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
Sharon Reeve
Historic (No Identified Response)
2019-0346 21 Oct 2019 West Yorkshire (West)
Calderdale and Huddersfield NHS Trust Leeds Teaching Hospitals NHS Trust
Concerns summary (AI summary) A lack of clear pathways for specialist referrals and suboptimal communication between hospitals led to inappropriate referrals, delayed diagnoses, and wasted time for complex cases.
Elisa Fuller
All Responded
2019-0481 17 Oct 2019 Gloucestershire
Gloucestershire Hospitals NHS Trust
Concerns summary (AI summary) Insufficient support and systems hinder junior staff from escalating concerns to seniors, and there is a lack of understanding regarding the essential retention of placentas post-delivery.
Action Taken (AI summary) Gloucestershire Hospitals NHS Trust provided a mandatory update day for midwives, including a presentation on lessons learned from inquests. They have also developed a draft policy on placental retention and review, and plan a 'Black Box' event in January 2020 to improve multi-professional learning.
Victor Hall
Partially Responded
2019-0482 16 Oct 2019 Manchester (West)
Medicines and Healthcare products Regul… Nursing and Midwifery Council Salford Royal Hospital NHS Trust
Concerns summary (AI summary) Ambiguous medication packaging contributed to an error, which the MHRA failed to address. There's a need for enhanced guidance and training for nursing and pharmacy staff on thorough medication checks and documentation at all stages.
Action Planned (AI summary) The Trust will undertake a full review of the dispensary environment at Salford Royal Hospital, looking at workspace design and dispensing processes, with implementation by the Learning and Development team by 31st December 2019. Nursing staff will ensure medicine safety mandatory training compliance, weekly senior nurse walkabouts will observe medication procedures, and a policy will be published to provide guidance about medicine safety incidents.
Matthew Williamson
All Responded
2019-0349 15 Oct 2019 London (West)
West London Mental Health Trust
Concerns summary (AI summary) Carers and family lack opportunities to provide vital information to mental health teams, and unclear inter-provider communication creates difficulty navigating treatment pathways for patients.
Action Taken (AI summary) The Trust has amended operational policies to include sections on strengthening family involvement and has mandated Carer Awareness and Triangle of Care training for Ealing PCMHS staff. They are also taking steps to establish a Carers Council.
Derek Weaver
All Responded
2019-0345 15 Oct 2019 London Inner (South)
Department of Health and Social Care Guys & St Thomas NHS Trust NHS England
Concerns summary (AI summary) Capacity limitations due to a surge in referrals delayed critical surgery, leading to a higher chance of death due to sepsis. Insufficient resources and beds risk future preventable deaths.
Noted (AI summary) The Department of Health acknowledges the concerns, notes that NHS England is responding separately, and highlights peer review activities of thoracic services in London and oversight to ensure timely access to thoracic surgery. The response also references the legal duty of candour for NHS trusts during investigations. The Trust has implemented a new triage process managed by Site Nurse Practitioners, enabling prioritization of patients needing urgent admission within 48 hours. They are also looking at an electronic referral system and increasing the number of beds for Thoracic Surgery patients by Q1 2020. NHS England is reviewing capacity for thoracic surgery, including critical care beds, in light of new lung cancer pilots and concerns raised. They will keep pathways under review to ensure timely access to high-quality services.
Alex Malcolm
Partially Responded
2019-0344 15 Oct 2019 London Inner (South)
Department of Health and Social Care HM Prison & Probation Service MOJ
Concerns summary (AI summary) Insufficient Approved Premises, delays in making MARACs statutory, and difficulties recruiting probation officers due to low pay are systemic issues hindering efforts to prevent future deaths.
Action Taken (AI summary) HMPPS introduced a new pay structure in April 2018 for the National Probation Service, including a two-year pensionable pay award and a London Allowance and Market Forces Allowance to address recruitment and retention issues.
Cesar Gonzalez Barron
Historic (No Identified Response)
2019-0342 14 Oct 2019 London Inner (North)
First Aid Cover Limited Roundhouse White Branch Live Limited
Concerns summary (AI summary) Multiple failures in event first aid included delayed recognition of collapse, inadequate first aider briefing and knowledge of venue protocols, poor communication, and a chaotic scene that delayed CPR and ambulance access.
Dev Naran
All Responded
2019-0341 14 Oct 2019 Birmingham and Solihull
Highways England
Concerns summary (AI summary) Motorway management lacks automatic detection for stationary vehicles in live lanes, compounded by long gaps in emergency refuge areas and confusing signage on dynamic hard shoulders, increasing the risk of fatal collisions.
