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
Marlon Watson
All Responded
2020-0010 14 Jan 2020 Staffordshire (South)
HMP Dovegate
Concerns summary (AI summary) Healthcare staff at HMP Dovegate demonstrated an inadequate understanding of the ACCT process, which is a significant concern for managing prisoner welfare and suicide risk.
Action Planned (AI summary) Care UK has offered additional refresher ACCT training to all staff, to be provided by the prison within 12 weeks. They are also implementing a system to ensure senior oversight on ACCT and SASH training across all Care UK sites. Care UK has offered additional refresher ACCT training to all staff, to be provided by the prison within 12 weeks. They are also implementing a system to ensure senior oversight on ACCT and SASH training across all Care UK sites.
Madhavbhai Patel
All Responded
2020-0006 14 Jan 2020 Black Country
Walsall Healthcare NHS Trust
Concerns summary (AI summary) A patient's family was not given clear, specific guidance on the definition of "bite-sized" food according to IDDSI standards for dysphagia, nor tailored advice for their cultural diet and eating practices.
Action Planned (AI summary) Walsall NHS Trust is implementing changes to improve patient safety related to choking risks, including staff training on IDDSI standards by June 2020, replacing patient documents with IDDSI materials by April 2020, and revising risk assessment documents to include eating methods. A clinical audit will be completed 90 days following launch.
Annette Lewis
Partially Responded
2020-0004 13 Jan 2020 Isle of Wight
Suicide Prevention Group, Isle of Wight… National Trust for the Isle of Wight Public Health for the Isle of Wight
Concerns summary (AI summary) There is a lack of protective fencing and crucial Samaritan signage at Tennyson Down cliff, despite a known risk of individuals in mental distress attempting suicide at this and similar sites.
Action Planned (AI summary) The Isle of Wight National Trust is engaging with Public Health, the Suicide Prevention & Intervention team, IOW Samaritans, and the Police to review and improve suicide prevention measures on their land. A full internal review of suicide prevention measures will be conducted after the meetings are complete.
Muhammed Wajid
Partially Responded
2020-0007 10 Jan 2020 West Yorkshire (West)
Highways England Kirklees Council
Concerns summary (AI summary) Scammonden Bridge is a notorious suicide location, and previous recommendations to Kirklees Council and Highways England for suicide prevention measures may not have been fully implemented.
Action Planned (AI summary) Highways England is planning to deliver a bridgeworks scheme including a new pedestrian barrier and vehicle barrier at Scammonden Bridge, pending funding. It will also deliver an alert/help telephone system and share learning with East Sussex County Council regarding vulnerable passengers accessing similar sites.
Miles Naylor
All Responded
2020-0005 10 Jan 2020 West Yorkshire (West)
Bradford District Care NHS Trust
Concerns summary (AI summary) Concerns were raised about the management of ligature risks from personal items and the unsafe design of ward doors, specifically regarding access to hinge pins, at a mental health facility.
Action Taken (AI summary) Bradford District Care NHS Foundation Trust has reviewed its policy for Blanket Restrictions and implemented daily safety checks in inpatient areas. Work has begun to install high specification full door alarms on identified bedrooms on 8 high risk wards, due to be completed by April 2020.
Colin North
All Responded
2020-0003 9 Jan 2020 Birmingham and Solihull
Incarace ORCi
Concerns summary (AI summary) There is a severe lack of pedestrian control on race tracks immediately post-race, with active vehicles and no designated safe zones or walkways. Risk assessments are inadequate for both pedestrians and staff on the track.
Action Taken (AI summary) Incarace Ltd has revised its risk assessment to prohibit pedestrians on the track during race events, and now undertakes prize giving when there are no moving vehicles on the track. The company states that no staff are permitted on the track area during a race. The ORCi distributed the Regulation 28 report to all members. Interim control measures addressing pedestrian/vehicle segregation were already sent to members in November 2019, specifying procedures for recovery vehicles entering the track after pedestrians have exited, drivers remaining in cars, and a one-way system at the pit gate.
Anthony Carroll
All Responded
2020-0018 8 Jan 2020 Liverpool and Wirral
National Police Chief’s Council
Concerns summary (AI summary) The public may misunderstand police emergency vehicle speed limits. Additionally, a lack of visual indicators led officers to mistakenly believe sirens were active, highlighting a safety flaw.
Noted (AI summary) The NPCC provides clarification on police vehicle speed limits and emergency equipment operation, stating that there's no national proposal to add further equipment activation indicators due to potential driver distraction.
Agnes Sansom
All Responded
2020-0002 7 Jan 2020 County Durham and Darlington
County Durham and Darlington NHS Trust
Concerns summary (AI summary) Patient record systems failed to communicate urgent information in a timely manner, and vulnerable patients were forced to share walking aids on hospital wards, creating safety risks.
Action Taken (AI summary) Following review, physiotherapists now record changes in mobility or interventions in the Nervecentre system to ensure all staff are aware, in addition to maintaining detailed paper records. A buffer stock of walking aids has also been implemented for out-of-hours emergency use.
James Wheeler
All Responded
2020-0001 3 Jan 2020 Manchester (South)
Department of Health and Social Care National Institute for Health and Care … Stockport Borough Council
Concerns summary (AI summary) There is a critical lack of national guidance for monitoring refractory epilepsy, particularly for assistive technology. Additionally, a local authority failed to consistently conduct legally required annual Care Act reviews due to resource constraints.
Noted (AI summary) NICE's guideline on epilepsies (CG137) is being updated, with a draft consultation expected in November 2020 and publication planned for June 2021. The update will consider the effectiveness of new technologies for detecting seizures and interventions for reducing seizure-related mortality. The Department of Health and Social Care acknowledges concerns regarding annual reviews and highlights the Social Care Act 2014. They note that a LeDeR review is being conducted and that the CQC has inspected Cheddle Lodge, finding it compliant with regulations in October 2019. Stockport Council is creating a dedicated review team of six social workers and a team manager to address the backlog of annual reviews in the Learning Disabilities Service, with an option to increase staff numbers as required.