2019
PFD Reports
Reports: 527
Areas: 66
70% response rate (above 63% average).
Jaspal Singh Bahra
All Responded
2019-0160
17 May 2019
Buckinghamshire
Civil Aviation Authority
Concerns summary (AI summary)
Aircraft operating in unregulated Class G airspace lack electronic proximity warning or collision avoidance devices, relying on the 'See and Avoid' procedure, which poses a safety risk.
Action Planned
(AI summary)
The Civil Aviation Authority will consider the merits of additional information on best practice CO contamination avoidance, in a ‘Safety Notice’ publication and will consult with stakeholders in making this decision by the end of Q3 2019.
Barry Fullarton
All Responded
2019-0159
17 May 2019
Liverpool and Wirral
Cheshire and Wirral NHS Trust
Concerns summary (AI summary)
Mental health assessments must account for the diurnal nature of reactive depressive illness, as an assessment at a good mood time may invalidate findings when mood is low.
Action Planned
(AI summary)
The Trust will develop and share a learning bulletin to outline the importance of responding to assessments for DMV, to be circulated to clinical teams by the end of July 2019. This learning will also be shared at a Trustwide Grand Round in September 2019 and included in the Suicide Prevention Training.
Jenson Francis
All Responded
2019-0158
17 May 2019
South Wales Central
Cwm Taf University Health Board
Concerns summary (AI summary)
A dysfunctional team exhibited unclear clinical leadership, poor CTG interpretation and communication, inadequate record-keeping, and insufficient staffing, with junior staff unable to challenge decisions.
Action Taken
(AI summary)
The University Health Board has implemented an Organisational Development Action Plan, including study days and mandatory training on communication and escalation, and has fully implemented PROMPT training. They have also implemented a new escalation policy, senior midwife on-call rota, and a birthrate plus acuity system for the labour ward.
Mellin Beard
All Responded
2019-0157
17 May 2019
Manchester (South)
Tameside and Glossop Care NHS Trust
Tameside General Hospital
Concerns summary (AI summary)
The Trust experiences persistent delays in timely referrals for community nursing post-discharge and relies significantly on agency nurses, impacting continuity of patient care.
Noted
(AI summary)
Tameside and Glossop Integrated Care NHS Trust states that the referral to District Nurses was made by hospital staff, contrary to evidence heard. They outline the Trust's processes for using Bank and Agency staff to fill vacancies and their recruitment/retention efforts.
Natasha Abrahart
All Responded
2019-0504
16 May 2019
Avon
Avon and Wiltshire NHS Mental Health Tr…
Department of Health and Social Care
Minister of Suicide Prevention
+1 more
Concerns summary (AI summary)
NICE guidelines for monitoring patients starting antidepressants, particularly those under 30 or at increased suicide risk, were not followed by the mental health trust or GP.
Action Taken
(AI summary)
The trust issued a "Red Top Alert" to medical personnel regarding NICE guidelines for prescribing anti-depressants (CG90), including communication with primary care and documentation. It will also be discussed at various meetings across the trust to share learning. The University practice now books appointments to review patients starting SSRIs within one week, and clinicians ideally book the next appointment before the patient leaves, with a message to alert staff if the patient cancels. They've also requested funding for a Mental Health Nurse. The Department acknowledges the concerns and highlights existing guidelines and initiatives, including updated NICE guidelines on antidepressant prescription and various government-funded projects to improve student mental health support and reduce suicide risks.
Benjamin Murray
All Responded
2019-0155
16 May 2019
Avon
Bristol University
Department for Education
Concerns summary (AI summary)
Low rates of mental health disclosure in university applications and the absence of formal investigation reports following student deaths indicate systemic gaps in student support.
Action Planned
(AI summary)
The University has shared its mental health and wellbeing strategies with sector colleagues and provided support to other institutions where student deaths have occurred. From September 2019 the SPRG will oversee the undertaking of a serious incident review for every suicide or serious attempted suicide. UCAS is redesigning the question about disabilities, special needs, or mental health issues on the application form, with a roundtable discussion planned for July and implementation in 2020 for the 2021 entry. The UCAS Hub is also being explored to alleviate anxiety and signpost support services. The department will work with Universities UK to remind HE providers of the recommendation to carry out serious incident reviews. Public Health England is happy to work alongside partners to support the development of a serious incident framework.
