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)
Clear 294 results
Callie Lewis
All Responded
2019-0414 3 Dec 2019 Kent (Central and South East)
Department of Digital, Culture, Media a…
Concerns summary (AI summary) An online suicide forum provided dangerous advice, enabling individuals to mislead mental health professionals and perfect suicide methods, thus frustrating necessary assessments and interventions.
Action Planned (AI summary) The DCMS outlines the Online Harms White Paper, which proposes a duty of care for companies to protect users online, overseen by an independent regulator. They have also convened a working group of social media companies to explore further safety measures and have held summits with social media providers regarding suicide and self-harm content.
David Moore
All Responded
2019-0413 3 Dec 2019 County Durham and Darlington
Durham County Council
Concerns summary (AI summary) A dark section of the A693, serving as an unofficial pedestrian crossing point with a 60mph speed limit and no street lighting, creates a critical hazard where vehicle stopping distances exceed driver visibility.
Action Taken (AI summary) Following a fatal accident investigation, the council replaced the pedestrian crossing signs with larger signs manufactured from a highly reflective material.
Sidney Baker
All Responded
2019-0407 2 Dec 2019 Manchester (West)
Care Quality Commission Rosewood Healthcare Group Wigan Life Centre
Concerns summary (AI summary) Poor record-keeping, including incorrect care plan entries and lack of documentation for referrals, indicates inadequate staff training and poses risks to patient care and safety.
Action Taken (AI summary) Rosewood Healthcare has implemented an Accidents and Incidents file, follows a Triage system, and has online and face-to-face training for falls and manual handling. They also have a new training provider who will be providing SALT and MUST training and audit systems are in place. The CQC conducted a comprehensive inspection of Barley Brook, and found that appropriate referrals were being made to dieticians and the falls team. They are highlighting possible breaches of the Health and Social Care Act 2008 and CQC Registration Regulations 2009 to the provider and will carry out a further inspection within 12 months. Wigan Council has taken action following a safeguarding enquiry, including developing a protection plan defining expectations for service delivery at Barley Brook. Staff will receive training in record keeping, dementia, and nutrition, and the council will monitor the uptake and impact of this training.
Connor Davies
All Responded
2019-0412 29 Nov 2019 South Wales Central
Cwm Taf Health Board
Concerns summary (AI summary) Repeated cancellation of consultant psychiatrist appointments without clinical input on patient urgency meant individuals at serious need could "fall through the net," as a preventative system was not yet operational.
Action Planned (AI summary) The University Health Board has developed an action plan to address the matters raised during the inquest and all outstanding actions are being implemented by the Mental Health Directorate.
Leah Cambridge
All Responded
2019-0408 29 Nov 2019 West Yorkshire (East)
Department of Health and Social Care GMC
Concerns summary (AI summary) A lack of regulatory oversight for BBL procedures in the UK, coupled with insufficient and untimely provision of information for informed consent, exposes patients to significant mortality and morbidity risks.
Noted (AI summary) The Department of Health and Social Care is awaiting research on the Brazilian Butt Lift procedure. They will be updating existing guidance about surgical fat transfer procedures to reference the Brazilian Butt Lift by March 2020. The operator of Elite Aftercare confirms the business has ceased trading since the conclusion of the inquest. The GMC acknowledges the concerns and shares information about their role in regulating doctors and setting standards. They note the BAAPS moratorium and discuss credentialing for cosmetic surgery, but state that they do not have the legal authority to make any postgraduate training mandatory.
Suzanna Bull
All Responded
2019-0404 29 Nov 2019 Birmingham and Solihull
Department for Transport Road Haulage Association Scania +1 more
Concerns summary (AI summary) A dashboard tray creates a dangerous blind spot in moving vehicles, yet there are no warnings on the product, nor general advisories to manufacturers or users, about this safety hazard.
Action Planned (AI summary) The DVSA will circulate information to haulage operators stating that aftermarket dashboard trays breach testing rules and should be removed when HGVs are driven and publish similar information on gov.uk. The Department for Transport will also make umbrella bodies aware of the concerns. DVSA published a Moving On blog on GOV.UK and sent a link to haulage operators reminding them to keep windscreens clear; they will highlight concerns at a Heavy Vehicle Industry Forum, and will update guidance to warn drivers against putting objects in their lorry which restrict their view.
