2019
PFD Reports
Reports: 527
Areas: 66
70% response rate (above 63% average).
Gail Bailey
Historic (No Identified Response)
2019-0027
23 Jan 2019
Lincolnshire
United Lincolnshire Hospitals NHS Trust
Concerns summary (AI summary)
A critical communication breakdown occurred between paramedics pre-alerting the hospital and the hospital's readiness for a critically ill patient, raising significant concerns for future emergency admissions.
Ann Swoffer
All Responded
2019-0026
22 Jan 2019
Birmingham and Solihull
University Hospitals Birmingham NHS Tru…
Concerns summary (AI summary)
Hospital practices diverged from national guidelines, junior staff failed to escalate issues during weekends due to senior staff absence, and a lack of integrated protocols across trust sites created inconsistent care standards.
Action Taken
(AI summary)
The Trust found the guidelines are recognized and used at Good Hope Hospital, and a gastroenterology consultant now attends weekend ward rounds. A unified operational structure will be established by May 2019, with alignment of protocols and guidelines across sites as a short-term goal.
Robert Norton
All Responded
2019-0295
21 Jan 2019
West Yorkshire (West)
Calderdale Council
Concerns summary (AI summary)
Unclear road markings and a confusing road layout contributed to motorist confusion, posing a risk of future accidents.
Action Planned
(AI summary)
Calderdale MBC will continue to inspect the white lining and renew it as required and will commission a study of similar accidents regarding the roundabout layout to determine if any remediation is needed.
Alfred Howell
All Responded
2019-0116
21 Jan 2019
West Yorkshire (East)
Mid Yorkshire Hospitals NHS Trust
Concerns summary (AI summary)
Concerns related to the process of identifying and responding to a patient's deteriorating lung condition, noted through serial CT scans and MDT reviews.
Noted
(AI summary)
The Trust acknowledges the coroner's concerns regarding radiology reporting turnaround times but states that there are no national standards. The Trust prioritizes resources to acute, clinically urgent, and cancer pathways, and routine outpatient work may wait longer.
Neil Black
All Responded
2019-0024
21 Jan 2019
Birmingham and Solihull
Birmingham Community Healthcare NHS Tru…
Concerns summary (AI summary)
Inadequate coordination and unclear responsibilities between prison nursing teams, compounded by a lack of protocols for examining critical injection and DVT sites.
Action Taken
(AI summary)
A new protocol clarifies physical observations for prisoners, and IDTS nurses now complete the National Early Warning Score (NEWS). Healthcare staff were reminded on February 13, 2019, to ensure appropriate observations are carried out during physical examinations.
Norman Pirie
All Responded
2019-0030
18 Jan 2019
London Inner (North)
Barts Health NHS Trust
Concerns summary (AI summary)
A surgical cuff device was used outside manufacturer guidelines in a non-emergency procedure, increasing the risk of device failure and the need for high-mortality open surgery.
Action Planned
(AI summary)
The Trust will implement enhanced MDT review of device selection including non-IFU treatments, document the decision in the patient's record, and inform the patient and GP about treatment options.
Mylon Sheppard
Historic (No Identified Response)
2019-0025
17 Jan 2019
Warwickshire
Coventry & Warwickshire Partnership Tru…
Coventry NHS Trust
Concerns summary (AI summary)
Failures included ineffective oversight of duty worker decisions, poor waiting list management, unclear processes for patient non-attendance, and inadequate family involvement in care planning.
Mark Harris
Historic (No Identified Response)
2019-0023
17 Jan 2019
Suffolk
Emergency Operation Centre Norwich
Melbourne Ambulance Station
Concerns summary (AI summary)
Police received incorrect name spelling and unclear instructions for a welfare check, indicating critical communication failures and a lack of agreed protocols between ambulance and police services.
George Thompson
All Responded
2019-0022
16 Jan 2019
Manchester (South)
Highlands and Trafalgar Square Surgery
Concerns summary (AI summary)
Insufficient doctor staffing meant no home visits could be undertaken even if clinically indicated, due to one doctor covering all duties and emergencies.
Action Planned
(AI summary)
The practice will arrange telephone triage training, provide one-on-one training on systems and processes, re-communicate the operational manual, and create a formal channel for team members to raise concerns about operational readiness and workload pressure.
Catherine Horton
All Responded
2019-0143
15 Jan 2019
London (South)
Metropolitan Police Service
Concerns summary (AI summary)
Multiple failures in a missing persons investigation, including incorrect closure due to severe understaffing and high workload in the police missing persons unit.