Marion Prance
All Responded
2019-0154
15 May 2019
South Wales Central
Welsh Ambulance Service
Concerns summary (AI summary)
Paramedics lacked awareness and training regarding the dangers of administering anticoagulants like Rivaroxaban to elderly fall patients with head injuries, requiring enhanced caution.
Action Planned
(AI summary)
The Trust acknowledged a paramedic's lack of awareness regarding Rivaroxaban and is implementing an action plan for individual learning and organizational changes. They will ensure all clinical staff are aware of the effects of Novel Oral Anti-coagulant drugs.
Karanbir Cheema
All Responded
2019-0161
10 May 2019
London Inner (North)
British Society for Allergy and Clinica…
Department for Education
Department of Health and Social Care
+5 more
Concerns summary (AI summary)
The report details issues at the deceased's school, including a patchy understanding of allergies, unchecked care plans and medical boxes, out-of-date medication, non-standardised allergy action plans, and a failure to send allergy action plans to the school.
Action Planned
(AI summary)
The London Ambulance Service raised the PFD regarding EpiPen usage with the UK Clinical Focus Group for IAED-MPDS and with the Executive Director of MPDS and awaits their conclusion. The Chief Medical Officer has shared the PFD with the Chair for The National Ambulance Service Medical Directors for their consideration. The Trust will review allergy action plans and injection techniques with children and carers in the clinic. They have added the additional process of posting or emailing each allergy plan to the school in question and advised the relevant department that before a clinic list is cancelled, the clinician is to review for time-critical appointments. Changes have been made so two adrenaline auto-injectors are kept with the child and two at school.
John Alliston
All Responded
2019-0153
9 May 2019
Gloucestershire
Department for Housing, Communities and…
Concerns summary (AI summary)
The lack of a mandatory requirement for electrical inspections in private rental properties, adhering to BS7671 standards, poses a risk of future deaths.
Action Planned
(AI summary)
The government will introduce a mandatory requirement for landlords in the private rented sector to ensure electrical installations are inspected at least every five years and will produce new guidance to which landlords may have regard in determining who is competent to carry out an electrical safety inspection.
Edward Hearn
All Responded
2019-0479
8 May 2019
London Inner (South)
Amgen Limited
Kings College Hospital
Medicines and Healthcare products Regul…
+3 more
Concerns summary (AI summary)
A system failure led to a critical high globulin blood test result in A&E not being followed up, delaying diagnosis. Additionally, prescribing information needs clearer guidance on cardiac monitoring.
Disputed
(AI summary)
Amgen believes that cardiac monitoring guidance is already definitively outlined in the prescribing information for Kyprolis, and that no further revisions to the SmPC are required. However, they will continue to conduct ongoing pharmacovigilance of Kyprolis and evaluate their SmPC guidance on cardiac monitoring. The case is being used to highlight to ED medical staff the importance of noting abnormal blood test results and ensuring appropriate follow-up, and work is ongoing to highlight the importance of reviewing test results on inpatients daily. A Safety Net is being prepared, and KCH and the PRUH standard lab comments to GP‟s for outpatient Biochemistry will be aligned. The MHRA considered whether the statutory information currently provided by the marketing authorisation holder for prescribers and patients on the safe use of carfilzomib is adequate. The statutory product information for cyclophosphamide and dexamethasone was also considered.
James Fletcher
All Responded
2019-0146
1 May 2019
Blackpool & Fylde
Blackpool Teaching Hospitals NHS Trust
Concerns summary (AI summary)
Inadequate guidance for caring for non-verbally communicative patients, poor record-keeping with missing entries and incomplete records, and significant miscommunication among medical and nursing staff compromised patient care.
Action Taken
(AI summary)
The Trust has implemented an Accessible Information Standard Policy, an Interpretation and Translation Procedure, and guidelines for the care of people with learning disabilities. It flags Blackpool residents with learning disabilities on electronic patient records and is working to extend this to Lancashire residents. A Red Alert has been issued to staff reminding them of vigilance for peritonitis in post-operative PEG tube patients.