Andrew Hogg
All Responded
2019-0400-wp26913 27 Nov 2019 Manchester (South)
Borough Care Limited
Concerns summary (AI summary) A care home failed to adequately assess and manage escalating falls risks, lacking a comprehensive falls policy, proper risk reassessments, internal investigations, and proactive measures or equipment to prevent repeated incidents.
Action Planned (AI summary) • All home managers will review falls on the Person Centered Software (PCS) system weekly and add notes regarding actions taken to the falls log and residents' support plans. • For any resident with more than two falls within a two-week period, a review with their GP or CPN will be arranged. • Area Managers will review this process as part of their monthly audit.
George Rogers
All Responded
2019-0484 27 Nov 2019 West Sussex
Sussex Partnership NHS Trust
Concerns summary (AI summary) The absence of a designated Lead Practitioner during patient transfers between mental health teams causes delays in treatment and leaves patients unmonitored during a critical transition period.
Action Taken (AI summary) A new process was introduced to allocate a Lead Practitioner which resulted in a 95% reduction in unallocated patients at the point of transfer between teams.
Trevor Oakley
All Responded
2019-0495 26 Nov 2019 Hampshire
HM Prison and Probation Service
Concerns summary (AI summary) Night staff at the prison may not be immediately aware of which prisoners are due in court the following morning, potentially overlooking increased self-harm risks among these prisoners.
Action Planned (AI summary) • The use of thromboprophylaxis to surgery has been relaunched and clarified to all pertinent staff, particularly the time period before which it should be withheld. • All speciality specific thromboprophylaxis guidelines are being reviewed.
Maureen Milton
All Responded
2019-0396 22 Nov 2019 Staffordshire (South)
British Medical Association Care Quality Commission Department of Health and Social Care +3 more
Concerns summary (AI summary) There is insufficient awareness among healthcare professionals and carers about the severe fire risk posed by petrol-based emollient creams, which impregnate clothing and accelerate burns.
Noted (AI summary) The MHRA has convened a stakeholder group to design educational resources for healthcare professionals and the public, aiming to launch a toolkit in 2020 with a press release and stakeholder propagation of key messages. NICE acknowledges the concerns but states that overseeing medicine safety, product warnings, and running safety awareness campaigns do not fall within its remit; they refer to existing BNF guidance for prescribers. Public Health England reviewed the report but defers to the Medical and Healthcare products Regulatory Agency (MHRA) as the concerns relate to medicines.
Shaun Dewey
All Responded
2019-0398 19 Nov 2019 Avon
HM Prison and Probation Service
Concerns summary (AI summary) The elevated risk of self-harm and suicide among remand prisoners is not adequately highlighted in staff training, care practices, or national guidance documents like ACCT.
Action Planned (AI summary) HM Prison and Probation Service will review and update lists of risks and triggers as part of replacing PSI 64/2011 with a policy framework on prison safety, considering the risks posed by remand status. They will also revise the Introduction to Suicide and Self Harm Prevention training.
Deborah Headspeath
All Responded
2019-0387 18 Nov 2019 Suffolk
Department of Health and Social Care
Concerns summary (AI summary) There's no unified database for tracking patient prescriptions, enabling uncoordinated medication supplies, especially from unregulated online prescribers. Advisory guidance for pharmacists on online prescriptions lacks mandatory adherence and clear sanctions.
Action Taken (AI summary) The Department of Health and Social Care is working with the CQC and regulators to better regulate online prescribers. Measures already taken include co-authoring principles of good practice in remote consultations, commissioning a review of overprescribing, and asking NICE to develop guidance on safe prescribing of dependence-associated drugs.
Emma Langley
All Responded
2019-0384 18 Nov 2019 Birmimgham and Solihull
West Midlands Ambulance Service
Concerns summary (AI summary) The current system for recording patients' refusal of hospital admission, involving a generic summary and electronic signature on a tablet, fails to adequately ensure distressed patients/families understand they are rejecting medical advice.
