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
William Vickers
All Responded
2019-0255 26 Jul 2019 Milton Keynes
HMP Woodhill South Central Ambulance Services
Concerns summary (AI summary) Ambulance crews attending the prison lack access to the main radio system, and the first response to emergencies does not consistently include a fully qualified paramedic, impacting effective communication and care.
Action Taken (AI summary) HMP Woodhill updated contingency plans to expedite emergency vehicle access, including immediate contact with ambulance services, staff reporting to the prison to await the ambulance, and training for Operational Support Grades (OSGs). All Custodial Managers will have had the opportunity to test these new arrangements. CNWL NHS Trust has implemented new AEDs with data cards, introduced an Offender Care Resuscitation Review Group, and commissioned an external review of emergency response practices. A 'Train the Trainer' course was also completed to enable regular local emergency response training.
Stanislawa Kmiecik
All Responded
2019-0258 25 Jul 2019 Nottinghamshire
URBN UK Ltd
Concerns summary (AI summary) An accessible mezzanine area with an 18-foot drop lacked adequate safety measures, including proper signage, secure barriers, safety netting, and presented trip hazards due to an uneven surface, risking falls for staff and the public.
Action Taken (AI summary) Following the incident, URBN UK replaced the broken lock, removed moveable items from beyond the gate, instructed staff not to access the area, installed signage, replaced scaffolding with high railings, infilled voids with steel plates, installed a pulley system, and trained staff in harness use.
Adam Harris
All Responded
2019-0247 23 Jul 2019 Manchester (South)
Greater Manchester Police
Concerns summary (AI summary) Lack of formal risk assessment for prisoners in van docks, failure to search suspects, poor handover between officers, inadequate custody record keeping, and conflicting guidance on prisoner positioning for aspiration risk were critical concerns.
Noted (AI summary) Greater Manchester Police explained their procedures for allocating detainee cell space and the role of the cell allocation team and Custody Inspector. They also detailed officer training and procedures for handling detainees who may be confused or intoxicated, as well as explaining when a full custody record may not be completed immediately.
Richard Carlon
All Responded
2019-0287 22 Jul 2019 Birmingham and Solihull
Birmingham and Solihull Mental Health N… Birmingham City Council West Midlands Police
Concerns summary (AI summary) The unavailability of Approved Mental Health Practitioners delayed critical assessments, and poor inter-agency communication led to mental health services missing opportunities to re-engage with a patient.
Action Planned (AI summary) Birmingham City Council is implementing a 60-point improvement plan for AMHP services, including commissioning urgent beds, developing urgent care pathways, and improving information sharing. A workshop will be held to improve joint working between the Mental Health Trust and the AMHP service, with monthly project board meetings to oversee improvements. West Midlands Police will provide further guidance to call handlers on managing calls and incident grading related to missing persons, and will ensure callers are updated when a missing person is located. Full implementation is expected by November 2019.
Allan Joslin
All Responded
2019-0241 17 Jul 2019 Exeter and Greater Devon
NHS England
Concerns summary (AI summary) There is a nationwide lack of adequate mental health facilities and policies for complex patients with co-occurring issues and potential violence, leading to a lack of formal assessment and treatment, contravening equality legislation.
Noted (AI summary) The response contains no content.
JJ Wilson
All Responded
2019-0243 17 Jul 2019 Surrey
Health and Safety Executive
Concerns summary (AI summary) The absence of mandatory regulations requiring fire retardant overalls for test track drivers creates a serious risk of injury or death from fire in the event of a crash, despite their availability.
Disputed (AI summary) The Health and Safety Executive believes existing UK law requiring assessment of foreseeable risk is sufficient regarding the need for fire-retardant overalls and that no further action is required. They state that FIA regulations are outside of HSE's comment.
Darren Cumberbatch
All Responded
2019-0289 16 Jul 2019 Warwickshire
HM Prison and Probation Service
Concerns summary (AI summary) Probation hostel staff lacked crucial training and awareness regarding Acute Behavioural Disturbance (ABD), a medical emergency, leading to missed opportunities for early recognition, de-escalation, and appropriate management.
