gave evidence was not working for the Trust. They also state that they were not made an Interested Person or provided with disclosure.
Mark Parry
1/1 responses identified
2019-0094 19 Mar 2019 Cheshire
Health and Safety Executive
Concerns summary (AI summary) A critical lack of published Health and Safety Executive guidelines for mechanics working with Heavy Goods Vehicle air suspensions exists. This absence means workers lack essential guidance on risks and safety strategies.
Action Planned (AI summary) HSE plans to issue a safety alert identifying control measures for air suspension systems on all vehicle types, aiming to finalise it by August 2019. Longer term, HSE will amend PM85 and review HSG261 to address control measures in relation to ejection.
Peter Knight
1/1 responses identified
2019-0219 18 Mar 2019 Norfolk
Queen Elizabeth Hospital
Concerns summary (AI summary) The Trust significantly delayed completing and implementing a crucial policy for transferring oxygen-dependent patients. New documentation was produced, but trials had not even commenced by the agreed deadline.
Action Taken (AI summary) The Trust revised its Transfer of Patients Policy, ratified on May 7th, and delivered "Transferring the Critically Ill Patient" training including a decision to not transfer patients on Hi Flo airvo2 without battery backup. They also redesigned transfer stickers using an SBAR format.
Frederick Brooker
1/1 responses identified
2019-0097 18 Mar 2019 London (East)
HC-One
Concerns summary (AI summary) The care home failed to implement adequate falls prevention, lacking care plans despite identified risks. Multiple falls were not properly investigated or reported, and patient safety was compromised by over-reliance on capacity.
Action Taken (AI summary) HC-One implemented an action plan at Bakers Court to address the concerns highlighted. Multi-factorial Falls Risk Assessments will inform the development and implementation of a daily plan of care.
Ellie Long
1/1 responses identified
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
1/1 responses identified
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
1/1 responses identified
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
1/1 responses identified
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
1/1 responses identified
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.
Margaret Wilson
0/2 responses identified
2019-0163 11 Mar 2019 Manchester (City)
MET MFT
Concerns summary (AI summary) Failure to conduct a crucial blood test, as per national guidelines, masked Endocarditis, leading to a missed diagnosis and delayed treatment that would likely have resulted in a different outcome.
Peter Carroll
1/1 responses identified
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.