2020
PFD Reports
Reports: 309
Areas: 57
83% response rate (above 63% average).
Clive Oxley
All Responded
2020-0301
23 Dec 2020
County Durham and Darlington
LNER and Network Rail
Concerns summary (AI summary)
Inadequate barrier construction and fencing on a railway platform allowed a pedestrian to access the track, despite warnings, with previous similar incidents noted.
Action Planned
(AI summary)
Network Rail altered the southbound platform end at Durham station in December 2019 to deter pedestrian access, including a lockable gate and fence, audible warning system, signage, and anti-trespass flooring. They also fund Samaritans-trained patrollers and BTP officers at Durham. LNER, in collaboration with Network Rail, will arrange a joint site visit to Durham station to ensure fencing meets rail industry standards. LNER has also trained a significant number of staff in suicide risk who are given guidance and training in dealing with vulnerable people.
Tina Murray
All Responded
2020-0296
22 Dec 2020
Blackpool and Fylde
Belgravia Care Home Ltd
Concerns summary (AI summary)
Plastic bags, which posed a risk to the deceased, appear to have been accessible within Belgravia Care Home.
Action Taken
(AI summary)
Belgravia Care Home removed plastic bags from resident bedrooms, safely disposed of shopping bags, locked away all other bags, and implemented robust risk assessments for residents at risk of suicidal tendencies.
Daniel Hughes
All Responded
2020-0295
22 Dec 2020
Shropshire, Telford and Wrekin
Highways England National Traffic Opera…
Concerns summary (AI summary)
Road safety concerns at a blind bend include poor visibility for right turns from a driveway, inappropriate speed limits, and the absence of warning signs.
Noted
(AI summary)
Highways England reviewed the location and determined that visibility is the responsibility of the property owner, the speed limit is appropriate, and they are not permitted to place a concealed driveway warning sign. No action is proposed.
Brian Easey
All Responded
2020-0293
21 Dec 2020
West Sussex
Lambeth Borough Council
West Sussex County Council
Concerns summary (AI summary)
Council records are potentially contaminated with asbestos fibres, posing a risk of exposure and fatal mesothelioma to anyone handling them.
Disputed
(AI summary)
The council disputes that there is a risk of asbestos exposure, citing air monitoring and dust sample tests that did not identify the presence of asbestos in the storage rooms. Lambeth disputes Mr Easey's employment history description and states that reports confirmed no asbestos contamination of Registrar files. The Council will not take further action.
Evadney Dawkins
All Responded
2020-0292
21 Dec 2020
East London
Department of Health and Social Care
Royal London Hospital
Concerns summary (AI summary)
Critical renal monitoring was delayed for four days, leading to a Grade 3 acute kidney injury. The Trust's governance systems also failed to promptly investigate this as a serious incident.
Action Taken
(AI summary)
The hospital has established a second site safety nurse role focused on nursing education and deteriorating patients and implemented an AKI bundle standardising responses to patients with AKI. Handover templates and simulation training have been developed, and new medical examiner and deputy medical director posts have been appointed to improve patient safety governance. The Trust has supported nurse training in renal monitoring, improved accuracy of records via electronic systems, improved patient handover and consultant ward rounds. The Trust is subject to strengthened inspection assessment of NHS trust’s learning from deaths by the CQC.
Jennifer Spencer
All Responded
2021-0010
18 Dec 2020
East Sussex
NHS England
Concerns summary (AI summary)
Mental health professionals lack awareness of "Shamanic" hallucinogenic drugs, leading to inadequate assessment and treatment for psychosis caused or exacerbated by their use.
Action Planned
(AI summary)
NHS England is providing targeted funding to STPs for multi-agency suicide prevention plans. The South East region suicide prevention lead is working to raise awareness regarding ‘shamanic hallucinogenic drugs’ and NHSE/I will share any learning generated by the South East regional team nationally.
Kalila Griffiths
All Responded
2020-0299
18 Dec 2020
East London
NHS England
Concerns summary (AI summary)
Many recommendations from the 2014 National Review of Asthma Deaths remain unimplemented. Conflicting guidelines and insufficient training for clinicians further compromise safe asthma care.
Action Planned
(AI summary)
NHS England published the NHS Long Term Plan which has a clear commitment to improve the outcomes for those with a respiratory condition including asthma. NHS England and NHS Improvement commission the National Asthma Audit Programme that provides data on a range of indicators to show improvements and opportunities in asthma outcomes.