Action Taken
(AI summary)
The MPS has updated investigator toolkits on mobile devices, provides safeguarding officers in BCU Operations Rooms, delivers mandatory week-long training to officers posted to MPUs, and increased staffing levels in the South Area MPU.
Marie Millward-Winter
Partially Responded
2019-0020
15 Jan 2019
Manchester (City)
Each Step Nursing Home
NORTH WEST AMBULANCE SERVICE
Concerns summary (AI summary)
Administration of anticoagulation medication after a head injury, advised by ambulance technicians, likely worsened an internal bleed and contributed to death.
Disputed
(AI summary)
The Ambulance Service argues the Regulation 28 report was issued prematurely because they were not notified of the inquest date or granted Interested Person status. They maintain the EMT acted outside their scope of practice to advise on medication.
John Preece
All Responded
2019-0019
15 Jan 2019
South Wales Central
Cardiff and Vale University Health Board
Nursing & Midwifery Council
Concerns summary (AI summary)
Significant failures in falls management, head injury recognition, and neuro observation training among staff, compounded by a lack of appropriate monitoring and early warning systems for mentally unwell patients.
Noted
(AI summary)
The Health Board has implemented a falls training program developed by Practice Nurse Educators, introduced an escalation policy specifically for St Barruc ward, and uses NEWS across MHSOP wards in University Hospital Llandough with clear escalation policies. The NMC outlines its regulatory role in setting and maintaining standards for registered nurses and refers to new standards and assurance processes to ensure nurses entering the register are properly trained. They will pursue any regulatory concerns which it is appropriate for them to take, through their fitness to practise procedures.
Dane Pearson
Partially Responded
2019-0056
14 Jan 2019
Manchester (South)
Greater Manchester Police
Home Office
Concerns summary (AI summary)
Police issued a CAWN without proper evidence, rationale, or risk assessment for a vulnerable person, and failed to communicate the decision to drop the investigation.
Action Planned
(AI summary)
The College of Policing is updating APP on issuing CAWNs to include a risk assessment and link to existing suicide prevention guidance. Additionally, GMP has implemented activities including providing districts with information, revising the bail and RUI policy, briefing front line officers, introducing trackers and dip sampling records.
Ricardo Holgate
Partially Responded
2019-0012
11 Jan 2019
Birmingham and Solihull
G4S
HM Prisons and Probation Service
MoJ
Concerns summary (AI summary)
Inadequate management of illicit substance misuse in prison requires further steps, including implementing CCTV on all wings and airport-style scanners at entry points.
Noted
(AI summary)
G4S states that HMP Birmingham is currently being managed by HMPPS and decisions regarding actions/equipment are not within their remit, but they agree with the need for CCTV and airport-style scanners and state that the governor's appointment has been extended.
Amanda Briley
All Responded
2019-0021
11 Jan 2019
Leicester City and Leicestershire South
East Leicestershire and Rutland Clinica…
Concerns summary (AI summary)
Lack of commissioned services for autism management and local inpatient provision forces out-of-area mental health placements, hindering family contact and local support.
Noted
(AI summary)
NHS England states that a central register of providers for specialist placements for individuals diagnosed with Asperger's Syndrome does not exist, but refers to the CQC website and mentions national initiatives aimed at improving services for autistic people. The Trust has increased mandatory autism training for staff, held meetings to ensure clear handover of patient care during bank holidays, reviewed and updated the Trust's Handover Policy, and will introduce Nerve Centre, a hand-held device for immediate access to patient information.
Ruth Gregory
All Responded
2019-0017
11 Jan 2019
Manchester (South)
Reinbek Care Home
Concerns summary (AI summary)
Regular unsupervised communal areas in the care home led to resident injuries from falls, highlighting inadequate risk management and supervision arrangements.
Action Taken
(AI summary)
Borough Care has increased staffing levels in their homes, including a deputy manager and senior carer on each shift, to reduce the time communal areas are left unattended.
Elizabeth Curtis
All Responded
2019-0018
11 Jan 2019
Avon
NHS Improvements
Concerns summary (AI summary)
Concerns arose that patient mobility, a key indicator of declining health, was not systematically assessed alongside other wellness scores in hospital care.
Action Taken
(AI summary)
NHS Improvement has shared information with the Royal United Hospital Bath NHS Foundation Trust about a mobility score, and has provided support for assessing its impact. They are also undertaking activities related to medication safety for older people.
Jacqueline Elliott
All Responded
2019-0016
11 Jan 2019
Manchester (South)
Delamere Medical Practice
Concerns summary (AI summary)
Inadequate medication review processes, poor documentation, high-volume painkiller prescribing despite overdose history, and lack of continuity of care led to reliance on painkillers.
