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
Ceara Thacker
Partially Responded
2025-0249 30 Sep 2019 Liverpool and Wirral
NHS England NHS Improvement, Patient Safety Team
Concerns summary (AI summary) Professionals failed to discuss family involvement in care planning for a young adult with mental health issues. Additionally, the residential advisor lacked training on safe intervention for hangings.
Action Planned (AI summary) NHS England will focus on ensuring consent is reliably and consistently considered for family involvement in mental health care, particularly regarding complex electronic patient record systems and differing patient needs. They are also working with Universities UK to develop information sharing guidance and a consensus statement on sharing information without breaching confidentiality.
Amy Allan
All Responded
2019-0343 30 Sep 2019 London Inner (North)
Great Ormond Street Hospital NHS Trust
Concerns summary (AI summary) Critical information sharing failures between hospital departments, absence of pre-operative ECMO assessment and post-operative planning, conflicting extubation advice, and delayed ECMO commencement critically compromised patient care.
Action Taken (AI summary) Great Ormond Street Hospital has improved the spinal surgery pathway with intensive care and ECMO support, including ensuring relevant MDT members are involved in decisions, creating consultant-level handovers to ICU, and creating spinal CNS high-risk patient reminders. They also established a clear process for escalation to the ECMO team.
Owen Carey
All Responded
2019-0335 30 Sep 2019 London Inner (South)
British Society for Allergy and Clinica… Byron Hamburgers Department of Environment, Food and Rur… +3 more
Concerns summary (AI summary) The restaurant's allergen training was inadequate, notices on menus lacked prominence to trigger discussions, and menus failed to clearly state key allergen information, creating false reassurance for customers.
Noted (AI summary) Byron has rectified the lack of records kept of on-job training immediately and each employee will now have records kept, and are investing in a market leading training system called "Flow" which is launched in the business from November where every employee will have their own personal training modules and records. BSACI will write to the chair of the FSA to advocate for funding for the UK Fatal Anaphylaxis Registry (UKFAR), which they are exploring closer working with to ensure its sustainability. National Trading Standards states that food safety and allergen regulation is outside their remit, which focuses on regional or national issues like complex consumer fraud. They note the Food Standards Agency is responsible for allergen legislation and policy. The FSA plans to develop an online reporting system and improve data sharing for allergic reactions, including those not resulting in death, to enable timely identification of trends and action by local authorities. DHSC will work to increase information prevalence on anaphylactic deaths and will support the FSA's reporting platform.
Charles Williamson
All Responded
2019-0326 30 Sep 2019 Manchester (South)
Department of Health and Social Care Greater Manchester Health and Social Ca… Mayor of Greater Manchester
Concerns summary (AI summary) A shortage of appropriate neuro-rehabilitation beds in Greater Manchester is preventing early effective rehabilitation, increasing the risk of complications and death.
Noted (AI summary) Greater Manchester neuro-rehabilitation services have been undergoing transformation since 2016, with investment in community neuro-rehabilitation services in seven out of 12 areas and implementation planning for inpatient service transformation commenced in July 2019. Actions include development of community and inpatient service standards, peer review of inpatient services, a GM-wide training program, and a patient & carer network. The Department of Health and Social Care states that the provision of neuro-rehabilitation services in Greater Manchester is a matter for local NHS commissioners. It acknowledges the GMHSCP is implementing a new model of care for neuro-rehabilitation services and improving the quality of inpatient and community services.
Julie Barrow
All Responded
2019-0325 30 Sep 2019 Manchester (South)
Department of Health and Social Care
Concerns summary (AI summary) The hospital failed to hold best interest meetings, implement a reasonable adjustments care plan, and communicate effectively, exacerbated by poor staff awareness and loss of a learning disability liaison role.
Action Planned (AI summary) The Department of Health and Social Care is developing a learning disability and autism training package to be tested in 2020/21, with wider rollout planned after evaluation. They will also amend the Health and Social Care Act 2008 to mandate relevant training for NHS and social care staff.
Kaiya Campbell
Historic (No Identified Response)
2019-0324 30 Sep 2019 Manchester (South)
King Street Medical Practice Tameside Clinical Commissioning Group
Concerns summary (AI summary) GP and midwifery staff failed to seek urgent neurology guidance for a high-risk epileptic mother on anticonvulsant medication, resulting in inadequate management of fetal abnormality risks.
Graham Earl
Historic (No Identified Response)
2019-0323 30 Sep 2019 Manchester (South)
Greater Manchester Health and Social Ca… Park View Group Practice Stockport Clinical Commissioning Group
Concerns summary (AI summary) GPs lacked understanding of medication links to pulmonary fibrosis, failed to seek specialist guidance before amending prescriptions, and were unaware of side effect escalation procedures.