Action Planned (AI summary) The National Probation Service plans to assess and develop a training package regarding acute behavioural disturbance (ABD) for approved premises staff, with rollout expected to start in early 2020.
John Shackley
All Responded
2019-0238 12 Jul 2019 Berkshire
Highways Authority
Concerns summary (AI summary) The lack of a footpath, street lighting, and poor visibility on the A329 near a hotel forces pedestrians to cross a dangerous, unlit road.
Action Planned (AI summary) • The Royal Borough of Windsor and Maidenhead met with the Police on 7th August 2018 to review the circumstances around the crash. • The Highway Authority will monitor and review pedestrian activity in the area. • There is existing street lighting on the road corresponding.
Jason Imi
All Responded
2019-0238-wp26735 12 Jul 2019 Berkshire
Highways Authority
Concerns summary (AI summary) The absence of a footpath and street lighting near a hotel entrance on a main road forces pedestrians to cross in darkness with poor visibility, creating a significant risk of collision.
Action Taken (AI summary) • The Highways Authority met with the Police on 7th August 2018 to review the circumstances around the crash. • The Highways Authority will monitor and review pedestrian activity in the area. • There is existing street lighting on the road.
David Jukes
All Responded
2019-0329 12 Jul 2019 Birmingham and Solihull
Birmingham and Solihull Clinical Commis… Birmingham and Solihull Mental Health N… Black Country Partnership NHS Foundatio… +2 more
Concerns summary (AI summary) Critical information was withheld from mental health assessors in custody, and communication breakdowns meant existing mental health teams failed to assess the patient, despite being notified, creating significant risk.
Disputed (AI summary) NHS England and NHS Improvement will hold a national event by the end of March 2020 to discuss information sharing issues with liaison and diversion practitioners, NHS Commissioners, and police representatives. They are also working with West Midland Police regarding their new IT system. Staffordshire Police argues that adequate information *was* available on the custody record and that the Liaison and Diversion practitioner could have requested further information from custody staff, therefore no action is required. Birmingham and Solihull Mental Health NHS Trust has increased resources to all Home Treatment Teams, launched two Quality Improvement Projects and is recruiting additional staff to improve services. Black Country Partnership NHS Trust has taken several actions, including reviewing the L&D process, providing additional training to staff, and improving access to mental health databases, including rolling out staff access to the Spine. NHS Birmingham and Solihull CCG highlights increased investment into mental health services including crisis cafes and crisis houses to improve accessibility and experience of those in crisis and reduce the impact of crisis on other agencies across the region.
Robert Rostron
All Responded
2019-0237 11 Jul 2019 Manchester (West)
HC-One
Concerns summary (AI summary) Critical over-reliance on inadequately inducted agency nurses as senior staff led to unfamiliarity with essential policies, records, and patient care plans, resulting in medication errors.
Action Taken (AI summary) HC-One has implemented actions including requiring two colleagues to support all insulin administrations, creating a Home Improvement Plan for insulin administration safety, and revising the agency procedure to include robust checks. They also use an agency procedure since 2016 which is being revised and have implemented agency profiles to be held within the quality assurance system.
Lindsey Bailey
All Responded
2019-0235 11 Jul 2019 Staffordshire (South)
Midlands Partnership NHS Trust
Concerns summary (AI summary) Despite the patient's consent and capacity, there was a significant failure to share relevant information with her parents, potentially hindering her treatment and care.
Action Planned (AI summary) Midland Partnership NHS Trust is improving carer engagement by developing a Carer Engagement Standard Operating Procedure for Crisis Response Home Treatment Services, introducing a bespoke training programme for staff and is developing a letter for service users which outlines the importance of family involvement.
Carl Sargeant
All Responded
2019-0236 11 Jul 2019 North Wales (East and Central)
Welsh Government
Concerns summary (AI summary) The report highlights a need to provide appropriate support channels for high-profile individuals removed from government roles, regardless of mental vulnerabilities or the reason for their removal.