Clive Jones
All Responded
2019-0217
30 Apr 2019
Plymouth, Torbay and South Devon
Department for Transport
Concerns summary (AI summary)
An independent review of UK Search and Rescue operational capability and HM Coastguard is needed, alongside a thorough review of their information technology systems for reliability.
Action Taken
(AI summary)
An independent review of the UK search and rescue (SAR) operational capability and functionality will be completed by Jersey Coastguard and Guernsey Coastguard between 24 and 26 June. A review of SAR information technology systems has been completed, and the MCA confirmed this in a letter sent to the MAIB on 31 May.
Mark Hinton
All Responded
2019-0142
30 Apr 2019
Shropshire, Telford & Wrekin
Shrewsbury and Telford NHS Trust
Concerns summary (AI summary)
Critical patient information regarding a potential blood clot was not recorded or passed on, and a requested D-Dimer test result was not seen by the discharging doctor due to systemic record-keeping failures and inadequate alert systems.
Action Taken
(AI summary)
Following an RCA, the Trust has audited ED staff compliance in completing documentation, with poor initial results leading to monthly repeats and discussion by senior management. The Trust reiterated that patient safety overrides national targets.
Bradley Trevarthen
All Responded
2019-0207
29 Apr 2019
Wiltshire and Swindon
Department for Digital, Culture, Media …
Concerns summary (AI summary)
School friends were aware of the deceased's increasing suicidal ideation and methods explored online but failed to report it to adults, partly due to fear of device bans.
Action Planned
(AI summary)
The UK government published its Online Harms White Paper which sets out plans for legislation to make the UK the safest place in the world to be online, establishing a new statutory duty of care overseen by an independent regulator with powers to issue substantial fines. The government has convened a working group of social media and digital sector companies to explore what more they can do to help keep children safe online.
David Price
All Responded
2019-0145
29 Apr 2019
Manchester (South)
Stockport Clinical Commissioning Group
Concerns summary (AI summary)
There is a critical lack of an integrated mental health counselling and detoxification service in Stockport to support individuals treating anxiety alongside alcohol dependency.
Action Planned
(AI summary)
The CCG and Local Authority will continue promoting services for people with alcohol and substance misuse problems experiencing mental health problems, request regular updates on service promotions, and monitor access, activity, and outcomes for people with alcohol issues accessing mental health/psychological therapy services.
Steffan Kuenzel
All Responded
2019-0002
29 Apr 2019
London Inner (North)
Barts Health NHS Trust
Concerns summary (AI summary)
The patient received insufficient specific guidance on safe alcohol reduction methods and was unaware of critical alcohol withdrawal symptoms beyond seizures requiring urgent medical attention.
Noted
(AI summary)
Barts Health NHS Trust acknowledges the seriousness of alcohol addiction and states that their public health consultant is working on improved health care packages for alcoholic patients, following successful packages for smokers.
Georgia Nelson
All Responded
2019-0140
29 Apr 2019
London Inner (West)
Central and North West London NHS Trust
Royal Borough of Kensington and Chelsea
Concerns summary (AI summary)
There is a lack of suitable housing specifically for young patients with severe and enduring mental health issues.
Action Planned
(AI summary)
RBKC and partner agencies are working together to identify ongoing needs and service developments arising from the closure of rehabilitation inpatient beds at Horton, including a potential local 'wrap around community rehab offer' with support and rehabilitation services in supported accommodation within 18 months. CNWL acknowledges the concerns raised and states that as discharge planning starts at admission, they will follow new NICE guidance on considering rehabilitation as appropriate. They offer a range of person-centred interventions and have a well-developed vocational service, offering Employment Support using the Individual Placement and Support Model, a User Employment Programme and a strong programme of Peer Support.
Alfonso Sinclair
All Responded
2019-0141
29 Apr 2019
London Inner (West)
Transport for London
Concerns summary (AI summary)
A distressed individual's overtly odd and illegal behaviour at a tube station went unnoticed and unchallenged by staff, despite CCTV, due to a lack of system to alert odd behaviour or alarms at platform end barriers.