Mary Jones
Historic (No Identified Response)
2019-0322 30 Sep 2019 Manchester (South)
Manchester University NHS Trust
Concerns summary (AI summary) Inadequate out-of-hours transfer for a frail patient led to delayed risk assessment, compounded by poor fluid chart documentation, lost records from an IT merger, and a lack of nutrition referrals.
Edna Evans
Historic (No Identified Response)
2019-0318 27 Sep 2019 North Wales (East and Central)
Emral House Nursery Home
Concerns summary (AI summary) The care home had incomplete staff falls training, incorrectly categorised a high-risk patient as medium, and lacked a policy for reassessment following multiple falls.
Anthony McCormack
All Responded
2019-0317 27 Sep 2019 Birmingham and Solihull
Birmingham and Solihull Mental Health N… NHS Birmingham and Solihull Clinical Co…
Concerns summary (AI summary) A severe shortage of mental health beds prevented necessary inpatient treatment, while an overstretched home treatment team lacked resources for adequate patient assessment and monitoring.
Action Planned (AI summary) NHS Birmingham and Solihull ICB is allocating funding towards community based crisis support services run by MIND and crisis houses to complement inpatient mental health facilities. BSMHFT is also actively recruiting staff into the Home Treatment Team and other services.
John Shrosbree
All Responded
2019-0260 26 Sep 2019 Milton Keynes
Milton Keynes University Hospital
Concerns summary (AI summary) Persistent daily staff shortages in the Emergency Department are putting patients' lives at risk and require urgent attention.
Noted (AI summary) • The company's Clinical Application Specialist (CAS) will provide on-site training and support for a total of 4 weeks. • The training programme will incorporate the alarm classifications and the importance of maintenance of the lead attachments to ensure optimal performance of the monitors. • The company will also deliver 'Train the Trainer' with individuals to ensure future new starters can be trained following this initial period.
Anna Hedman
Historic (No Identified Response)
2019-0321 25 Sep 2019 London Inner (West)
Metropolitan Police
Concerns summary (AI summary) A police call handler's inadequate training led to a gross failure to prioritize preservation of life and call an ambulance, even when prompted, in an emergency situation.
Patrick Bolster
All Responded
2019-0314 25 Sep 2019 London Inner (North)
Network Rail
Concerns summary (AI summary) A broken fence was not inspected for over two years due to dense vegetation blocking the view, inspectors failed to view the fence from the public side, and system failures led to the track engineer and internal auditors not seeing evidence of the failure to inspect the fence.
Action Planned (AI summary) Network Rail is issuing a National Safety Bulletin to Off Track teams, completing a special topic audit on compliance with the new boundary inspection standard, and reviewing national data. These actions are tracked via the Network Rail CMO-Compliance Tracked Action system.
Ben Haddon-Cave
All Responded
2019-0314-wp26824 25 Sep 2019 London Inner (North)
Network Rail
Concerns summary (AI summary) Railway fence inspection failures, exacerbated by dense vegetation and inadequate viewing practices, alongside systemic flaws in dual inspection reporting, led to a lack of oversight and repair.
Action Planned (AI summary) • A National Safety Bulletin will be issued to all Off Track teams, which are the Network Rail maintenance teams that carry out boundary inspections. • The National Safety Bulletin will reference the key learning from this tragic event, specifically stating that where a team is unable to view a boundary fence from trackside due to vegetation, they must view the fence from the other (public) side. • The National Safety Bulletin will also state that if the fence cannot be viewed from either side, the team must record this and escalate it to their supervisor.
William Moody
Historic (No Identified Response)
2019-0312 25 Sep 2019 Hampshire
Hampshire Constabulary South Central Ambulance Service
Concerns summary (AI summary) The 999 call system caused confusion and delays in emergency response for a mental health crisis at home due to unclear agency responsibilities and lack of public awareness.
Iain Macinnes
Historic (No Identified Response)
2020-0118 24 Sep 2019 Milton Keynes
Central Northwest London NHS Foundation…
Concerns summary (AI summary) The trust failed to inform the patient's family about his deteriorating condition and transfer to the Home Treatment Team, despite his expressed wish for their involvement in his care.
Francis Hodge
All Responded
2019-0338 24 Sep 2019 London Inner (South)
University Hospital Lewisham
Concerns summary (AI summary) Inadequate and incorrect post-surgery discharge advice led the patient to delay seeking critical medical attention, compounded by the absence of a patient information leaflet.