Action Planned (AI summary) The First Minister of Wales has consulted with current and former ministers and the family of the deceased to make changes to the process for ministers leaving the Cabinet. A new section will be added to the Welsh Government Ministerial Code to ensure the well-being of ministers is taken into account during reshuffles and that they are aware of available support services.
Allan Davies
All Responded
2019-0291 9 Jul 2019 Birmingham and Solihull
NHS Digital NHS England
Concerns summary (AI summary) The NHS Pathways triage system for overdose patients is too generic, failing to assess specific drug risks for sudden collapse, potentially categorizing high-risk cases incorrectly and endangering lives.
Action Taken (AI summary) NHS England highlighted the issue of triaging overdose cases to ambulance services and asked them to ensure robust clinical oversight is in place for self-harm and suicidal patients. A new diagnostic code (Dx0124) is being introduced in 'NHS Pathways Release 18' to raise visibility to clinicians, with widespread deployment planned for October 2019 after beta testing. NHS Digital (NHS Pathways) is deploying Release 18 which includes a new disposition code (Dx0124) to highlight potential overdose/suicide cases. They also reference a letter from NHS England to Ambulance Services about oversight of self-harm patients.
Keith Battman
All Responded
2019-0231 5 Jul 2019 West Sussex
West Sussex County Council
Concerns summary (AI summary) Insufficient road safety features, including inadequate chevrons, faded road markings, and lack of vehicle-activated warning signs, contribute to a dangerous sharp bend.
Action Taken (AI summary) West Sussex County Council has replaced small chevrons with a larger yellow-bordered chevron at the collision site. They plan to install a vehicle-activated flashing bend warning sign, and will remark 'SLOW' markings and junction markings by the end of August.
Alexander Boamah
All Responded
2019-0232 5 Jul 2019 London Inner (North)
Department for Work and Pensions
Concerns summary (AI summary) A lack of process for clinicians to alert DWP about vulnerable individuals receiving large funds, particularly those without capacity, puts them at high risk of illicit substance misuse.
Action Planned (AI summary) The DWP is currently reviewing its safeguarding policy and guidance with the aim of strengthening existing procedures. The review will consider communication channels between the Department and treating clinicians and is scheduled to provide a revised policy and guidance in September 2019.
Jennifer Withey
All Responded
2019-0225 3 Jul 2019 Cornwall and the Isles of Scilly
NHS England NHS Pathways
Concerns summary (AI summary) The 111 call system lacks automated red flags for critical symptoms like sepsis, and fragmented response pathways between organizations create unnecessary delays in urgent patient care.
Action Taken (AI summary) NHS England confirms they liaised with NHS Digital and NHS Pathways. NHS England updated standards by which Out-of-hours organisations are measured with IUC KPIs in October 2018, and have been collecting data to measure and monitor KPIs since January 2019. NHS Digital updated NHS Pathways (Release 15, deployed May 2018) to better identify critically ill patients at risk of sepsis, including the qSOFA assessment, compliant with NICE guidance NG51. This includes questions about functional impairment, with positive answers leading to emergency ambulance dispatch.
Andrew McCall
All Responded
2019-0228 1 Jul 2019 Stoke-on-Trent & North Staffordshire
NHS England
Concerns summary (AI summary) A critical lack of verification for patients' methadone prescriptions by GPs, who rely on self-declaration, led to potentially harmful prescribing of other medications for drug-seeking behavior.
Action Planned (AI summary) NHS England will contact Addiction Dependency Solutions to review processes for collecting/verifying GP data and information sharing. They will also write to all Staffordshire GP practices to highlight risks and ask them to alert the clinic if they receive information relating to a patient not registered at the practice.
Peter Lawrence
All Responded
2019-0245 1 Jul 2019 Black Country
Walsall Mental Health Partnership Walsall Metropolitan Borough Council
Concerns summary (AI summary) Inadequate joint multi-disciplinary care planning and excessive reliance on a tribunal decision led to delayed responses to relapse indicators and insufficient follow-up for a patient with a history of disengagement.
