2019

PFD Reports
Reports: 527 Areas: 66

70% response rate (above 63% average).

527 results
Iris Skinner
All Responded
2019-0427 17 Dec 2019 Surrey
Barchester Healthcare
Concerns summary (AI summary) Agency staff employed by the care home, and potentially across the healthcare group, may be unfamiliar with the critical Head Injury Policy, unlike permanent staff.
Action Taken (AI summary) Windmill Manor has created a new Agency Folder with key policies. Barchester is rolling out a modified induction checklist, pocket guide and poster across all homes by the end of February 2020, and compliance will be checked via the Quality Governance Framework.
Alice Sloman
All Responded
2019-0442 16 Dec 2019 Avon
Torbay and South Devon NHS Trust University Hospitals Bristol
Concerns summary (AI summary) Failure to refer a patient for a clinical geneticist's opinion, despite repeated parental requests and available services, led to a critical underlying condition remaining undiagnosed, resulting in premature death.
Action Planned (AI summary) Torbay and South Devon NHS Trust has discussed the case with relevant clinical teams and is implementing actions including: Paediatric clinicians learning about the Regional Genetic Service, Head of Regional Clinical Genetics Service attending a meeting with Paediatric clinical teams, twice yearly educational contact at clinical educational meetings, establishment of a regular advice point during/after the monthly clinics undertaken by the Regional Clinical Genetics Service in TSDFT. Bristol NHS Foundation Trust is working with Torbay and South Devon NHS Foundation Trust to finalise the Principles of Shared Care for Endocrine and has developed a patient information leaflet. It has been agreed that Service Levels Agreements will formalise the agreements in place with clear lines of accountability and responsibility.
Henry Campbell-Byatt
Historic (No Identified Response)
2019-0438 16 Dec 2019 London Inner (West)
Peligoni Club
Concerns summary (AI summary) The resort lacked essential deep-water rescue equipment and trained staff. The system for monitoring swimmers was inadequate, necessitating improved watchtower manning and safety equipment.
Arnold Ward
All Responded
2019-0433 16 Dec 2019 Manchester (South)
Fernlea Nursing Home, Care Quality Comm…
Concerns summary (AI summary) Care home forms failed to capture pressure ulcer deterioration or require detailed monitoring, delaying escalation to specialists. There was no system to follow up on unresponsive referrals.
Action Taken (AI summary) Stockport CCG reports that Fernlea Nursing Home now uses photographs to track the progress of pressure sores, and referrals to the Tissue Viability Team are escalated if not actioned within 2 working days. A "React to Red" training programme has been developed and rolled out across the Stockport Care Home community. The CQC inspected Fernlea Care Home and found the service had failed to send a statutory notification regarding Mr. Ward's pressure ulcer. They will consider further enforcement action regarding this and will provide a copy of the inspection report to HM Coroner. Fernlea Care Home has arranged for all Registered Nurses to undertake third party wound management refresher training and has extended "React to Red" training to 87% of the care team. They have adopted the NHS wound management document, changed referral processes to TVNs, and will notify the GP of all TVN referrals.
Clive Miles
All Responded
2019-0432 16 Dec 2019 Manchester (South)
Stockport Clinical Commissioning Group
Concerns summary (AI summary) The deceased had a toxic combination of prescribed medications, raising concerns about the monitoring and management of multiple high-dose prescriptions.
Action Planned (AI summary) Stockport CCG will remind all GPs across Stockport of the importance of recording clear and detailed notes explaining the basis on which any change to prescribing frequency has been made.
Shirley Nightingale
Historic (No Identified Response)
2019-0431 16 Dec 2019 Manchester (South)
Tameside and Glossop Integrated Care NH…
Concerns summary (AI summary) No clear system existed for escalating or prioritizing urgent OGD procedures when capacity was an issue. Additionally, deviations from best practice timescales lacked documented rationale or senior clinician approval.
Joyce Marchant
Historic (No Identified Response)
2019-0429 16 Dec 2019 Manchester (South)
Department of Health and Social Care NHS England
Concerns summary (AI summary) Delays in critical medical procedures due to a shortage of specialists, coupled with an unreliable postal system for GP communication and poor inter-hospital communication, risked patient safety.
Layla Dobson
All Responded
2019-0425 16 Dec 2019 West Yorkshire (East)
Leeds and York Partnership NHS Trust
Concerns summary (AI summary) Lack of a formal process to guide practitioners on appropriate mental health support routes and insufficient flagging of self-harm/suicide risk on referral forms contributed to inadequate scrutiny.