Noted
(AI summary)
The CCG provides context on medication management practices, GP workload challenges and national initiatives to increase the GP workforce, but doesn't describe specific local actions.
Christopher Seal
All Responded
2019-0013
10 Jan 2019
Avon
Avon and Wilshire Mental Health NHS Tru…
Concerns summary (AI summary)
Multiple failures in information sharing, record keeping (RIO system), and lack of "no response" or "welfare check" policies in primary care, exacerbated by staff training issues and limited communication options.
Action Taken
(AI summary)
The Trust has already taken action to address the issues including emphasizing the need for staff to record explicit consent on information sharing forms and reviewing the Trust's consent to share information procedures. They have also clarified that the AWP switchboard can call 999 in an emergency and ensured that staff are aware of individualised communication options for service users.
Natasha Chin
Partially Responded
2019-0011
10 Jan 2019
Surrey
Chief Inspector of Prisons
Care Quality Commission
MoJ
+1 more
Concerns summary (AI summary)
Significant failures in prison medication management, including lack of information sharing with officers, unclear protocols, absent audits for critical processes, inadequate response to previous concerns, and insufficient staff training on withdrawal.
Noted
(AI summary)
HM Inspectorate of Prisons acknowledges the report and will place a copy in their intelligence file to inform future inspections of HMP Bronzefield. They are unable to direct the prison service to take any specific action.
Richard Lockley
All Responded
2019-0010
10 Jan 2019
Staffordshire (South)
University of North Midlands Hospital N…
Concerns summary (AI summary)
Poor inter-hospital communication during patient transfers and difficulties securing specialist gastroenterology beds risk patient safety and timely care.
Action Taken
(AI summary)
The Trust has reviewed the process for transfers between hospitals and is clarifying roles and responsibilities. They are also looking to 'RAG rate' all requests to transfer patients based on clinical need.
Michael Flynn
All Responded
2019-0008
10 Jan 2019
Manchester (South)
Tameside General Hospital
Concerns summary (AI summary)
The report identifies a lack of EWS monitoring in the post-operative recovery area, failure to adhere to Trust policy regarding monitoring and trigger points for escalation, a lack of doctor review despite deteriorating EWS scores, and incomplete fluid balance charts.
Action Taken
(AI summary)
The Matron for Theatres has confirmed that vital signs are continuously monitored in the recovery area post operatively and documented at set intervals. New signage has been introduced at the bedside to further support staff in recognizing which patients have a fluid balance chart in place; and a trust wide audit of fluid balance chart compliance has been added to the Trust Audit Programme for 2019/2020.
Malcolm Shaw
All Responded
2019-0007
10 Jan 2019
Manchester (South)
Stockport NHS Trust
Concerns summary (AI summary)
A fundamentally flawed patient safety investigation into a fall highlighted inadequate investigation training and a lack of guidance for frontline staff on capturing immediate post-fall evidence.
Action Taken
(AI summary)
The Trust has launched a revised programme of investigation training, including in-depth statement gathering and writing sessions, and implemented a checklist for investigation panel meetings to ensure key requirements are met. They also launched a Safer Mobility Collaborative aimed at reducing inpatient falls.
Marian Hoskins
All Responded
2019-0005
9 Jan 2019
City of London
Barts Health NHS Trust
Concerns summary (AI summary)
An unclear system for obtaining full and informed consent, particularly lacking sufficient outpatient discussion prior to admission, led to insufficient patient information on investigatory options.
Action Planned
(AI summary)
A new Trust policy on informed consent and supported decision making for elective surgical procedures is being drafted, clarifying that informed consent is a process over time in the outpatient clinic. St Bartholomew’s Hospital has committed to a programme of improvement for consent as one of their Key Objectives for 2019/20.
Diana Gudgeon
All Responded
2019-0015
9 Jan 2019
Northamptonshire
111 Service
East Midlands Ambulance Service
Concerns summary (AI summary)
Inadequate 111/EMAS triaging, particularly for sepsis, resulted in delayed response. A shortage of ambulances and a high threshold for escalation in the capacity management plan further compromised patient safety.
Action Taken
(AI summary)
The ambulance service uses the Advanced Medical Priority Dispatch System (AMPDS) and is actively recruiting staff to a newly created Clinical Hub to address call volume, with some staff already trained and operational. The Capacity Management and Escalation Plan is reviewed annually. The 111 service uses NHS Pathways software, updated twice yearly, with staff training covering sepsis, including a Distance Learning Pack with a formal assessment, and NICE Guidance on feverish illness. Clinicians receive sepsis risk stratification tools and are notified of a free online course on Sepsis in Primary Care.