Ruben Bousquet
All Responded
2020-0298
18 Dec 2020
London Inner South
Department of Health and Social Care
Food Standards Agency
Ministry of Housing, Communities and Lo…
Concerns summary (AI summary)
Weak reporting and information sharing processes for food allergy fatalities hinder timely investigations and learning. The feasibility of food businesses carrying adrenaline auto-injectors also needs official investigation.
Action Planned
(AI summary)
The MHRA sought advice from the UK Commission on Human Medicines (CHM) on a range of areas to support the effective and safe use of AAIs. The AAI EWG recommended a number of other measures including reinforcement of the need for all patients at risk of anaphylaxis to carry two AAIs at all times. The FSA is undertaking consumer research to gather information and insights from people with food allergies and is considering the benefits of developing a food allergy safety scheme for allergen management within food businesses. They are supporting businesses to prepare for new allergen labelling rules coming into effect on 1st October 2021. The FSA is establishing a way for people to directly report information regarding anaphylactic reactions caused by food allergies that do not result in death. The MHRA is considering making AAI devices more widely available for use in exceptional, emergency situations.
Andrew Gibbins
All Responded
2020-0290
17 Dec 2020
Suffolk
West Suffolk Hospital and The Wedgewood…
Concerns summary (AI summary)
A security guard's concern about a patient expressing suicidal feelings was not reported to clinical staff at the hospital, leading to a missed opportunity for assessment.
Action Taken
(AI summary)
The Trusts have commenced monthly meetings between the head of mental health and the lead nurse, and reviewed the handover process, incorporating SBAR documentation into the WSFT risk assessment. The acute hospital missing person’s policy has been reviewed and deemed fit for purpose in January 2021. Hellesdon Hospital reports that they have established regular interface meetings with the West Suffolk Hospital to improve communication and have formalized these meetings with agreed actions and minutes for governance purposes.
Philip Taylor
All Responded
2020-0289
17 Dec 2020
Greater Manchester South
Care Quality Commission, Department of …
Concerns summary (AI summary)
GP failed to recognise dehydration risk and document observations. Paramedics' national triage tool did not clearly mandate immediate transfer for sepsis. Care home staff lacked national guidance on recognising and escalating dehydration risks.
Noted
(AI summary)
The GP confirmed that it is now his practice to carry the equipment with him whenever he attends a patient away from the practice and he will now carry the mobile technology with him and will update patient records immediately following consultation/visit. The CQC acknowledges the concerns, outlines its role as a regulator, and states that a review found insufficient evidence of a breach of regulations regarding the care provided to Mr. Taylor. They will continue to monitor the service and liaise with the local authority. The Department expresses condolences and highlights existing guidance and training related to hydration and nutrition in care homes, referencing the Care Certificate and CQC oversight, but doesn't describe any new actions in response to the PFD.
Patricia Douglas
All Responded
2020-0286
16 Dec 2020
County of Cumbria
Covid-19 Pandemic Response Service and …
Concerns summary (AI summary)
NHS 111's assessment pathway failed to account for a patient's significant medical history, leading to an incorrect referral. The call was then closed due to an incorrect number, missing a crucial opportunity for care.
Noted
(AI summary)
NHS Digital provides background information on NHS Pathways, its functions, and governance, but does not describe any specific actions taken or planned in response to the coroner's concerns. They are also requesting to be named an interested party going forward.
Don Fernandes
All Responded
2021-0172
15 Dec 2020
Oxfordshire
Oxford University Hospitals NHS Foundat…
Concerns summary (AI summary)
Concerns remain about the implementation of NG tube policy changes and staff competency reassessment. Policy variations to reduce x-ray exposure led to confusion about the need for confirmation, risking tube misplacement.
Disputed
(AI summary)
The Trust outlines actions taken following the RCA report, including policy changes and audits. They do not accept the recommendation that the nurse should have sought advice from a senior clinician, and dispute that there was a change in normal policy or uncertainty regarding Don Maximus' care.
Eddie Coffey
All Responded
2020-0287
15 Dec 2020
Hertfordshire
Department of Health and Social Care
East and North Hertfordshire NHS Trust
Concerns summary (AI summary)
The Trust's internal report was contradicted by inquest evidence, highlighting a gross failure in foetal heart rate monitoring during labour. Concerns remain about current training and the use of incorrect guidelines in maternity units.