Action Taken (AI summary) West Midlands Ambulance Service is changing its electronic patient report software to include a clearer statement about refusing treatment/transport. They have also updated their policy on refusal of care and revised the patient discharge advice leaflet.
Francesca Sio
All Responded
2019-0390 15 Nov 2019 London (South)
Bromley Clinical Commissioning Group Greenbrook Healthcare
Concerns summary (AI summary) Mixing adult and child patients in urgent care centres creates a significant risk of children quietly deteriorating unnoticed, delaying crucial assessment and appropriate referral.
Noted (AI summary) NHS Bromley CCG is reviewing options for re-procuring services at Urgent Care Centres and will give due consideration to the coroner's concerns as part of the re-procurement process. Greenbrook Healthcare acknowledges the coroner's concern, but states it is mitigated against in their UCC. They detail measures taken to monitor the waiting room and point to a Serious Incident investigation that raised no concerns.
Averil Skoric
All Responded
2019-0383 15 Nov 2019 Manchester (South)
Department of Health and Social Care
Concerns summary (AI summary) There is a lack of clear national and local guidance for care home staff on safe sleeping positions for vulnerable adults who lack capacity, increasing the risk of unsafe sleeping.
Noted (AI summary) The Department of Health and Social Care notes the concerns and highlights existing regulations, guidance from NICE, and the role of the Social Care Institute for Excellence (SCIE).
Jamil Ahmed
All Responded
15 Nov 2019 Birmingham and Solihull
National Highways
Concerns summary (AI summary) The use of hard shoulders as running lanes on smart motorways creates a severe risk of collisions with stationary vehicles, especially given high speeds and limited escape options on elevated stretches.
1 response from National Highways
Jamie Staley
All Responded
2019-0463 12 Nov 2019 Gwent
Monmouth County Council
Concerns summary (AI summary) Lack of signage and relatively easy access points allow pedestrians to inadvertently stray onto the A40 near Gibraltar tunnels, posing a risk of future collisions.
Noted (AI summary) Monmouthshire County Council expresses condolences and explains the existing footpath infrastructure. They state that signage did not contribute to the accident, but will continue to work with SWTRA to identify any additional safety measures. Monmouthshire County Council confirms that the South Wales Trunk Road Agent (SWTRA) has installed Pedestrian Prohibition signs on existing signing infrastructure.
Costel Stancu
All Responded
2019-0379 12 Nov 2019 Cheshire
Highways England
Concerns summary (AI summary) The lack of lighting on a section of the motorway is an ongoing risk, having contributed to collisions, and its safety implications were not reassessed during the 'smart motorway' conversion.
Action Planned (AI summary) National Highways will conduct a lighting assessment on the M6 between junctions 16 and 19, and complete the final Road Safety Audit (Stage 4) by Summer 2020.
Antonis Hannides
All Responded
2019-0382 8 Nov 2019 Avon
Spire Bristol Hospital
Concerns summary (AI summary) Spire Bristol lacks formal systems for managing unexpected patient reattendances post-discharge, ensuring comprehensive record-keeping, and immediately informing consultants of these cases.
Action Taken (AI summary) Spire Bristol Hospital has undertaken shared learning sessions with clinical staff to reiterate documentation procedures for patients who re-attend and asked the RMO involved to complete a reflection of the case for their appraisal. Spire Healthcare updated their Admission and Discharge Policy in January 2020.
Sam Spooner
All Responded
2019-0378 8 Nov 2019 Cheshire
Rope Green Medical Centre
Concerns summary (AI summary) A severe lack of multi-agency information sharing, communication, and co-operation led to fragmented care for a suicidal patient, with an over-reliance on the family and inadequate intervention by healthcare providers.
Noted (AI summary) BACP acknowledges the challenges faced by private counsellors regarding information sharing and will pass the report to their Professional Standards Department to consider strengthening current guidance. The counsellor, via their legal representation, outlines the existing procedures for information sharing, including obtaining client consent, and emphasises the limitations faced by private practitioners.
Joshua Hoole
All Responded
2019-0458 1 Nov 2019 Birmingham and Solihull
MOD
Concerns summary (AI summary) A persistent failure to learn from previous heat-related deaths is evident, with commanders lacking awareness and training on critical heat illness guidance (JSP539), which itself is complex and lacks clear protocols for individual risk and new fitness tests.