Action Planned (AI summary) National Highways is introducing stopped vehicle detection capability, exploring other technologies to reduce risk, and running information campaigns on emergency procedures and safe driving practices from January 2020 to March 2021.
Liane Davenport
Partially Responded
2020-0136 10 Oct 2019 Cumbria
Medicines and Healthcare Products Regul… North Cumbria University Hospitals NHS …
Concerns summary (AI summary) There is a need to consider and recommend routine blood level monitoring for patients on long-term, high-dose antipsychotics, especially for older and frailer individuals.
Noted (AI summary) The Trust states that the care provided to Ms Davenport was appropriate. They have reviewed HDAT monitoring policy which includes ECG, Urea and electrolytes, Liver function, Prolactin, blood pressure and pulse, clinical signs of hydration, glucose regulation, review of side effects and PRN medication, but excludes monitoring blood levels.
Ian Bean
Historic (No Identified Response)
2019-0340 10 Oct 2019 Cornwall and the Isles of Scilly
East Midlands Ambulance Service
Concerns summary (AI summary) An ambulance was incorrectly dispatched to the wrong address, sending it to Mr. Bean's father in a different county instead of to Mr. Bean.
Abdeslam Benelghazi
All Responded
2019-0337 10 Oct 2019 Avon
Department of Health and Social Care
Concerns summary (AI summary) Concurrent prescribing of methadone with multiple sedative medications, particularly clonazepam, created a dangerous combined effect of central nervous system and respiratory depression, significantly increasing the risk of sudden death.
Action Planned (AI summary) The Department of Health and Social Care plans to publish a White Paper in early 2020 responding to the Independent Review of the Mental Health Act and will consult publicly on proposals to amend the Act.
Emily Sims
All Responded
2019-0336 9 Oct 2019 Cornwall and the Isles of Scilly
Antron Manor Care Home
Concerns summary (AI summary) Care plans were not updated to reflect changing needs or multidisciplinary decisions. There was a lack of appropriate equipment, specialist advice, and staff training in equipment use and moving/handling.
Action Taken (AI summary) The care home implemented a new care plan template that includes a system for recording outcomes of meetings with professionals. Staff receive regular training and supervision, and a manual handling assessment is included in the new care plan.
James Frankish
Partially Responded
2019-0468 9 Oct 2019 Nottinghamshire
British Psychological Society Chief Medical Officer for England National Autistic Society +5 more
Concerns summary (AI summary) Healthcare professionals lacked understanding of Pica's dangers, and there is no national guidance for its identification, assessment, management, or monitoring for complications like bezoars.
Action Planned (AI summary) The British Psychological Society will emphasize Pica training and management in Clinical Psychology doctoral programmes and actively support the development and dissemination of multi-professional guidelines relating to the management of Pica.
Mary Chapman
All Responded
2019-0360 8 Oct 2019 Cheshire
Nuffield Health
Concerns summary (AI summary) The hospital's discharge policy is unclear regarding staff responsibilities and communication for critical post-discharge investigations. There's a lack of evidence that new procedures or multidisciplinary approaches have improved patient safety or consistent practice.
Action Taken (AI summary) Nuffield Health has implemented a new national discharge policy, provided additional training, and improved communication protocols. They are extending consultant pharmacist support across all 31 locations and are standardising discharge processes.
Steffan Evans
All Responded
2019-0339 8 Oct 2019 Staffordshire South
County Highways Department Staffordshire County Council
Concerns summary (AI summary) There are continuing concerns regarding the high volume and speed of traffic on the B5017, particularly at junctions, warranting a further review to improve road safety.
Noted (AI summary) Staffordshire County Council acknowledges the coroner's concerns regarding the B5017 Burton Road but states that collision data does not currently justify traffic calming measures. They are investigating if the road can be included in another funded scheme.
Dylan Henty
All Responded
2019-0334 8 Oct 2019 Cornwall and the Isles of Scilly
Pentree Lodge Home
Concerns summary (AI summary) Risks included unsupervised bathing for residents with seizure risk, GP unawareness of critical issues like hoarding, failed medication compliance systems, and inconsistent reporting/monitoring for absconding incidents.
Action Planned (AI summary) The care home will encourage residents with seizures to be escorted in the bathroom. The home will review its Risk Assessments and Care Plans and put in place the relevant measures surrounding bathing and showering, training on this specialist area will be undertaken by all staff. All staff will attend face to face medication training on the 10th December 2019.