Action Taken (AI summary) Leeds and York NHS Trust has created guidance for staff on assessing risk in referrals, ensuring consideration of self-harm/suicide risk. They will update the referral form and information leaflet, and implement a standard referral receipt letter providing details of relevant crisis support services.
Steven Marsland
Historic (No Identified Response)
2019-0428 13 Dec 2019 Manchester (South)
Department of Health and Social Care Pennine Care NHS Trust Tameside and Glossop Clinical Commissio…
Concerns summary (AI summary) Inadequate family engagement and a lack of clear policy for it post-discharge compromised patient support. Flawed care transfer procedures between borough teams resulted in no follow-up appointments or consistent community contact.
Catherine McNamara
Historic (No Identified Response)
2019-0424 13 Dec 2019 Manchester (South)
Trafford Clinical Commissioning Group
Concerns summary (AI summary) The amount of prescribed opiates had increased to a level where she fell asleep and fell over, raising concerns about how she had reached such high levels initially and the understanding of the impact this had on her.
Heather Planner
Historic (No Identified Response)
2019-0490 13 Dec 2019 Buckinghamshire
Carewatch
Concerns summary (AI summary) Inadequate procedures for communicating and acknowledging medication changes, lack of systems for carers to confirm care plan adherence, and poor record-keeping by the care provider created significant medication error risks.
Samantha Higgins
All Responded
2019-0483 13 Dec 2019 London (East)
North East London Hospital Trust
Concerns summary (AI summary) A patient remained under a "brief intervention" team for an extended period without an overarching care plan or key-worker, and faced excessive delays (17 months) in accessing crucial psychotherapy treatment.
Action Planned (AI summary) The Trust has considered the concerns and agreed to actions, outlined in an attached action plan, to improve care quality and patient safety.
Raees Rauf
Historic (No Identified Response)
2019-0503 12 Dec 2019 Derby and Derbyshire
Bristol University
Concerns summary (AI summary) The university's non-mandatory tutorials and homework in Mathematics made it difficult to identify struggling students, allowing some to go without face-to-face contact for nearly a year and delaying support until exam failures.
Peter Frosdick
Historic (No Identified Response)
2019-0423 12 Dec 2019 Norfolk
Norfolk & Suffolk NHS Trust
Concerns summary (AI summary) Mental health issues were overlooked due to a focus on alcohol dependency, and the patient was denied care as his condition didn't fit service criteria. Teams lacked awareness of referral criteria and dismissed GP insights, hindering appropriate treatment.
Daniel Akam
Historic (No Identified Response)
2019-0461 10 Dec 2019 South Yorkshire (East)
Advisory Panel on Deaths in Custody HM Inspector of Prisons HMP Lindholme +3 more
Concerns summary (AI summary) ACCT observations were missed and recorded as completed, officers did not appear to know their obligations and responsibilities, and there was inadequate ACCT training for officers.
Frances Gibb
All Responded
2019-0422 10 Dec 2019 Brighton and Hove
Brighton and Sussex University Hospital…
Concerns summary (AI summary) There were serious and recurring failings in the application and use of the National Early Warning Score (NEWS) system, indicating a systemic risk to patient safety.
Action Taken (AI summary) The Trust disputes that lessons haven't been learned regarding NEWS, citing the implementation of electronic patient observations (Patientrack) in all adult and paediatric inpatient areas since July 2019, with Maternity and ED to follow. All Radiologists have been reminded to look at the SMA, the protocol has changed to enable better visualization and overnight scans are reviewed by a Consultant the following morning.
Brenda Drew
All Responded
2019-0421 10 Dec 2019 Dorset
Royal Pharmaceutical Society
Concerns summary (AI summary) The deceased received unrequested, repeat prescriptions for high-dose Oramorph. The GP surgery failed to formally review this potent medication for several months, raising concerns about prescribing oversight.
Action Taken (AI summary) The RPS highlights existing guidance for pharmacy teams covering prescription requests to GPs, published in 2015 and available on their website. They also updated and published a Prescribing Competency Framework in 2017 covering safe prescribing of repeat medicines.
John Wells
Historic (No Identified Response)
2019-0485 9 Dec 2019 West Sussex
NHS Digital NHS Pathways South East Coast Ambulance Service +1 more
Concerns summary (AI summary) Incomplete medical records failed to accurately relay critical patient vulnerabilities to telecare providers. Additionally, responder contact details were not integrated into the call handling system, and there was no automatic flagging for medical risks.