Noted
(AI summary)
The Trust will ensure that when obtaining an independent third-party or independent clinical opinion in the future, this is done on a more formal basis with clear terms of reference. A sticker with independent palpation of maternal pulse will be in front of CTG machine by the end of February 2021, and actions are planned to ensure a robust process is in place regarding CTG monitoring interpretation and escalation. The DHSC expresses condolences and highlights existing NICE guidelines and national initiatives related to maternity care and fetal monitoring. It also notes that HSIB has been made aware of the report.
Robert Goodman
All Responded
2020-0285
15 Dec 2020
Hampshire, Portsmouth and Southampton
University Hospital Southampton NHS Fou…
Concerns summary (AI summary)
The Trust's head injury policy was outdated, failing to reflect revised NICE guidance requiring a CT scan within 8 hours for patients on any anticoagulant, leading to delayed diagnosis.
Noted
(AI summary)
The hospital acknowledges the delay in CT scan but argues the policy was reasonable and reflects national guidance, and awaits clarification from NICE on prophylactic anticoagulants. They will ensure patients receiving prophylactic Enoxaparin with clinical signs and symptoms following a fall will undergo a CT scan within 8 hours of a suspected head injury.
Christopher Swain
All Responded
2020-0284
14 Dec 2020
West Sussex
Sussex Partnership NHS Foundation Trust
Concerns summary (AI summary)
Inconsistent patient observation practices, inadequate mental health reviews, risk assessments, and record-keeping were identified. There was also a failure to provide staff escorts for sectioned patients being transferred.
Noted
(AI summary)
The Trust acknowledges failings in care and outlines previous actions taken following the death, including an internal investigation and sharing of learning. The Trust states that policies for Section 17 leave were in place, but not followed, and weekly audits are now conducted to ensure compliance.
Elsie Taylor
All Responded
2020-0281
14 Dec 2020
Black Country
West Midlands Ambulance Service
Concerns summary (AI summary)
Paramedics failed to document a patient's refusal of hospital admission, the advice given, or to provide information to her family or GP, leaving a vulnerable patient unmonitored.
Action Taken
(AI summary)
The paramedics attended further training which covered the Trusts expected standard of completing and checking documentation. The local management team for the Black Country have been reminded of the importance of providing statements in a timely manner.
Shyama Rampadaruth
All Responded
2021-0005
11 Dec 2020
Inner North London
Whipps Cross Hospital
Concerns summary (AI summary)
A frail, elderly patient suspected of COVID-19 waited six hours in discomfort for dialysis. No attempt was made to contact family for temporary care, despite their proximity and willingness.
Action Taken
(AI summary)
Barts Health NHS Trust now swabs all dialysis patients weekly, isolates COVID-positive patients on a single site, and has access to portable dialysis machines. They have also started vaccinating dialysis patients during their sessions and are actively planning to increase dialysis capacity.
Claire Lilley
All Responded
2020-0297
11 Dec 2020
Inner London South
Oxleas NHS Trust
Concerns summary (AI summary)
Risk assessments for Mental Health Act patients on Section 17 leave are fragmented across different records and tools, lacking a central, formulated document for comprehensive clinician review.
Action Planned
(AI summary)
Oxleas NHS Foundation Trust will require consistent recording of service users' and carers' feedback in the MDT template, make risk decisions at every MDT meeting, assign responsibility for updating risk assessments after each MDT, and update the Clinical Risk Assessment and Management Policy accordingly. The Medical Director and Director of Nursing will communicate these standards to all clinicians, facilitated by a team approach to risk management led by Matrons.
Katy Samuels
All Responded
2020-0282
11 Dec 2020
Coventry
Chief Executive and Mental Health lead …
Concerns summary (AI summary)
The Section 17 Leave Policy lacked clear guidance on escorted leave and escort identity verification, enabling a detained patient to leave unobserved, return intoxicated, and subsequently self-harm.
Action Taken
(AI summary)
Coventry and Warwickshire Partnership NHS Trust has amended its Section 17 Leave Policy to ensure patients are collected from and returned to the ward by identified individuals. The Trust is also implementing structured handover meetings at shift changes and introducing competency-based training for staff.