Action Planned (AI summary) The Trust has commenced a communication exercise to remind staff in preoperative assessment to ensure that the appropriate information leaflet is handed to patients, and to document that this has been done. An audit of the provision of these leaflets will be completed by December 2019 to ensure that the communication strategy has been effective.
Muhammed Haleem
All Responded
2019-0316 24 Sep 2019 Manchester (North)
North west Ambulance Service Pennine Care NHS Trust
Concerns summary (AI summary) The NWAS system contained outdated DNA-CPR guidance for paramedics, and communication between community paediatric teams and emergency services regarding advance care plans was insufficient.
Action Planned (AI summary) NWAS acknowledges the need to improve its DNA-CPR marker system. The Trust’s EOC Governance Group has been tasked with reviewing the position and making recommendations, and an update will be provided within the next 3 months. Alerts have been placed on the NWAS system for all children with current advance care plans (ACP), to be reviewed annually. Archived paper notes/records for children with palliative care needs known to the Children's Community Nursing Team (CCNT) are being reviewed to ensure any ACP's are included, and the Lead Nurse at the Royal Oldham Hospital Children's A&E department has been given a list of the children known to CCNT who have ACPs to enable them to set up their own alert system.
Rebecca Marshall
All Responded
2019-0313 24 Sep 2019 London Inner (South)
Kent and Medway NHS and Social Care Tru…
Concerns summary (AI summary) The provided text is largely boilerplate and does not detail specific safety concerns beyond the general risk of future deaths related to hospital and mental health care.
Action Taken (AI summary) KMPT has reviewed its Transfer and Discharge of Care policy, developed a shared care protocol with local universities, created a fast-track referral route from universities to the Community Mental Health Team, piloted a direct referral form from the University Health Centre, strengthened the Consent to Share Information process, and incorporated the South London and Maudsley's Transient People policy.
Myla Deviren
Historic (No Identified Response)
2019-0311 24 Sep 2019 Cambridgeshire and Peterborough
Herts Urgent care Limited NHS 111 NHS Digital +1 more
Concerns summary (AI summary) NHS 111 and Out of Hours services lack mandatory annual training for staff on paediatric symptoms, sufficient specialist clinical review, and clear guidance to default to ambulance calls for sick children.
Annette Hewins
All Responded
2019-0310 24 Sep 2019 South Wales Central
Cwm Taf Morgannwg University Health Boa…
Concerns summary (AI summary) Inconsistent and inadequate nursing documentation for FACE records and NEWS charts, missed observations, ad hoc ECG request systems, and poor detail in patient observation charts indicate significant training and procedural failures.
Action Taken (AI summary) The Health Board developed and is implementing an action plan to address the matters raised during the inquest with a number of the issues already addressed and marked as complete.
Daniel Williams
All Responded
2019-0309 24 Sep 2019 London Inner (South)
St Thomas NHS Foundation Trust
Concerns summary (AI summary) Deficient fundamental nursing care on a general ward led to patient deterioration, exacerbated by a flawed C-diff infection investigation process that failed to examine initial care failures on the transferring ward.
Action Taken (AI summary) The Trust's C-diff Action Group reviewed the Trust's C-diff investigation process and revised it to include a stage to check whether the mandatory infection control data forms need to be sent to another ward in addition to the ward where the patient is currently located.
Kristiyan Danailov
Historic (No Identified Response)
2019-0315 23 Sep 2019 Dorset
Chemical Business Association Department for Environment, Food and Ru… Health and Safety Executive
Concerns summary (AI summary) Insufficient identity checks and obstacles exist to prevent vulnerable individuals from purchasing hazardous items online, indicating a lack of industry awareness about associated risks.
Ricky Barcock
Partially Responded
2019-0462 21 Sep 2019 West Yorkshire (West)
Oasis Recovery Communites Treatment Direct Limited
Concerns summary (AI summary) The client wellbeing check protocol during sleep needs review to ensure effective physical checks and rousing clients, especially drug users, to properly monitor their wellbeing.
Action Taken (AI summary) Oasis Bradford has reviewed and updated its Observation and Client Wellbeing Checks Policy December 2019 and plans to provide staff training to ensure working practice is safe and effective and in line with the policy changes.
Karis Braithwaite
Historic (No Identified Response)
2019-0415 20 Sep 2019 London (East)
Goodmayes Hospital NHS Trust
Concerns summary (AI summary) Important risk information provided by a paramedic was not available to the MHA assessment team, and insufficient steps have been taken to improve the handover process from first responders to Trust staff following serious incidents in the community.