Matthew Fitten
All Responded
2020-0275 7 Dec 2019 Suffolk
Public Health England, General Pharmace…
Concerns summary (AI summary) A change in methadone prescription to larger bottles, without providing a measuring jug, likely led to inaccurate dosing and a fatal overdose.
Noted (AI summary) Haverhill Pharmacy continues to supply methadone in individual containers, in line with normal working procedures. The pharmacy will make prescribers aware in advance if it faces any issues. PHE provides context on its COVID-19 guidance to the drug and alcohol treatment sector, developed with sector representatives. They emphasize the need for individualised risk assessments before changing medication dispensing arrangements and that the CQC is monitoring these changes.
Safoora Alam
All Responded
2019-0426 6 Dec 2019 Black Country
Black Country Partnership NHS Trust Sandwell Council
Concerns summary (AI summary) Inconsistent information sharing and a lack of multi-agency collaboration between mental health and social care led to inadequate risk assessment and slow referral processes for a patient with escalating mental health needs.
Action Planned (AI summary) Sandwell Council has set up an operational group to develop a vulnerable adult risk management protocol. They are also reviewing current practice guidance for social workers and plan to review joint agency protocols with the Mental Health Trust. The Black Country Partnership NHS Foundation Trust will instigate a steering group of senior clinicians and managers from both the Trust and Local Authority to look at introducing joint complex care panels for patients with complex needs. They also agreed to set up task and finish groups to review joint agency protocols.
Maureen Wharton
Historic (No Identified Response)
2019-0420 6 Dec 2019 Gateshead & South Tyneside
Cumbria, Northumberland, Tyne & Wear NH… North East Ambulance Service NHS Trust Northumbria Police Service
Concerns summary (AI summary) Ambulance control failed to adequately assess the immediate danger of Maureen's admitted actions, leading to a significant delay in response and missed opportunities to enlist other agency support or inquire about her location and potential assistance.
Youngson Nkhoma
All Responded
2019-0416 6 Dec 2019 Birmimgham and Solihull
Capita MOD
Concerns summary (AI summary) Non-UK military selection candidates are not screened for sickle cell trait, posing a significant increased risk of death or collapse during military exercise.
Action Taken (AI summary) The Ministry of Defence outlines changes made to the Army recruitment process, including revised medical screening for Sickle Cell Trait, updated risk management processes for physical training, and clarified roles and responsibilities for training staff. They also removed previous versions of AGAI Vol 1 Ch 7 from use and circulation. The Ministry of Defence reports on actions taken, including improvements to sickle cell trait screening, mandating training for staff on exertional collapse, and implementing a joint clinical policy for exertional collapse. They also ensure Defence Medic training incorporates exertional collapse scenarios.
Kamil Iddrisu
All Responded
2019-0416-wp26929 6 Dec 2019 Birmimgham and Solihull
Capita MOD
Concerns summary (AI summary) There is a critical need to screen all non-UK military selection candidates for sickle cell trait, both before and after selection, due to the significant risk of collapse or death during military exercise.
Noted (AI summary) • Following the death of two candidates, the 2000m run was suspended for all Commonwealth Candidates. • Multidisciplinary meetings have taken place, informed by an Evidence-Based Medicine approach, to address the risk of Exertional Collapse Associated with Sickle Cell Trait (ECAST). • Actions taken have been applied to all candidates applying to join the Army, not just non-UK candidates.
Darren Wilson
Historic (No Identified Response)
2019-0418 5 Dec 2019 Lincolnshire
Lincolnshire County Council
Concerns summary (AI summary) A notorious accident hotspot lacked essential traffic calming measures, including reduced speed limits and double white lines, contributing to numerous near misses and non-fatal collisions.
Gemma Macdonald
Partially Responded
2019-0417 5 Dec 2019 Suffolk
1st For Health International; StockXS L… Medicines and Healthcare products Regul…
Concerns summary (AI summary) The unchecked online availability of large quantities of medication, without systems to verify purchaser suitability or limit transaction amounts and frequency, poses a significant risk.
Noted (AI summary) The Department of Health and Social Care acknowledges concerns about online access to medicines and outlines existing regulations and initiatives to improve patient safety, including the Falsified Medicines Directive and Local Health and Care Record Exemplars.