Action Planned (AI summary) The Trust, in conjunction with Walsall Council, has formulated a joint action plan to ensure that policies and procedures relating to multidisciplinary/agency care plans and risk assessments meet the needs of community patients with complex needs.
Edir DA Costa
All Responded
2019-0211 27 Jun 2019 London (East)
Metropolitan Police
Concerns summary (AI summary) Many police officers are not up-to-date with mandatory Emergency Life Support training, and monitoring compliance is difficult, leading to critical delays in commencing CPR.
Action Taken (AI summary) The Metropolitan Police have reduced the number of officers who need mandatory Emergency Life Support training. They have also circulated a reminder to all staff via a weekly MetCC Operational Update bulletin regarding policy compliance and will emphasise this policy in MetCC initial call handler training and Personal Development Days in October 2019.
Maureen Martin
All Responded
2019-0220 26 Jun 2019 Staffordshire South
University Hospitals of Derby and Burto…
Concerns summary (AI summary) The Nurses' Station desk on the ward was improperly positioned, obstructing staff visibility, which contributed to a patient's fall.
Action Taken (AI summary) The Trust removed the nursing station desk on Ward 5 and provided staff with a "desk on wheels" to improve visibility. A walkaround review has been undertaken of all of the nursing stations/desks at Queens Hospital Burton and they are all positioned correctly.
Colin Cameron
All Responded
2019-0218 26 Jun 2019 Gloucestershire
Network Rail
Concerns summary (AI summary) Signallers lacked instructions for extracting information from users, and authorities had not sufficiently considered closing the railway crossing.
Noted (AI summary) Network Rail states that instructions *are* provided to signallers, and closing the crossing would require agreement from the authorised user, for which compensation has been offered. They have also contacted the public rights of way officer at Gloucestershire County Council to consider the feasibility of extinguishing or diverting the bridleway.
Priscilla Tropp
All Responded
2019-0213 24 Jun 2019 London (North)
Department for Transport Govia Thameslink Railway Office of Rail and Road
Concerns summary (AI summary) The station lacked a clear flow chart or plan to guide staff on appropriate steps to take when a person falls ill, risking further injury.
Noted (AI summary) The Office of Rail and Road believes the report would be better served to the station operator and infrastructure manager, as ORR does not have the power to take the action proposed by the Coroner. Govia Thameslink Railway has produced a new staff aide-memoire and is briefing staff on it, is updating Local Incident Response Plans, and has ordered new privacy screens for key locations. The Department for Transport is satisfied that measures undertaken by Govia Thameslink Railway should resolve the Coroner's concerns and will continue to manage all of its franchises through normal commercial management procedures.
Marcus McGuire
All Responded
2019-0209 23 Jun 2019 Birmingham and Solihull
HMP Birmingham, MOJ, G45
Concerns summary (AI summary) HMP Birmingham failed to consistently assign single case managers for ACCT plans, leading to deficiencies in care and follow-up. Concerns exist that management is not accurately reporting the extent of improvements.
Noted (AI summary) HMP Birmingham has trained additional case managers, monitors compliance with the single case manager model daily, reviews it monthly, and has introduced further quality assurance of every ACCT document. G4S states that actions at HMP Birmingham are not within its remit as the prison is now operated and managed by HMPPS, but they reflect on every death in custody and consider lessons learned to inform best practice across their establishments.
Michael Cox
All Responded
2019-0203 20 Jun 2019 Cornwall and the Isles of Scilly
Cornwall Council
Concerns summary (AI summary) There is a critical shortage of suitable long-term placements for individuals with complex mental health histories, causing persistent difficulties for social workers in finding appropriate facilities.
Action Planned (AI summary) Cornwall Council is developing a multiagency strategy (2019-23) to improve support for people with complex needs, including mental health and substance use issues. A task and finish project will review prevention services, domiciliary care, and supported housing, aiming to develop specialist supported housing and address gaps in service provision by April 2021.