2019
PFD Reports
Reports: 527
Areas: 66
70% response rate (above 63% average).
Robert Lowe
Historic (No Identified Response)
2019-0319
20 Sep 2019
Durham and Darlington
Chilton Care Centre
Concerns summary (AI summary)
Ineffective placement of pressure mats allowed residents to bypass them, and unreliable audible alarms meant falls went undetected by staff.
Kathryn Barrow
Historic (No Identified Response)
2019-0308
19 Sep 2019
Manchester (South)
Heaton Moor Medical Group
Concerns summary (AI summary)
GPs prescribed Diazepam without verifying consultant advice or checking for illicit access, and the practice had not reviewed its prescribing approach for this medication.
Ian Bromley
All Responded
2019-0307
19 Sep 2019
Manchester (South)
Pennine Care NHS Trust
Concerns summary (AI summary)
The Home Treatment Team lacked a dedicated Consultant Psychiatrist, and interim psychiatric support via a rota system was inconsistently effective due to varying individual approaches and workloads.
Action Taken
(AI summary)
The Home Treatment Team has an Advanced Practitioner and the team manager is now a qualified prescriber. The Home Treatment Team has acquired additional CCG funding to extend the medical cover, with the Trust Medical Director is providing part-time cover to the team.
Irene Collins
Historic (No Identified Response)
2019-0306
19 Sep 2019
Manchester (South)
MHPRA
Concerns summary (AI summary)
Unrestricted access and disposal of clinical examination gloves in care settings pose a risk, particularly for residents with cognitive impairment who can easily access them.
Caspian Thorn
Historic (No Identified Response)
2019-0305
19 Sep 2019
Manchester (South)
HSIB
The Secretary of State for Health
Concerns summary (AI summary)
Poor communication between midwifery and social work teams, undocumented calls, and delayed review of pathological CTGs contributed to missed opportunities for monitoring a vulnerable baby and identifying early sepsis.
Mark Jarvis
Historic (No Identified Response)
2019-0304
19 Sep 2019
Suffolk
NHS England
SystemOne TPP Ltd
Concerns summary (AI summary)
The prison's SystmOne prescription system was difficult to use and incompatible, preventing medical staff from clearly verifying patient medication history, repeat prescriptions, and potential drug misuse.
Peter Harrison
Historic (No Identified Response)
2019-0303
19 Sep 2019
Manchester (South)
Stamford Quarter Shopping Centre
Concerns summary (AI summary)
An external maintenance staircase, not requiring regular public access, was easily accessible and unsecured, posing a safety risk.
Graham Saffery
All Responded
2019-0301
18 Sep 2019
Bedfordshire & Luton
N.I.C.E
Concerns summary (AI summary)
The BNF, a key GP resource, lacks warnings for co-prescribing amitriptyline and oxycodone, despite other guidance recommending caution and monitoring for this interaction.
Action Taken
(AI summary)
The CCG has shared learning from the incident with other practices and the East of England NHS England, developed a SystmOne search to identify at-risk patients, briefed prescribing leads, and will continue to monitor a national dashboard for patients on specific medication combinations. They have also discussed the learning with chief pharmacists at local hospitals and ELFT.
Jonathan Ball
Partially Responded
2019-0507
17 Sep 2019
West Yorkshire (East)
DAF Trucks Ltd
DVSA
Office of the Traffic Commissioner
+3 more
Concerns summary (AI summary)
The HGV lacked a warning device for stranded vehicles, the driver was not trained to report hazards, and the rear hazard warning light was hard to see, with no added resilience from duplicate lights.
Noted
(AI summary)
Whitelocks Development Ltd has purchased warning triangles for HGVs, instructed drivers on emergency service contact, instructed drivers to clean light lenses and are considering fitting auxiliary warning lights, with completion of these actions planned for end of November 2019. The Office of the Traffic Commissioner explains the Traffic Commissioners' role and refers the coroner to the Department for Transport regarding legislation and the DVSA regarding driver training. DAF Trucks states that the vehicle was originally supplied with a safety kit including warning triangles, and that a bulb monitoring system was in place. They deem no action is required from them, as the lighting system was subsequently altered by another organisation. The RHA will raise awareness of equipment shortages and driver training issues through member emails, a magazine article, and at member events.
Tyla Cook
All Responded
2019-0299
17 Sep 2019
Norfolk
Norfolk and Suffolk NHS Trust
Norfolk County Council
Queen Elizabeth Hospital
+1 more
Concerns summary (AI summary)
Significant delays in accessing specialized services due to heavy caseloads, outdated written care plans despite family requests, and a failure to implement crucial multi-disciplinary emergency response training.
