2020
PFD Reports
Reports: 309
Areas: 57
83% response rate (above 63% average).
Jennifer McKoy
All Responded
2020-0080
11 Mar 2020
Black Country
Black Country Hospital Trusts
Black Country Pathological Service
Walsall Manor Hospital
Concerns summary (AI summary)
An inadequate audit process for sample monitoring and a lack of clear protocol for managing anticoagulation/prophylaxis regimes in community patients posed significant risks.
Noted
(AI summary)
BCPS is implementing audit processes for the routine review of malignant cases in preparation for MDT meetings, and modified Southampton audits. They will also improve pathways to notify BCPS of increasing cancer work. A consultant histopathologist post will continue to be advertised. Actions are to be completed by 31 May 2020. The response forwards information from Black Country Pathology Services and The Royal Wolverhampton NHS Trust relating to previous concerns. It notes that the patient was under the care of Walsall Healthcare NHS Trust. The Trust will develop a Community Standard Operating Procedure for VTE risk assessment and prophylaxis for specific patient groups, and will liaise with the CCG regarding procedures in Care Homes. Completion is expected by 31 October 2020.
Rifky Grossberger
All Responded
2020-0070
11 Mar 2020
London Inner North
NHS England
Royal College of Nursing
Concerns summary (AI summary)
Insufficient communication of blind cord dangers to new parents, absence of a national safety leaflet, and missed opportunities for healthcare professionals to provide warnings contributed to the risk.
Noted
(AI summary)
NHS England highlights the existing advice available on the NHS Choices website and the role of Health Visitors in delivering the Healthy Child Programme. PHE aims to reduce preventable accidents as part of the national priority on Best Start in Life (2020-2025) through the modernisation of the Healthy Child Programme. The RCN has reviewed and strengthened its guidance about the potential risks of strangulation and suffocation on its clinical webpages for Health Visitors, Midwives, School Nurses, Children’s Nurses, Neonatal Nurses and General Practice Nurses. This matter has also been brought to the attention of members through Forums and social media platforms.
Robert Brown
All Responded
2020-0065
9 Mar 2020
Staffordshire (south)
National Offender Management Service
Concerns summary (AI summary)
Information in central NOMIS records, medical system records, and the security department was not available to all prison staff who may have benefitted from having it.
Action Planned
(AI summary)
NHS England and NHS Improvement are leading a project with HMPPS to implement inter-operability between SystmOne and NOMIS to improve information sharing; Phase one is delayed until August 2020 due to COVID-19 priorities, and Phase three is expected in 2021. The Safer Custody Zone at Dovegate was formed in 2019, to facilitate information sharing between prison and healthcare staff.
Darren Goddard
All Responded
2020-0060
9 Mar 2020
South Wales Central
Cwm Taf Morgannwg University Health Boa…
Concerns summary (AI summary)
Failures in consent processes, misleading risk information, premature discharge, and significant delays in triage, escalation, fluid/antibiotic administration, and critical care admission collectively led to sepsis complications.
Action Taken
(AI summary)
The Health Board has agreed to use consistent terminology regarding sepsis and exclude reference to the word 'rarely' on the TRUS biopsy consent form. A single leaflet produced by the British Association of Urological Surgeons (BAUS) is now used. Sepsis training is being reinstated for medical and nursing staff.
Roy Campbell
All Responded
2020-0059
9 Mar 2020
Worcestershire
Worcestershire Health and Care NHS Trust
Concerns summary (AI summary)
Inadequate systems to prevent detained patients from absconding included a flawed visitor tracking system and environmental checks not properly implemented or enshrined in policy with mandatory staff training.
Action Planned
(AI summary)
The Trust is implementing environmental risk assessment forms on wards, with completion covered in new staff inductions and existing staff supervision sessions. While a business case for an electronic visitor system is awaiting approval, additional manual checks are in place, and pre-signing of forms is prohibited.
Rebecca Hursey
Historic (No Identified Response)
2020-0058
9 Mar 2020
London Inner (West)
NHS East Leicestershire and Rutland CGC
NHS England
Springfield Hospital
Concerns summary (AI summary)
Policy violations in patient observations, inadequate handover procedures, and a prolonged, unsuccessful search for appropriate alternative placement negatively impacted the patient's mental state and ability to manage self-harm risks.
Arthur Hughes
Partially Responded
2020-0057
9 Mar 2020
North Wales (East and Central)
Betsi Cadwaladr University Health Board
Ysbyty Gwynedd
Concerns summary (AI summary)
A lack of protocol for assessing locum staff's practical skills and managerial reluctance to thoroughly check references created risks that locums might perform tasks beyond their capabilities.