Action Taken (AI summary) The Ministry of Defence has taken corrective action following concerns raised regarding the death of Corporal Joshua Hoole, including improved awareness of Joint Service Publication 539, updating the User Guide video for WBGT monitors, and providing refresher training for staff delivering Physical Training, whilst robust plans are in place to deliver remaining requirements.
Hajra Sidat
All Responded
2019-0370 1 Nov 2019 Cheshire
Cheshire East Council Cheshire East Highways Department
Concerns summary (AI summary) The A34 bypass (Melrose Way Bend) is dangerous due to the lack of a continuous white line, allowing unsafe overtaking on a dark stretch of road.
Action Planned (AI summary) Cheshire East Highways has accepted the recommendation to replace the existing hazard centreline marking with a hatched hazard centreline on A34 Melrose Way, with works programmed to be carried out in March. • A road safety assessment report was prepared for A34 Melrose Way. • The existing centre line marking was replaced with a hatched hazard centreline and red surfacing in March 2020 to discourage overtaking. • These measures comply with national regulations and guidance.
Salma Sidat
All Responded
2019-0370-wp26883 1 Nov 2019 Cheshire
Cheshire East Council Cheshire East Highways Department
Concerns summary (AI summary) The A34 bypass (Melrose Way Bend) is dangerous due to the lack of a continuous white line, allowing unsafe overtaking on a dark stretch of road.
Action Planned (AI summary) Cheshire East Highways has accepted the recommendation to replace the existing hazard centreline marking with a hatched hazard centreline on A34 Melrose Way, with works programmed to be carried out in March. Following a road safety assessment, Cheshire East Highways replaced the centre line marking on A34 Melrose Way with a hatched hazard centreline and red surfacing in March 2020, aiming to discourage overtaking.
Liyakat Sidat
All Responded
2019-0370-wp26882 1 Nov 2019 Cheshire
Cheshire East Council Cheshire East Highways Department
Concerns summary (AI summary) The A34 bypass at Melrose Way Bend is dangerous due to the absence of a continuous white line, allowing unsafe overtaking in dark conditions and posing a risk to lives.
Action Planned (AI summary) • A road safety assessment report for the A34 Melrose Way was reviewed. • The council accepted the report's recommendation to replace the existing hazard centreline marking with a hatched hazard centreline to narrow the carriageway visually. • The works were programmed to be carried out in March. • A road safety assessment report for A34 Melrose Way was prepared. • The existing centre line marking was replaced with a hatched hazard centreline and red surfacing. • These works were completed in March 2020.
London Bridge & Borough Market Terror Attack
All Responded
2019-0332 1 Nov 2019 London Inner (South)
Department for Transport Metropolitan Police Service British Vehicle Rental and Leasing Asso… +6 more
Concerns summary (AI summary) The coroner identified matters of concern which are being reported to the addressees, after taking into account submissions from the bereaved.
Noted (AI summary) The City of London Police (CoLP) are working with partner agencies to test interoperability of communications and enhance training scenarios, including a 7 day live trial in February 2020 to station staff in the MPS control room, with a review in Autumn 2020, and are engaging with the MPS in ICCS and CAD upgrade projects, planning an interim solution until upgrades are complete. The BVRLA has worked with the DfT and law enforcement to prevent the use of rental vehicles in terrorist attacks, providing training, guidance and engagement opportunities to members, and has included additional criteria within member audits from Jan 2020 to monitor awareness, training and compliance against the Rental Vehicle Security Scheme. The LAS is planning a live trial for seven days in February 2020, with LAS and LFB staff based in the MPS control room, and will analyze the outcome and consider a recommendation for approval by Autumn 2020; it is also working with its emergency service partners and increased visibility of the HART and TRU teams. The Home Office acknowledges the coroner's concerns and provides context, stating that the issues raised are technical and will be considered by the police in collaboration with the Emergency Services Network programme. It also mentions ongoing work led by the National Police Chiefs' Council. The MPS is trialing a "London Emergency Services Contact Centre" with representatives from the LFB and LAS deployed within the Specialist Operations Room, with a table top exercise followed by a real-life 7-day trial planned for early 2020.