2020

PFD Reports
Reports: 309 Areas: 57

83% response rate (above 63% average).

Response Status
Responded 256 Historic 53
AI Classification
Action Taken 40%
Action Planned 36%
Noted 22%
Disputed 3%
Based on 390 classified responses
Top Categories
Hospital Death (Clinical Procedure… (99) Other related deaths (65) Mental Health related deaths (64) Community health care and emergenc… (62) Suicide (from 2015) (54)
309 results
Beryl Holland
All Responded
2020-0037 25 Feb 2020 Greater Manchester South
National Institute for Health and Care …
Concerns summary (AI summary) Inconsistent hospital policies and a lack of national guidance for managing pressure ulcer risks in Emergency Departments led to prolonged waits and inadequate care for vulnerable patients.
Noted (AI summary) NICE notes that its guideline CG179 provides relevant guidance on pressure sore prevention in emergency departments and no further action is required, but mentions a multi-year programme to improve how NICE produces and presents guidance and advice. The Department for Health and Social Care notes the existence of NICE guidelines on pressure sore prevention and that Stockport NHS Foundation Trust has adopted a Patient Safety Checklist and improved access to dynamic mattresses.
Jake Lee
Historic (No Identified Response)
2020-0039 24 Feb 2020 Norfolk
Select Healthcare
Concerns summary (AI summary) The nurse in charge lacked training for patient arrest, panicked, left a collapsed patient with an untrained HCA, and performed incorrect resuscitation, demonstrating severe gaps in emergency response.
Mary Nelson
Historic (No Identified Response)
2020-0036 24 Feb 2020 Cumbria
Medicines and Healthcare Products Regul…
Concerns summary (AI summary) Dangerous fluoxetine accumulation suggests a need to revise dosage guidance, especially for the elderly, and consider in-life drug testing. This death was also not reported to the Yellow Card system.
Billy Jenkins
Partially Responded
2020-0068 21 Feb 2020 London South
ADAPT Oxleas NHS Foundation
Concerns summary (AI summary) An inadequate mental health assessment, lacking robust information gathering and documentation, failed to properly diagnose and treat the patient, with no clear evidence of lessons learned or staff training.
Action Taken (AI summary) Oxleas NHS Foundation Trust has shared the RCA report with the team and across the Trust so that similar Teams can reflect on the lessons learnt and implemented actions from the investigation including areas of training support and the formulation of risk in the risk assessment.
Anita Loi
All Responded
2020-0067 21 Feb 2020 London South
Central London Community Healthcare NHS…
Concerns summary (AI summary) Repeated GP and family referrals for leg wound management were unaddressed by community nursing teams, who also failed to engage in case review meetings, highlighting systemic referral and response failures.
Action Planned (AI summary) Central London Community Healthcare NHS Trust outlines ten planned actions to improve communication and management of referrals between Tissue Viability Nurses and District Nurses, including establishing clearer processes for reviewing referrals, clarifying GP information requirements, and reviewing caseload prioritisation.
Andrew Goldstraw
Partially Responded
2020-0041 21 Feb 2020 Hampshire (Central)
Central and North West London NHS Found… Government legal department HM Prison +1 more
Concerns summary (AI summary) The SystmOne computer system hindered mental health nurses from identifying critical suicide risk information due to search difficulties, unpopulated summary sections, and a non-functional keyword search.
Action Taken (AI summary) Central and North West London NHS Foundation Trust has made changes to healthcare services at HMP Winchester, including internal training on SystmOne, Mental Health risk assessments and a joint learning bulletin stressing the importance of sharing information.
Jon James
All Responded
2020-0042 20 Feb 2020 South Wales Central
National Institute for Health and Care …
Concerns summary (AI summary) There is no national NICE guidance on Acute Behavioural Disturbance, which is vital for emergency services and police, contributing to a rising number of related deaths.
Action Planned (AI summary) NICE acknowledges concerns about the need for guidance on acute behavioral disturbance (ABD) and will consider this in a future update to its guideline on violence and aggression (NG10).
Zachary Johnson
Historic (No Identified Response)
2020-0035 18 Feb 2020 Black Country
Walsall Healthcare NHS Trust
Concerns summary (AI summary) Lack of waterproof fetal heart rate monitoring equipment during birthing pool delivery, coupled with incorrect newborn resuscitation techniques by midwives and infrequent mandatory training, contributed to the death.
Malika Shamas and Haider Ali
Historic (No Identified Response)
2020-0034 18 Feb 2020 Essex
Tendering District Council
Concerns summary (AI summary) Inadequate and poorly located beach signage, insufficient surveillance, and lack of warnings contributed to fatalities, suggesting a need for improved information boards and increased beach patrol presence.
