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
Jessica Duckworth
Historic (No Identified Response)
2019-0419 4 Dec 2019 West Yorkshire (East)
Kirklees Council
Concerns summary (AI summary) The lack of fencing or other preventative measures at a bridge known as a suicide spot creates an ongoing risk of future deaths from falls.
Gareth Warburton
Historic (No Identified Response)
2019-0411 4 Dec 2019 Worcestershire
HMP Hewell
Concerns summary (AI summary) Important letters from a clinician regarding a prisoner's prescription error and medication were neither acknowledged by the Governor nor passed to the prison healthcare team, posing a risk to prisoner welfare.
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.
Luke Jones
Partially Responded
2019-0409 3 Dec 2019 North Wales (East and Central)
Government Legal Department HMP Berwyn MOJ
Concerns summary (AI summary) Concerns exist regarding the continuing accessibility and use of novel psychoactive substances (NPS) within HMP Berwyn, posing significant health risks and a high probability of future deaths.
Action Taken (AI summary) HMP Berwyn has implemented various measures to tackle psychoactive substances, including improved gate searching, changes in the supervision of domestic visits, safe detoxification on reception, and extended mandatory drug testing. A Rapiscan machine is also in place to improve detection of contraband items.
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.
Archie Spriggs
Partially Responded
2019-0405 2 Dec 2019 Shropshire, Telford & Wrekin
CAFCASS Shropshire Council Shropshire Safeguarding Children's Board +1 more
Concerns summary (AI summary) The concerns are covered within the 8 recommendations of the SCR regarding referral pathways, understanding of private law proceedings, notification processes for Section 37 reports, and engagement with multi-agency frontline staff.
Noted (AI summary) The Shropshire Safeguarding Partnership (SSP) acknowledges the report and states they are responsible for owning and governing delivery against the action plan related to the Serious Case Review, which was commissioned by the previous Shropshire Safeguarding Children’s Board (SSCB).
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.
Brenda McWilliams
Historic (No Identified Response)
2019-0406 29 Nov 2019 Manchester (North)
National Institute for Health and Care …
Concerns summary (AI summary) Medical practitioners failed to consistently prescribe VTE medication post-discharge, and an interpretation of NICE guidance may leave high-risk community patients unassessed and untreated, despite recognized serious risks.
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.
Christina Lawal
Historic (No Identified Response)
2019-0410 28 Nov 2019 London Innner (North)
Creative Support Limited
Concerns summary (AI summary) Delays in emergency calls due to lack of cordless phones, combined with triage systems requiring real-time patient information that callers remote from the patient cannot provide, risk inadequate and delayed emergency response.
Thomas Wedrychowski
Historic (No Identified Response)
2019-0403 28 Nov 2019 Wiltshire and Swindon
Avon and Wiltshire Mental Health NHS Tr… National Institute for Health and Care …
Concerns summary (AI summary) Annual monitoring for diabetes in patients on antipsychotics may be insufficient for high-risk individuals, and there is a critical lack of physical healthcare information sharing between primary and secondary care providers.
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.
David Potts
Historic (No Identified Response)
2019-0496 26 Nov 2019 Norfolk
Norfolk and Norwich University Hospital
Concerns summary (AI summary) Critical medication (Beriplex) was not administered promptly, its delivery was unchecked, and staff lacked awareness regarding its non-administration and the patient's location.
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.
Gareth Williams
Historic (No Identified Response)
2019-0464 25 Nov 2019 Gwent
Newport County Council
Concerns summary (AI summary) Safety on a road known for speeding and overtaking would be improved by extending double white lines to restrict dangerous overtaking maneuvers.
Thomas Browne
Historic (No Identified Response)
2019-0401 25 Nov 2019 South Wales Central
Cwm Taf University Health Board
Concerns summary (AI summary) Patients on finite oxygen supplies risk being unmonitored; oxygen administration training is incomplete, and there are no formal procedures for tracking oxygen expiry times. The root cause analysis was also deficient.
REDACTED
Historic (No Identified Response)
2019-0397 22 Nov 2019 Cornwall and the Isles of Scilly
College of Policing
Concerns summary (AI summary) Police guidance for missing person risk assessments lacks clarity, potentially leading to inconsistent decision-making by officers in complex cases.
Jonathan Adebanjo
Historic (No Identified Response)
2019-0399 22 Nov 2019 London Inner (North)
London Borough of Tower Hamlets
Concerns summary (AI summary) Swimming prohibition signs are too small and lack detail regarding specific dangers like poor visibility, undercurrents, and submerged debris.
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.
Gary Leyland
Partially Responded
2019-0395 20 Nov 2019 Manchester (North)
HM Prison and Probation Service Jigsaw Homes Group
Concerns summary (AI summary) The probation service failed to refer mental health concerns to medical practitioners. Supported accommodation exhibited poor documentation, unclear welfare check protocols for security staff, and inadequate risk assessment updates, without policy for GP contact.
Action Planned (AI summary) The National Probation Service (NPS) launched its Health & Social Care Strategy 2019-22, along with a Suicide Prevention Strategy Action Plan, to support collaborative and multi-agency working.
Nimo Younis
Historic (No Identified Response)
2019-0394 20 Nov 2019 London Inner (North)
Camden & Islington NHS Trust Metropolitan Police Service
Concerns summary (AI summary) There was a critical communication breakdown between mental health ward staff and police regarding a missing patient, with staff lacking understanding of police protocols and information requirements, leading to delayed high-risk classification.
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.