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 160 results
Gwyneth Edwards
Historic (No Identified Response)
2019-0472 5 Feb 2019 Bedfordshire & Luton
Bedford Hospital
Concerns summary (AI summary) Inadequate weekend transfer protocols, staff failing to action NEWS scores, and a flawed Mobile Medic system marking incomplete requests as done, coupled with staffing pressures, jeopardized patient monitoring and record-keeping.
Andrew Carr
Historic (No Identified Response)
2019-0038 31 Jan 2019 Birmingham and Solihull
G4S HM Prisons and Probation MOJ
Concerns summary (AI summary) Critical information on a prisoner's drug history was missed by the receiving prison, while drugs could be passed through the plumbing system, and contraband mobile phones exacerbated substance misuse.
Terence Penney
Historic (No Identified Response)
2019-0034 28 Jan 2019 Lincolnshire
Glen Dimplex Home Appliances Ltd LEC Refrigeration Office for Product Safety and Standards
Concerns summary (AI summary) A fatal fire resulted from a vapour leak in a relatively new domestic fridge, highlighting a potential widespread safety risk with similar units in circulation.
Jack Hubbard
Historic (No Identified Response)
2019-0033 28 Jan 2019 London Inner (North)
Egg London Nightclub
Concerns summary (AI summary) The nightclub's protocol for calling an ambulance, requiring duty manager approval and a second set of observations, created dangerous delays in emergency response.
Dennis Warner
Historic (No Identified Response)
2019-0470 28 Jan 2019 London (West)
Care Quality Commission Royal United Hospital
Concerns summary (AI summary) An elderly patient with advanced dementia received incomprehensible discharge information and inadequate follow-up due to ED overcrowding, suboptimal imaging, delayed senior review, and failed contact attempts.
Gareth Bickerstaff
Historic (No Identified Response)
2019-0029 25 Jan 2019 Manchester (North)
Joint Royal Colleges Ambulance Liaison …
Concerns summary (AI summary) Dangerous discrepancies exist between national and local ambulance guidance on the 15-minute timeframe for resuscitation, creating ambiguity and potential misinterpretation regarding when cardiac arrest officially begins.
Arun Viswambaran
Historic (No Identified Response)
2019-0487 24 Jan 2019 London Inner (North)
North East London NHS Trust
Concerns summary (AI summary) Excessive waiting times of up to 18 weeks for IAPT therapy and difficulties in contacting the team risked mental health deterioration and disengagement from services.
Gail Bailey
Historic (No Identified Response)
2019-0027 23 Jan 2019 Lincolnshire
United Lincolnshire Hospitals NHS Trust
Concerns summary (AI summary) A critical communication breakdown occurred between paramedics pre-alerting the hospital and the hospital's readiness for a critically ill patient, raising significant concerns for future emergency admissions.
Mylon Sheppard
Historic (No Identified Response)
2019-0025 17 Jan 2019 Warwickshire
Coventry & Warwickshire Partnership Tru… Coventry NHS Trust
Concerns summary (AI summary) Failures included ineffective oversight of duty worker decisions, poor waiting list management, unclear processes for patient non-attendance, and inadequate family involvement in care planning.
Mark Harris
Historic (No Identified Response)
2019-0023 17 Jan 2019 Suffolk
Emergency Operation Centre Norwich Melbourne Ambulance Station
Concerns summary (AI summary) Police received incorrect name spelling and unclear instructions for a welfare check, indicating critical communication failures and a lack of agreed protocols between ambulance and police services.