Wayne Millett
All Responded
2020-0031 18 Feb 2020 Manchester South
Priory Group
Concerns summary (AI summary) The care provider's investigation lacked critical analysis, revealing an inability to learn from serious incidents, inconsistent staff adherence to care plans, and failure to review medication side-effect monitoring protocols.
Action Taken (AI summary) The Priory Group acknowledges the need to improve staff understanding and adherence to care plans and has allocated a Clozapine learning and development module to all doctors and qualified nurses. They have also issued Clozapine guidelines and a care plan template with details on potential side effects and management strategies, and systems are in place for regular auditing of patient care plans.
Liam Clark
All Responded
2020-0030 18 Feb 2020 Staffordshire South
Commissioner for Highways
Concerns summary (AI summary) A fatal road collision involving an agricultural vehicle with a protruding boom highlights the need for a review of road layout, signage, and safety improvements at the A5 junction.
Noted (AI summary) Highways England reviewed the A5 junction with Streetway Road and concluded that no improvements are warranted at this time. The junction will be routinely monitored for collisions and the condition of highways assets. The Department for Transport will review advice in driver learning materials and consider a hazard perception clip covering tail-swing for the driver theory test. They will also raise the marking of projections with the National Farmers' Union to remind them of the need to provide and maintain warning signs where required.
James Anthony Lewis and Lorraine Molyneaux
Partially Responded
2020-0033 17 Feb 2020 Dorset
Bournemouth, Christchurch and Poole Cou… Department for Transport
Concerns summary (AI summary) Repeated pedestrian fatalities at an uncontrolled crossing point, driven by bus stop proximity and inadequate lighting, highlight an urgent need for a new controlled crossing and neglected funding applications.
Action Planned (AI summary) BCP Council will carry out a site assessment to confirm lighting levels and inform a new lighting design linked to the planned road layout adjustments and a new crossing. They will prioritize the additional survey and design work, although definitive timescales cannot be provided yet.
Liam Seager
All Responded
2020-0029 17 Feb 2020 London Inner (North)
Tower Hamlets Council Transport for London
Concerns summary (AI summary) The absence of a pedestrian crossing on the A12 near a fatal collision site, coupled with delays in implementing a traffic management order and building a new crossing, poses ongoing risks.
Action Planned (AI summary) Tower Hamlets Council has produced plans for new pedestrian phases at the A12 / Wick Lane junction, including railings and signage. These works will commence once approval is secured from TfL to close the A12 slip roads. TfL plans to prohibit pedestrian access to the A12. LBTH will design and construct a new pedestrian crossing at the mouth of the junction and provide new wayfinding signs to direct pedestrians over the A12 via a safe crossing point; TfL are working with other London boroughs along the route to develop improved wayfinding signs.
Joseph Gingell
All Responded
2020-0027 17 Feb 2020 Essex
NHS England
Concerns summary (AI summary) Permitting "self-certification" for medication without checks, allowing abuse by vulnerable individuals, and not involving the GP removes crucial safeguards, contributing to toxic drug interactions.
Noted (AI summary) NHS England acknowledges concerns about drug toxicity, self-certification, and not informing GPs but states the death appears to be from services outside the NHS, restating commitment to improving the safety of controlled drugs and online prescribing, highlighting existing guidelines and initiatives.
Marley Slack
All Responded
2020-0040 14 Feb 2020 Leicester City and South Leicestershire
Staffordshire, Shropshire and Black Cou…
Concerns summary (AI summary) The Red Book's prominent co-sleeping advice misleadingly omits the critical warning against co-sleeping with premature or low birth weight babies from its quick-reference "Don'ts" section.
Noted (AI summary) The document provides general guidance on safer sleep practices for newborns, focusing on recommendations for reducing the risk of sudden infant death syndrome (SIDS).
Martin Ellis
Historic (No Identified Response)
2020-0028 13 Feb 2020 London Inner (North)
High Commissioner for Saint Lucia to th…
Concerns summary (AI summary) Easy public access to a restricted dam, inadequate signage, and exposed live wiring led to an electrocution, with no explanation or report on building regulations enforcement provided.
Donald Elliott
All Responded
2020-0109 12 Feb 2020 Lincolnshire
Glenholme Holdingham Grange Care Home
Concerns summary (AI summary) Contradictory evidence regarding care home staffing levels and compliance with training/supervision regulations, coupled with unaddressed witness non-attendance, raises concerns about adequate care provision.