Action Planned
(AI summary)
The Health Board is revising and implementing a SOP for locum appointments, including additional pre-employment checks and reviews of practice. Implementation was delayed due to COVID-19 but is intended from 01 June 2020.
REDACTED
All Responded
2020-0061
6 Mar 2020
Inner North London
Department of Health and Social Care
NHS England
Concerns summary (AI summary)
There is limited public awareness of stroke risks associated with cocaine use and variable access to thrombectomy services due to geographical and timing factors.
Action Planned
(AI summary)
NHS England is rolling out access to thrombectomy nationally via specialised neuroscience centres over a 5-year period, commenced in April 2017. They are developing a bespoke training programme endorsed by the General Medical Council and Health Education England to address the shortfall in practitioners, due for roll out imminently. PHE will ensure that stroke is included in the list of health risks of cocaine use on the FRANK website.
Carl Newman
All Responded
2020-0056
6 Mar 2020
Liverpool and the Wirral
HMPPS
Concerns summary (AI summary)
Prison staff lacked accessible, up-to-date training records for critical safety procedures (ACCT & SASH), indicating a national issue with tracking and ensuring current staff competence.
Action Taken
(AI summary)
Following the inquest, the Governor of HMP Liverpool issued a staff information notice promoting the use of the myLearning system for accessing training records, and a comprehensive guide on how to use the system will follow. The ACCT case management system is being updated and training packages refreshed.
Jose Orlando
Historic (No Identified Response)
2020-0063
4 Mar 2020
East London
Tradomi S.L. Transporte
Concerns summary (AI summary)
Lorries lacked essential safety features like hand holds for driver access and necessary equipment (CO2 detectors, telescopic mirrors) for Border Force checks, tempting drivers to use unsuitable alternatives.
Eileen Pollard
Historic (No Identified Response)
2020-0053
3 Mar 2020
South Yorkshire (West)
Crown Care
Concerns summary (AI summary)
Call bell maintenance records are pre-populated as 'pass', creating a risk that checks are missed or failures aren't recorded, potentially endangering patients if call bells are non-functional.
Lee Carpenter
Historic (No Identified Response)
2020-0052
3 Mar 2020
East London
Goodmayes Hospital Foundation Trust
Concerns summary (AI summary)
An urgent GP mental health referral was downgraded without documented rationale, patient/GP discussion, or identification of the decision-making staff, indicating no system for clear documentation and accountability in clinical triage.
Katrina O’Hara
All Responded
2020-0051
3 Mar 2020
Dorset
College of Policing
Crime, Policing and Fire Service
National Police Chief’s Council
Concerns summary (AI summary)
Outdated police policy led to a high-risk 999 call being downgraded, and officers failed to recognise the increased danger to the victim when the perpetrator expressed suicidal intent. The victim was also left without a replacement phone after hers was seized for evidence.
Noted
(AI summary)
The NPCC has undertaken a major refresh of the National Contact Management Strategy since 2015, with revised principles and practice that cover the issue of inappropriate channel selection. The report will be raised at the next meeting of the National Contact Management Steering Group. The Home Office is working to pilot and evaluate approaches to identifying and tackling high risk offenders, including adding suicide indicators to the list of potential risk indicators. Work is ongoing to review findings from domestic homicide reviews and academic research with a view to more accurately identifying key characteristics and risk factors for domestic homicides.
Shaun Turner
All Responded
2020-0050
3 Mar 2020
Manchester South
Department of Health and Social Care
Concerns summary (AI summary)
Significant delays in accessing mental health services and support, along with the adverse psychological impact on patients of missed contact attempts, raised serious concerns.
Action Planned
(AI summary)
The government has introduced access and waiting time standards for mental health services, is expanding access to talking and psychological therapies through the IAPT programme, and is working to improve mental health crisis care. They published the first Cross-Government Suicide Prevention Workplan in January 2019 and are investing £57million in suicide prevention through the NHS Long Term Plan.
Sophie Boothe
All Responded
2020-0142
2 Mar 2020
Hampshire (Central)
Berkshire Healthcare NHS Foundation Tru…
Concerns summary (AI summary)
Poor communication and insufficient exploration of information from foreign jurisdictions, specifically misunderstanding critical medical terms, led to inadequate mental health assessment and referral downgrading.
Action Taken
(AI summary)
Learning events have taken place reflecting on the case, attended by both Talking Therapies and CPE teams, utilising the referral as a case study for further training on how the teams should work together. The Trust is undertaking transformation of its wellbeing services with redefinition of roles and a suite of training to support this, and there will be careful supervision and auditing.