Action Planned
(AI summary)
Norfolk and Suffolk NHS Foundation Trust has developed a process for joint working between teams for complex cases, implemented a risk assessment process for transfers, and is planning a multi-agency meeting to plan a learning event, following recommendations from a review. The Queen Elizabeth Hospital reports that a multi-disciplinary meeting has been held and a learning event is planned for February 2020, with the West Norfolk CCG taking the lead on organisation. Norfolk County Council commissioned a Serious Case Review with findings and recommendations and a learning event has taken place on 7th November 2019. A further event will take place in early February 2020. The CCG is organizing a multi-disciplinary learning event for NSFT, QEH, NCC, and EEAST staff to address concerns raised in the PFD, with an external facilitator identified and a date in mid-February 2020 planned. The event will include a pen portrait of the deceased, wishes from their parents, and messages from involved staff.
Blaithin Buckley
All Responded
2019-0465
16 Sep 2019
Northamptonshire
General Council
Concerns summary (AI summary)
An unexplained delay occurred in calling an ambulance to transfer a patient from a mental health setting during a medical emergency, with unclear policies regarding ambulance activation.
Action Taken
(AI summary)
St Andrews Healthcare sent a red-top alert concerning the NEWS chart, refreshed NEWS training, is reviewing the deteriorating patient policy, has implemented a change so an ambulance is called when a medical emergency is called, and responses to medical emergencies will be monitored at governance meetings.
Arthur Jepson
All Responded
2019-0300
16 Sep 2019
South Yorkshire (West)
Yorkshire Ambulance Service
Concerns summary (AI summary)
High resource pressure resulted in a missed two-hour review of an emergency call, preventing re-categorisation and potentially impacting outcomes in future cases.
Action Taken
(AI summary)
The Trust has refreshed its approach to call-backs, implementing a filter in the CAD system to highlight incidents exceeding expected timeframes, and assigning senior clinical advisors to make call-backs. Reporting mechanisms are being implemented to ensure call-back procedures are followed.
Ffion Jones
Historic (No Identified Response)
2019-0298
16 Sep 2019
South Wales Central
Welsh Ambulance Service
Concerns summary (AI summary)
The improvement plan failed to address specific issues, and there's no dedicated pathway for urgent clinical discussions between external healthcare professionals and ambulance staff to ensure proper assessment of response urgency.
Taejelle Francois
Historic (No Identified Response)
2019-0297
16 Sep 2019
West Yorkshire (West)
Calderdale and Huddersfield NHS Trust
Chief Coroner
Concerns summary (AI summary)
A critically ill patient was taken to the A&E waiting area without visual assessment by reception or triage, missing crucial opportunities for early intervention and escalation of care.
Lucia Stear
All Responded
2019-0296
13 Sep 2019
Liverpool and Wirral
Department of Housing, Communities & Lo…
Local Government Association
Concerns summary (AI summary)
Other public authorities may have unaddressed safety issues similar to Wirral MBC's tree management, necessitating national learning and action from the tragic death.
Noted
(AI summary)
The LGA will include an item in its email bulletins to local authority chief executives and environmental officers, will host an online event with relevant officers by the end of December 2019, and will liaise with the Ministry of Housing, Communities and Local Government to address recommendations nationally. The Ministry acknowledges the coroner's concerns and highlights the increase in Core Spending Power for local government and the allocation of funds for park renovations, noting that spending on parks is a matter for local authorities.
William Oliver
All Responded
2019-0494
12 Sep 2019
Manchester (North)
Blackpool Clinical Commissioning Group
Department of Health and Social Care
North West Ambulance Service
Concerns summary (AI summary)
The ambulance service's rigid meal break policy reduced vehicle availability during peak demand, compounded by excessive hospital turnaround times, leading to significant delays.
Action Planned
(AI summary)
The Trust has implemented measures to improve ambulance turnaround times, including daily meetings to review patient flow, screens displaying ambulance information, purchasing additional trolleys, and having Ambulance Liaison Officers on site during high demand. The Trust also joined a Phase 2 NWAS ambulance handover collaborative project. Blackpool CCG emphasized a Roster Review in commissioner requirements and are involved in initiatives to improve hospital handover times by using improvement methodology with several hospitals. They are also part of a North West Handover Improvement Board. NWAS is trialing a pilot program in the Cheshire and Mersey EOC to manage meal breaks differently, involving a mandatory staggered stand down of resources. They will also be adding 250 paramedics to the service by March 2020. The Department of Health and Social Care outlined actions to improve ambulance services, including implementing an improved ambulance performance framework, issuing revised hospital handover guidelines, and improving monitoring and reporting of patient handover delays. They also made the AACE aware of the coroner's concerns.
Carl Schmidt
All Responded
2019-0358
11 Sep 2019
West Yorkshire (East)
University of Birmingham
Concerns summary (AI summary)
The chemo-radiotherapy in a clinical trial potentially exposes patients to neurological damage, requiring further investigation into the mechanism of injury.
Noted
(AI summary)
The University of Birmingham offers condolences and provides background information on its commitment to clinical trials, then addresses specific questions raised by the coroner regarding the medical details of the case, without outlining any actions to be taken.