Action Taken (AI summary) Holdingham Grange Nursing Home investigated the circumstances around a resident's fall, finding sufficient staffing levels were in place, staff receive training, and no summons to the inquest were received. They have reviewed all falls risk assessments and are working with OTs, and falls training is available for all staff.
Gemma Azhar
All Responded
2020-0026 11 Feb 2020 West Sussex
Sussex Community NHS Foundation Trust
Concerns summary (AI summary) Repeated mental health appointment cancellations by administrators, without clinical follow-up, left patients at risk. The "formal position" for duty worker contact after cancellations lacks proper policy, training, or consistent application.
Action Taken (AI summary) Sussex Community NHS Foundation Trust has reviewed its Time to Talk Service procedures. A new Standard Operating Procedure (SOP) was developed regarding the use of the 'Reasonable Adjustments Alert' on patient records, and a SOP has been updated with guidance on writing clinical and administrative notes.
Joan Howard
All Responded
2021-0007 10 Feb 2020 South Yorkshire (West)
Sheffield Teaching Hospitals NHS Founda…
Concerns summary (AI summary) Inadequate adherence to specialist nutritional guidelines, including providing inappropriate food and failing to escalate concerns, coupled with a lack of thickener for fluids, contributed to patient neglect.
Action Taken (AI summary) The Trust has already completed several actions, including providing further training to the staff member involved, reviewing issues with senior staff and external expertise, modifying the patient meal observation chart, and implementing a 'Meal Time Huddle' to ensure staff are aware of patients' dietary requirements.
Sarah Young
Historic (No Identified Response)
2020-0119 10 Feb 2020 Bedfordshire and Luton Coroner Service
Bedford Hospital NHS Trust
Concerns summary (AI summary) A significant delay in obtaining a neurological opinion and a failure of the medical team to review the patient in ED, exacerbated by unreliable referral systems, led to a delayed diagnosis and treatment.
Kerry Aldridge
Partially Responded
2020-0055 10 Feb 2020 London Inner South
Metropolitan Police service South London and Maudsley NHS Foundation
Concerns summary (AI summary) Police safeguarding teams lack established links with NHS mental health services and officers need further training to appropriately assess and refer individuals requiring urgent mental health support.
Action Planned (AI summary) The trust acknowledges the concerns and will have preliminary discussions regarding providing Mental Health First Aid training to specific Metropolitan Police officers in designated roles by the end of March 2020. They also highlight existing mental health support services available to police officers, including a crisis and assessment team and a Pan London S.136 telephone advice line.
Mark Mallinson
Historic (No Identified Response)
2020-0137 7 Feb 2020 West Sussex
Sussex Police
Concerns summary (AI summary) Life-saving suicide intervention training, developed for new police recruits, is not being provided to all front-line staff, leaving many officers untrained in critical situations.
Adrian Ashford
All Responded
2020-0054 7 Feb 2020 London Inner South
Queen Elizabeth Hospital
Concerns summary (AI summary) There was no systematic process for recording patient weights to identify critical changes, and a consultant failed to recognise serious GI bleed risks or make appropriate specialist referrals for a deteriorating patient.
Action Taken (AI summary) Lewisham and Greenwich NHS Trust has implemented a trust-wide electronic patient record system that enables weight to be consistently recorded and observed by all staff. The consultant involved in the case has conducted a case review and reflection to use in their annual appraisal, and a new standard operating procedure for managing suspected upper GI bleeding has been produced and circulated.
Benjamin Leonard
All Responded
2020-0032 7 Feb 2020 North Wales (East and Central)
Scout Association
Concerns summary (AI summary) The Scout Association failed to implement or ensure understanding of critical safety policies, including risk assessments and leadership oversight, for an organised trip, directly endangering young people.
Action Taken (AI summary) The Scout Association has made further changes and improvements to guidance, rules and systems described in a previous response, as a result of their ongoing review of safety in Scouting. They have also committed to considering all evidence from the inquest and conducting a Safety Incident Learning Inquiry.
Marc Cole
All Responded
2020-0087 6 Feb 2020 Cornwall and the Isle of Scilly
College of Policing Home Office
Concerns summary (AI summary) There is insufficient independent data and understanding regarding the lethality and incremental risks of multiple Taser activations, potentially leading to deficient police training and unsafe use.
Noted (AI summary) The College of Policing explains its role and details existing guidance and learning material addressing the risks associated with Taser use, particularly multiple activations, and highlights the role of SACMILL in advising on medical issues. The Home Office acknowledges the concerns about Taser use and refers to existing policy, guidance, training, and scrutiny mechanisms. It states satisfaction that current measures are adequate but acknowledges every death in police custody is a tragedy.