Alf Rewin
All Responded
2019-0469 7 Oct 2019 Buckinghamshire
NHS Pathways
Concerns summary (AI summary) No specific safety concerns were identifiable from the provided administrative text.
Action Planned (AI summary) NHS Digital is requesting that ambulance trusts review their internal assurance processes regarding the management of patients who have self-harmed. NHS Digital agreed that all services should review the identification and management of these patients to ensure they are receiving the correct type of response and timely clinical assessment.
Jane Livingston
All Responded
2019-0359 4 Oct 2019 Swansea Neath & Port Talbot
ABMU Health Board
Concerns summary (AI summary) Gateway assessors lacked full access to patient notes, risking incomplete assessments and treatment plans based on insufficient information.
Action Taken (AI summary) • A detailed review of the information in the report has been undertaken by the Quality and Safety team for the Mental Health Swansea locality at Swansea Bay University Health Board. • A full investigation has been conducted into the events of the 14th December. • The Health Board confirms that the PARIS system has been audited during our investigation, and can confirm that the CMHT staff accessed the system at 12.29hrs on the 14th December 2018 to document the duty assessment conducted on Ms Livingston.
Jane Livington
Historic (No Identified Response)
2019-0359-wp26871 4 Oct 2019 Swansea Neath & Port Talbot
ABMU Health Board
Concerns summary (AI summary) Gateway assessors had incomplete access to patient notes, potentially resulting in inadequate assessments and treatment plans due to missing critical information.
Pamela Evans
All Responded
2019-0333 4 Oct 2019 Bedfordshire and Luton
Bedford Hospital NHS Trust
Concerns summary (AI summary) Nurses had a fundamental misunderstanding of when to call the critical care outreach team, compounded by a lack of audit, limited CCOT authority, incorrect NEWS scoring, and the Trust's failure to identify these issues.
Action Planned (AI summary) Bedford Hospital NHS Trust will ensure assessments and patient observations are carried out. The post falls protocols and level of escalation will be reviewed and there will be Shared learning and a reminder on contacting the critical care outreach team. Learning from this investigation will be shared using multi-channel communications.
Michael Lobban
Historic (No Identified Response)
2019-0489 4 Oct 2019 London Inner (West)
Boots UK Limted GPC NHS England
Concerns summary (AI summary) Boots' controlled drug audit and investigation processes for methadone disparities were inadequate, and the General Pharmaceutical Council lacks sufficient reporting requirements, investigative powers, and sanctions for such discrepancies.
Richard Ridout
All Responded
2019-0331 2 Oct 2019 West Sussex
Western Sussex Hospitals NHS Trust
Concerns summary (AI summary) A trauma call was not initiated despite clear indicators like a high-speed roll-over collision and high-force injury, leading to a failure to carry out a trauma series CT scan or c-spine imaging.
Action Planned (AI summary) The Trust is developing a protocol for the management of trauma patients with differing accounts of the incident and a protocol for patients who have sustained a fractured scapula, to be completed within 3 months.
Philip Owen
All Responded
2019-0330 2 Oct 2019 Manchester (South)
MOJ
Concerns summary (AI summary) Challenges exist in safely releasing high-risk offenders after short custodial sentences, compounded by limited probation supervision and unclear communication of risks or guidance to sentencing courts.
Action Taken (AI summary) HMPPS issued Probation Instruction (PI 05/2018) setting out arrangements agreed between the Ministry of Justice and the Senior Presiding Judge for liaison between courts and probation providers.
Saeid Hedayat
All Responded
2019-0327 2 Oct 2019 West Sussex
West Sussex County Council
Concerns summary (AI summary) West Sussex County Council's drain clearance risk assessment was inadequate, failing to account for specific blockages and lacking regular review or warning signs for known flood risks, despite available data and increased storm severity.
Action Taken (AI summary) WSCC reviewed their risk assessment process, taking into account changes in risk level and now account for flood events and silt levels when arranging gully cleansing. They dispute the need for permanent warning signs about flooding.
Oliver Sharp
Historic (No Identified Response)
2019-0328 1 Oct 2019 Manchester (South)
Department for Education Department of Health and Social Care Greater Manchester Health and Social Ca… +1 more
Concerns summary (AI summary) Inconsistent post-16 mental health services, long autism diagnosis waiting lists, and schools' lack of understanding for accelerated autistic adolescents create high-risk situations for mental health and self-harm.