Action Planned
(AI summary)
London Underground will review its training for front-line station staff on spotting unusual suicidal behaviour to include customer behaviours at the gateline and ticket hall, with changes implemented by late 2019. Initial trials of new remote accessibility systems for CCTV and other systems are expected by the end of 2020.
Michael Davies
All Responded
2019-0134
25 Apr 2019
Camarthenshire and Pembrokeshire
Welsh Ambulance Trust
Concerns summary (AI summary)
The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.
Disputed
(AI summary)
The Trust acknowledges the concerns raised but states that they do not propose to take any action in relation to the three matters, providing explanations for their position, primarily focusing on resource availability rather than categorization issues.
Deborah Hopkinson
All Responded
2019-0133
24 Apr 2019
Manchester (North)
Pennine Acute Hospitals NHS Trust
Concerns summary (AI summary)
Frequent equipment failures and significant delays in specialist consultant involvement due to lack of expertise and communication issues severely impacted patient diagnosis and treatment.
Action Planned
(AI summary)
The Trust plans to incorporate awareness of Cushing's Disease into annual training for Core Medical Trainees, using the case as a study, and will discuss the case at local and Salford Royal MDT meetings to disseminate learning.
Ioannis Avgousti
All Responded
2019-0135A
24 Apr 2019
Brighton and Hove
Brighton and Sussex University Hospital…
Concerns summary (AI summary)
The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.
Action Taken
(AI summary)
The Trust has already taken several actions, including ensuring compliance with NICE guidelines for allergy management, incorporating a reaction tool into prescription charts, rolling out an electronic NEWS recording system, expanding the Critical Care Outreach service, and reviewing practices for preventing fatigue in junior doctors.
Kerry Hunter
All Responded
2019-0137
23 Apr 2019
Suffolk
Norfolk & Suffolk NHS Trust
Concerns summary (AI summary)
The proposed in-house Borderline Personality Disorder service access pathway may inadvertently exclude patients due to their condition's characteristics, like avoidance and previous negative treatment experiences.
Action Planned
(AI summary)
The Trust is implementing a new Personality Disorder Service with a phased approach, including needs-based interventions, crisis support, peer support workers, and training for all staff, with regular review points to assess impact and adjust the service as needed. The Trust has co-produced patient-facing information, is reviewing its personality disorders strategy, has rolled out a training program, upskilled community teams, and is supporting MHPs to offer evidence-informed approaches, and is recruiting a specialist post and setting up a working group to provide for people with comorbid ASD and personality disorder.
Graham Jones
All Responded
2019-0131A
18 Apr 2019
Gloucestershire
Gloucestershire Hospitals NHS Trust
Concerns summary (AI summary)
Concerns include insufficient falls prevention measures, inadequate understanding of post-fall protocols and medication review, and poor handover of patient safety information between wards.
Action Taken
(AI summary)
The Trust has implemented several measures, including local ward training on falls prevention, the Silver QI project to improve staff awareness of falls prevention, enhanced identity verification procedures in radiology, and additional questions relating to clinical history to identify patient referral errors.
June Russell
All Responded
2019-0128
17 Apr 2019
Berkshire
Slough Borough Council
Concerns summary (AI summary)
The junction has a persistently high injury collision rate, requiring urgent improvements to signage, traffic lights, and line of sight, with existing work progressing too slowly.
Action Planned
(AI summary)
The Council has commissioned an independent road safety review of the junction and will provide a detailed report with proposals for improvements in approximately 6-8 weeks, with recommendations for short, medium, and long-term actions.
Brian Goodman
All Responded
2019-0129A
17 Apr 2019
London Inner (North)
One Hosing Group
Concerns summary (AI summary)
A known ligature point in the patient's room was not addressed, and similar hazardous door closing mechanisms remain in use in other properties, despite a history of suicide attempts by hanging.
Action Planned
(AI summary)
One Housing will work with their property services to explore alternative fire door closures in high-risk schemes and implement ASIST suicide intervention skills training for staff.