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
David Mobsby
Historic (No Identified Response)
2019-0087 11 Mar 2019 Brighton and Hove
Blatchington Mill School Brighton and Hove City Council Department of Education
Concerns summary (AI summary) Inadequate health and safety guidance failed to address work at height risks, leading to an untrained and unsupervised employee performing dangerous tasks without risk assessments. There was also a lack of first aid provision and management training.
Terence Bradfield
Historic (No Identified Response)
2019-0086 11 Mar 2019 Plymouth Torbay and South Devon
University Hospitals Plymouth NHS Trust
Concerns summary (AI summary) Failures in steroid administration, prescription, and staff training on steroid management were identified. There was also a lack of policy on steroid use and insufficient staff understanding of "Nil by Mouth" for complex patients.
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.
Meirion James
Historic (No Identified Response)
2019-0460 4 Mar 2019 Pembrokeshire & Camarthenshire
Dyfed Powys Police Hywel Dda Health Board National Police Chief’s Council
Concerns summary (AI summary) Concerns exist regarding the content of police training for restraint and Appropriate Adult responsibilities. Criteria for identifying and transporting individuals to a place of safety under MHA 1983 also require review.
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.
Kelvin Speakman
Partially Responded
2019-0074 27 Feb 2019 Worcestershire
HMP Hewell HM Prison Service
Concerns summary (AI summary) The ACCT process at HMP Hewell suffered from inadequate documentation, poor healthcare input, and inconsistent staff communication, leading to incomplete patient information. These systemic failings are recurring despite previous assurances.
Action Planned (AI summary) HMPPS will deliver coaching sessions to ACCT case managers at HMP Hewell, emphasizing information sharing and accurate recording. A updated ACCT case management system is being piloted and will be rolled out nationally in early 2020.
Theresa Feehan
Partially Responded
2019-0070 27 Feb 2019 London Inner (West)
Care Quality Commission Lisson Grove Health Centre
Concerns summary (AI summary) The practice's medication review system was inadequate, with outdated patient records and poor correlation between problem lists and prescribed drugs. This led to dangerous medications being continued and a lack of proper rationale for prescribing.
Noted (AI summary) The CQC conducted inspections of Lisson Grove Health Centre but ultimately did not find concerns in the areas identified in the prevention of future death report. They rated the health centre 'Good' overall.
Peter Garvin
Partially Responded
2019-0069 27 Feb 2019 London Inner (West)
Central and North West London NHS Trust NHS England
Concerns summary (AI summary) Poor communication between the CMHT and GP, a lack of local mental health beds, and a policy to discharge NHS patients seeking private care negatively impacted patient care. A carer's assessment was also not offered.
Action Taken (AI summary) CNWL NHS Trust has drawn up a protocol for staff working with patients who seek advice or treatment from a private clinician, setting out how to work with private sector colleagues and how to explain the process to patients, drawing on national guidance.
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.
Geoffrey Jackson
Historic (No Identified Response)
2019-0071 26 Feb 2019 Manchester (South)
Manchester University Hospitals NHS Tru…
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.
Christopher Moss
Historic (No Identified Response)
2019-0066 26 Feb 2019 Staffordshire South
MOJ
Concerns summary (AI summary) Concerns exist regarding the availability of appropriate equipment, specifically a hooligan bar, for dealing with cell door barricade incidents in prisons, potentially delaying emergency access to inmates.
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.