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
Katie Croft
Historic (No Identified Response)
2019-0393 19 Nov 2019 Manchester (South)
College of Policing Department for Education Department of Health and Social Care
Concerns summary (AI summary) Inexperienced police officers handled serious allegations, failing to seize evidence promptly or collaborate effectively with social services. Reliance on agency social workers, poor information sharing, and a lack of mechanisms for schools to receive assessment data further compromised child safeguarding.
Helen Barker
Historic (No Identified Response)
2019-0392 19 Nov 2019 Lincolnshire
CAT East Midlands Ambulance Service
Concerns summary (AI summary) Concerns exist regarding emergency medical service protocols: specifically, the lack of a mechanism for escalating low-priority calls (C3) to high-priority (C2) when response times are exceeded, and inadequate contact with NHS 111 for unassessed C3 calls.
James Fennell
Historic (No Identified Response)
2019-0391 19 Nov 2019 Berkshire
South Western Railways Office of Rail and Road
Concerns summary (AI summary) Wokingham Station has insufficient and poorly located signage for the live third rail, with no warnings visible from main platform areas or tactile paving, despite high footfall and significant electrocution risk.
Andrew Wells
Historic (No Identified Response)
2019-0389 19 Nov 2019 Birmingham and Solihull
Midlands Partnership NHS Trust
Concerns summary (AI summary) The Trust's Root Cause Analysis was flawed due to a lack of psychiatric expertise, resulting in an inadequate review of clinical decisions. Clinicians also failed to appropriately apply the Mental Health Act, using "de-facto" detention without proper safeguards.
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.
Alex Grady
Historic (No Identified Response)
2019-0386 18 Nov 2019 Manchester (North)
Village Medical Centre
Concerns summary (AI summary) A GP-led alcohol detoxification lacked specialized support, follow-up appointments were insufficient, and a computer system glitch prevented GPs from accessing a complete list of previous prescriptions.
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.
Mary Hoare
Historic (No Identified Response)
2019-0385 15 Nov 2019 Birmingham and Solihull
Friendship Care and Housing Limited
Concerns summary (AI summary) Care providers rely on incomplete applicant information and fail to routinely seek GP records or complete thorough service user assessments before admission. This leads to unsuitable placements and a lack of post-admission care plans and risk assessments.
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
Serena Nicholas
Historic (No Identified Response)
2019-0381 14 Nov 2019 West Yorkshire (East)
Hull University Teaching Hospitals NHS …
Concerns summary (AI summary) Disjointed management and lack of identified consultants for a high-risk pregnancy led to poor continuity of care. Critical information about fetal inactivity went unreported and unheeded, causing a delay in necessary intervention.
Joanna Flynn
Partially Responded
2019-0369 14 Nov 2019 Essex
Department of Health and Social Care Fern House Surgery Mid Essex Clinical Commissioning Group … +1 more
Concerns summary (AI summary) There is a significant lack of specialised assistance, referral agencies, and adequate training for General Practitioners to help patients safely wean off addictive prescription opiates.
Noted (AI summary) NHS England/Improvement acknowledges the need for national-level guidance and support, highlighting a review group established in response to the PHE review. They note the complexity of patients with addiction to prescribed medications and the need for multidisciplinary input. The Department of Health and Social Care highlights the PHE report on prescription drug dependence and the review of overprescribing led by Dr Keith Ridge. The Mid-Essex CCG will implement a Management of Prescribed Opioid Dependence Locally Enhanced Service from April 2020. Mid Essex CCG details plans for a Local Enhanced Service for substance misuse, joint guidance for de-prescribing, and a session on Opioids and Safe Prescribing at the CCG's Time to Learn event in March.
Edward McGivern
Historic (No Identified Response)
14 Nov 2019 Berkshire
Slough Borough Council Highways Departm…
Concerns summary (AI summary) The current road layout and cycle lanes at a junction create a risk of cyclists being struck by left-turning motor vehicles, especially commercial ones, due to poor visibility and positioning.
Dorothy Macey
Historic (No Identified Response)
2019-0388 13 Nov 2019 Mid Kent and Medway
Medway Community Healthcare
Concerns summary (AI summary) Failures in district nurse care included not photographing wounds, poor information sharing with GPs about treatment delays, incomplete electronic records, missed sepsis checks, and inadequate care plan updates.
Evha Jannath
Historic (No Identified Response)
2019-0368 13 Nov 2019 Staffordshire (South)
Alton Towers Drayton Manor Theme Park Legoland +3 more
Concerns summary (AI summary) The ride suffered from inadequate CCTV monitoring due to staffing issues, lack of clear safety warnings to guests, poor signage, and no staff training or equipment for water rescue, alongside unclear emergency procedures.
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.
Pamela Moran
Historic (No Identified Response)
2019-0367 12 Nov 2019 Swansea Neath & Port Talbot
ABMU Health Board
Concerns summary (AI summary) Missed opportunities for a CT scan and lack of a system for overnight consultants to authorise scans contributed to delayed diagnosis and potentially preventable death.
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.
Peter Connelly
Historic (No Identified Response)
2019-0376 7 Nov 2019 North Wales (East and Central)
Betsi Cadwaladr University Health Board Ysbyty Gwynedd
Concerns summary (AI summary) Persistent, unacceptable delays in patient handover at emergency departments and prolonged ambulance waits continue to put patients' lives at risk by delaying timely medical intervention, despite previous assurances.
Charlotte Jacobs
Historic (No Identified Response)
2019-0365 7 Nov 2019 Manchester City
Manchester University NHS Foundation Tr…
Concerns summary (AI summary) A consultant lacked understanding of appropriate patient transfers and capacity assessments, while key staff were unaware of internal investigation findings. An essential transfer protocol also remained uncompleted, risking inappropriate discharges.
Hazel Lewis
Historic (No Identified Response)
2019-0377 6 Nov 2019 Manchester (North)
Advocacy Together Heywood Health Pennine Care NHS Trust +1 more
Concerns summary (AI summary) Inadequate Mental Capacity Act training resulted in staff failing to understand decision-making processes, consultation requirements, and the need to explore all options, leading to unconsulted and potentially inappropriate treatment decisions.
Darren Williams
Historic (No Identified Response)
2019-0375 6 Nov 2019 Milton Keynes
HMP Woodhill
Concerns summary (AI summary) ACCT reviews in prison were frequently held without healthcare staff present, and relevant information from prior ACCTs was not consistently used when new ones were opened.