Maureen Jarvis
All Responded
2019-0357
11 Sep 2019
Staffordshire South
Midland Partnership NHS Trust
Concerns summary (AI summary)
A psychiatric patient lacked a proper medical examination due to consent issues, highlighting the need for a clear, disseminated policy on physical health examinations for admitted psychiatric patients.
Action Taken
(AI summary)
Midland Partnership NHS Trust circulated existing policies and SOPs to staff, provided bespoke training on physical health difficulties, developed an electronic dashboard for physical health assessments, secured regular input from an Advanced Nurse Practitioner, and reminded staff to record consent. A full action plan was developed and is enclosed.
Gurdeep Singh Dundhal
All Responded
2019-0294
10 Sep 2019
Birmingham and Solihull
Birmingham City Council
Birmingham Women’s and Children’s NHS T…
Priory Group of Hospitals
+1 more
Concerns summary (AI summary)
Systemic delays in mental health act assessments due to inter-agency confusion and resource shortages led to critical information being missed and the incorrect legal framework being applied. Walsall MBC also failed to investigate these failings.
Disputed
(AI summary)
Birmingham Women's and Children's NHS Foundation Trust redistributed the safer inter agency information sharing guidance within the urgent care team. They have also been contacted by Walsall MBC and have been invited to participate in a multi agency meeting to discuss this matter. Priory Group states that relevant information relating to Mr. Dundhal was made readily available to the assessing team and that their clinician was available for contact, disputing concerns that information was unavailable. Walsall Council conducted an investigation and review, increased the number of AMHPs, changed AMHP working practices, and opened discussions with neighboring authorities to formalize practices of asking neighboring authorities to carry out reviews within the borough of Walsall. There will also be a manager on duty or on call.
Shannon Quinn
Partially Responded
2019-0499
6 Sep 2019
Black Country
Camino Healthcare
Care Quality Commission
Department of Health and Social Care
+1 more
Concerns summary (AI summary)
Multiple failures in multi-agency communication, inadequate staff training, and poor risk management regarding ligature use, patient observations, and resuscitation significantly compromised care for a patient with complex mental health needs.
Action Taken
(AI summary)
Camino Healthcare has undertaken a significant review, appointed a new Executive team, evaluated training, provided further training in Intensive Life Support and Basic First Aid, and made changes to make the environment anti-ligature. The service is also in the process of closing. CQC took urgent enforcement action against Oak House, imposing conditions on the provider's registration. The provider submitted an action plan to deliver new training to staff, which CQC will follow up on at the next inspection.
Millie Creasy
Historic (No Identified Response)
2019-0293
6 Sep 2019
Bedfordshire & Luton
Luton & Dunstable NHS Trust
Concerns summary (AI summary)
A child was discharged after a prolonged seizure without sufficient observation, and neuroprotective strategies for potential hypoxic brain injury were not considered by the hospital.
Tillie Spencer-Adams
All Responded
2019-0356
5 Sep 2019
Hertfordshire
East and North Hertfordshire NHS Trust
Concerns summary (AI summary)
Serious fractures and head injuries sustained in a road traffic collision were critically overlooked when the deceased attended the hospital.
Noted
(AI summary)
The Trust explains the care provided to Tillie Spencer-Adams on 4th May 2018, stating it was appropriate and in line with national guidance, and that there was no indication of injury to her forearm or head, and highlights existing clinical governance measures.
Imran Mahmood
All Responded
2019-0355
4 Sep 2019
Staffordshire South
HM Prison and Probation Service
Concerns summary (AI summary)
E-cigarettes in prison are being misused as heating devices for drug preparation, highlighting a significant safety risk related to both illicit drug use and potential fires.
Action Planned
(AI summary)
HMPPS is considering alternative vape devices, including one using vapourless valve technology, to mitigate risks associated with e-cigarettes in prisons, but is constrained by cost and commercial availability.
Evelyn Swift
Historic (No Identified Response)
2019-0354
29 Aug 2019
Nottinghamshire
Beechdale Medical Group
Concerns summary (AI summary)
The medical group lacked safe procedures for triaging patients, allocating home visits, providing urgent clinical advice, documenting calls, and ensuring sufficient clinical capacity; they also lacked processes to review significant events and learn from them.
Michael Hoolickin
All Responded
2019-0292
29 Aug 2019
Manchester (North)
Greater Manchester Police
Lancashire Constabulary
Ministry of Justice
+2 more
Concerns summary (AI summary)
The coroner is reporting to prevent future serious further offence reviews following a death.
Noted
(AI summary)
The NPCC acknowledges the concerns and explains its role in encouraging collaboration between forces, stating that it will share the report and IOM guidance with chief constables across the country, but does not have the authority to direct action. The Probation Service acknowledges the need for learning and improvement. The Greater Manchester IOM Framework is currently subject to review and your concerns will be considered as part of this review. Where deemed necessary further guidance or clarification including templates such as draft agenda, minutes and action logs will be included. Response contains no text. Response contains no text.