Gary Webster
All Responded
2020-0049
2 Mar 2020
West Yorkshire (East)
JV Ltd
Nuttall Ltd
Concerns summary (AI summary)
Inadequate risk assessment procedures led to untrained staff performing hazardous tasks. The safety boat's permissioning system was ineffective, allowing unauthorised operation, and the weir lacked a safe platform for debris removal.
Noted
(AI summary)
BAM Nuttall was not involved in the design of the weir installation but will share the Coroner’s Report to Prevent Future Deaths with any designers of weirs in future projects where BAM Nuttall is acting as Principal Contractor. They are committed to the ongoing training of its workforce and the development of ever safer systems of work. BMM JV was not involved in construction or site operations or in the weir design, but will ensure the Report is shared with other designers in future weir projects.
Ibiyemi Ereoah
Historic (No Identified Response)
2020-0048
2 Mar 2020
East London
Barts NHS Trust
Concerns summary (AI summary)
Insufficient gynae-oncology consultant cover led to a lack of advocacy in MDT meetings and delayed consultant reviews. There was no system to ensure timely consultant intervention for patients deemed unfit for surgery.
Peter Cole
All Responded
2020-0123
28 Feb 2020
Hertfordshire
NHS England
Concerns summary (AI summary)
Inadequate monitoring of repeat medication allows vulnerable patients to accumulate dangerous quantities, a widespread problem leading to significant waste of healthcare resources.
Action Taken
(AI summary)
NHS England references the Long Term Plan as covering monitoring of repeat prescribing. It also highlights the Medicines Safety Improvement Programme and the Dementia Care Pathway guidance, both of which aim to reduce medication-related harm and optimise medication use for specific patient groups.
Irene Whittingham
Partially Responded
2020-0047
28 Feb 2020
Manchester West
EMIS
Royal Bolton Hospital
Wellsky
Concerns summary (AI summary)
Conflicting guidance on Vitamin D and Calcium blood level monitoring for high-dose patients and confusing software interfaces allowed prescribing errors that exceeded national guidelines without GP notification.
Action Taken
(AI summary)
The Trust developed a prescribing guideline to standardize and support the safe prescribing and administration of colecaliferol in adult patients, in response to concerns about monitoring following a high loading dose.
Lewys Crawford
Historic (No Identified Response)
2020-0046
28 Feb 2020
South Wales Central
Cardiff and Vale University Health Board
Concerns summary (AI summary)
A&E consultants and agency nurses lacked adequate training in paediatric sepsis identification and management, including using risk stratification tools and appropriate terminology. Failures were noted in considering alternative antibiotic administration methods.
Kenneth Clarke
Historic (No Identified Response)
2020-0088
27 Feb 2020
Derby and Derbyshire
Care Quality Commission
Normanton Village View Nursing Home
Rushcliffe Care
Concerns summary (AI summary)
The nursing home lacked formal policies for crucial areas including resident observation, food storage security, managing dementia residents, and caring for patients on liquid diets.
Mohan Acharya
All Responded
2020-0045
27 Feb 2020
Northampton
Department of Health and Social Care
Concerns summary (AI summary)
Emergency department crowding is a significant risk factor associated with increased mortality among admitted patients, contributing to approximately 500 deaths annually.
Action Planned
(AI summary)
The Department of Health and Social Care highlights NHS plans to improve urgent and emergency care, including implementation of the NHS Long Term Plan, expansion of NHS 111, and embedding the Same Day Emergency Care model.
Jack Postle
All Responded
2020-0044
26 Feb 2020
Hertfordshire
Watford General Hospital
Concerns summary (AI summary)
The maternity unit suffered from insufficient capacity for safe care, and consultant guidance inappropriately limited the availability of caesarean sections following failed inductions.
Action Planned
(AI summary)
West Hertfordshire Teaching Hospitals NHS Trust has developed a Prevention of Future Deaths Action Plan for 2020/21 including measures to improve the maternity pathway and is scoping the possibility of a three bedded induction bay on the current Delivery Suite.
Thomas Reilly
Historic (No Identified Response)
2020-0043
25 Feb 2020
Brighton and Hove
Sussex Police
Concerns summary (AI summary)
The lack of a formal, structured intervention system at suicide hotspots, relying on ad-hoc approaches, raises concerns about consistent prevention of self-harm.
Elaine Renshaw
Historic (No Identified Response)
2020-0038
25 Feb 2020
Greater Manchester South
Care Quality Commission
Concerns summary (AI summary)
Inadequate controlled drug check processes in care homes resulted in unaccounted drugs and inaccurate stock sheets, highlighting a national lack of clear guidelines for controlled drug handling and recording.