Rory Attwood
All Responded
2021-0086
10 Dec 2020
Gwent
Aneurin Bevan University Health Board
Concerns summary (AI summary)
The patient fell between gaps in primary, acute, psychiatric, and social services. GPs are rarely involved in serious incident reviews, which limits learning and partnership working for community-supervised patients.
Action Taken
(AI summary)
Aneurin Bevan University Health Board has reviewed its practices regarding GP involvement in Serious Incident Reviews and devised a process and pro forma to ensure GPs are invited to participate. The Mental Health and Learning Disabilities Division is also reviewing processes to ensure third sector and other organisations' involvement is recorded sooner.
Marion Glover
All Responded
2021-0004
10 Dec 2020
South Manchester
Able Care and Support Services Ltd
Concerns summary (AI summary)
Residents with cognitive illnesses in independent living flats could leave the building unnoticed due to unlocked doors and lack of foyer observation. The environment was unsuitable for confused residents, posing a wandering risk.
Action Taken
(AI summary)
Able Care and Support Services Ltd, under new ownership, has implemented enhanced pre-admission risk assessments, weekly meetings with authorities, multi-disciplinary meetings, and a falls management reporting form. Scheduled annual reviews of resident needs, with updated support plans, are also in place.
Edward Mallaby
All Responded
2020-0277
10 Dec 2020
Sunderland
Alexandra View Care Home
Concerns summary (AI summary)
The care home lacked clear policy for handling hazardous personal property and a functioning sensor mat for falls detection. Observation protocols were unclear, and no rapid learning exercise followed the incident.
Action Taken
(AI summary)
Roseberry Care Centres updated policies regarding residents' belongings, admission of residents, and falls management, issuing them to all homes with 'read and sign' sheets and discussing changes in small group supervisions. Policy updates covered management of hazardous property, sensor mat monitoring, frequency of observations, and staff awareness of individual resident risk assessments.
Thomas Rawnsley
All Responded
2020-0283
9 Dec 2020
South Yorkshire (West District)
NHS England
Yorkshire Ambulance Service
Concerns summary (AI summary)
Virtual consultations risk misunderstanding due to lack of written follow-up. Inconsistent initial questioning across emergency services leads to incomplete clinical triage, and paramedic patient leaflet information is often inaccurate.
Noted
(AI summary)
Yorkshire Ambulance Service NHS Trust will audit patients treated at home to gather feedback on information provided, review the PIL template content, conduct spot audits of care plans, launch a communications campaign for staff on detailed care plans for non-conveyance, and develop tick-box indicators on the EPR. The future intention is to embed the PIL content into the EPR and email it to the patient and their primary care provider. The National Medical Director describes existing NHS Pathways triage processes, including the use of a standard set of questions and validation of information by clinicians. They state that shared care records allow clinicians to access information on long-term conditions, medical history, medications, and allergies.
Leslie Harris
All Responded
2020-0280
9 Dec 2020
Manchester South
NHS England
Public Health England
Concerns summary (AI summary)
The Trust misinterpreted Public Health England guidance, exposing vulnerable patients to COVID-19 by moving them to isolation wards. Concerns remain as the unamended guidance might lead other trusts to similar unsafe practices.
Action Planned
(AI summary)
NHS England contributed to updated Public Health England guidance published January 2021, strengthening messaging and providing further clarity on care pathways, testing, and exposure regarding COVID-19 in healthcare settings. The trust involved has also changed their policy so that patient movement no longer takes place in the same way. The UK Health Security Agency (formerly Public Health England) updated its guidance several times during the pandemic and will further review it to tighten wording and prevent misinterpretation regarding COVID-19 management in healthcare settings.
Kimberley Smith
All Responded
2020-0279
9 Dec 2020
Surrey
Surrey and Borders Partnership NHS Foun…
Concerns summary (AI summary)
The Trust lacks clear written policies for managing informal patients' leave requests, including risk assessments and monitoring. A vital recommendation for a comprehensive alcohol detoxification protocol also remains unimplemented.
Action Taken
(AI summary)
The Trust has developed guidance regarding alcohol detoxification for people admitted to inpatient wards and are developing new guidelines for managing people with Alcohol Use Disorders (AuDs). They have also completed a retrospective baseline audit and will complete a second audit to check for improvements.