2020
PFD Reports
Reports: 309
Areas: 57
83% response rate (above 63% average).
Sharon Kelly
Partially Responded
2020-0250
24 Nov 2020
Essex
EFAS
Essex Partnership University NHS Founda…
Essex Police
Concerns summary (AI summary)
Inadequate training and unclear communication protocols between emergency services led to delays in identifying and responding to mental health crisis risks, including police attendance and urgent mental health assessments.
Action Planned
(AI summary)
The Trust will ensure referrals for urgent MHA assessments are accompanied by a telephone conversation, risks will be made explicit, and the timing of the MHA assessment will be explored with the referrer to agree/mitigate risk.
Christopher Sparks
Historic (No Identified Response)
2020-0249
24 Nov 2020
Essex
PCRSteel Ltd
SE Galvanisers
Concerns summary (AI summary)
The incident resulted from a lack of safe loading and lifting plans, absence of a banksman, inadequate designated safe zones for drivers, and insufficient equipment for handling large products.
Claire Richards
Partially Responded
2020-0253
23 Nov 2020
County Durham and Darlington
Home Office
Royal Pharmaceutical Society
Concerns summary (AI summary)
Illegally dealt prescription drugs are of increasing concern, and what steps are projected for stemming the leakage of prescription medication out of the lawful dispensing process into criminal hands?
Noted
(AI summary)
The Royal Pharmaceutical Society acknowledges the concerns regarding prescription medicine misuse and highlights their role in promoting best practices, noting that the General Pharmaceutical Council regulates pharmacy. They suggest Public Health England and the Advisory Council for the Misuse of Drugs should be aware of the report.
Elena Wells
All Responded
2020-0248
23 Nov 2020
Brighton and Hove
Brighton and Hove City Council
Sussex Partnership Foundation NHS Trust
Concerns summary (AI summary)
Mental health crisis management failures included delayed bed availability, insufficient overnight support, confusion over professional responsibility, and a lack of in-person checks when the patient's condition worsened.
Action Planned
(AI summary)
The Trust and BHCC are developing a joint policy and guidance to improve communication and define responsibility between the organisations to improve the safety of voluntary patients waiting for acute mental health beds. Actions include reviewing existing policies and protocols, implementing new documentation procedures, and providing staff training, to be completed by April 2021.
Jason Thompson
All Responded
2020-0246
20 Nov 2020
County Durham and Darlington
Department of Health and Social Care
eBay UK Ltd
Metalchem Ltd
Concerns summary (AI summary)
A website may be illegally promoting suicide methods, and a lethal substance is too easily available online under a misleading description, posing significant public safety risks.
Action Taken
(AI summary)
Metalchem Ltd stopped selling Sodium Nitrite on eBay in April 2020 after becoming aware of its recommendation on suicide forums. They contacted other sellers to request they stop selling the product online and enlisted help to remove persistent sellers on Ebay and Etsy. Ebay banned the sale of sodium nitrite as a chemical globally in 2019 and updated filters to prevent listings, after a report of potential misuse for suicide attempts. They analyzed the listing from which the deceased purchased the chemical to improve filter algorithms. The Department of Health and Social Care highlights existing actions to reduce suicide rates, including the Suicide Prevention Strategy for England and the Cross-Government Suicide Prevention Workplan, which addresses harmful online content. They are working with online retailers to raise awareness of the potential for suicide and investing in suicide prevention through the NHS Long Term Plan.
John Tucker
Historic (No Identified Response)
2020-0266
19 Nov 2020
Gwent
Gwent Police
Concerns summary (AI summary)
There are concerns about the inadequate nature and extent of basic life support and first aid training provided to Gwent police staff, despite their regular contact with unwell or injured individuals.
Paul Hills
Partially Responded
2020-0247
19 Nov 2020
North East Kent
Ministry of Defence
Woolwich Station Medical Centre
Concerns summary (AI summary)
Inadequate mental health care during COVID-19 involved no risk assessment for virtual appointments, outdated care plans, failure to share escalating risks with family, and poor documentation of suicidal disclosures.
Action Taken
(AI summary)
The MOD has taken several steps, including launching the Defence People Mental Health and Wellbeing Strategy in 2017 and a new online platform, HeadFIT, in 2020. Mandatory annual mental health and wellbeing training will be introduced in April 2021, and a Defence Suicide Registry project has begun to inform a MOD suicide prevention strategy.
Yo Li
All Responded
2020-0245
19 Nov 2020
Surrey
British Association of Perinatal Medici…
NHS England
Concerns summary (AI summary)
National guidance for central venous catheters in neonates lacks a key risk factor, and there's no mandatory requirement for NHS Trusts to ensure clinician familiarity or policy compliance with existing guidelines.
Disputed
(AI summary)
The BAPM acknowledges the coroner's concerns but argues that their existing Framework for Practice (FfP) for the use of Central Venous Catheters in Neonates already addresses the issues. They contend that a requirement for NHS Trusts to ensure clinicians are familiar with the FfP is unnecessary. NICE acknowledges the concerns but states that BAPM guidance should cover UVC insertion and risks, and that the GMC requires clinicians to be aware of relevant specialty guidance. They have logged the concerns for consideration when guideline NG154 is next reviewed.
Katherine Hogan
All Responded
2020-0243
18 Nov 2020
Mid Kent and Medway
Maidstone and Tunbridge Wells NHS Found…
Concerns summary (AI summary)
Persistent staff shortages led to patients being kept overnight in unsuitable clinical areas, with the Trust failing to address reported staffing issues or implement requested increases.
Action Taken
(AI summary)
The Trust has implemented several changes including increased monitoring of patients in the clinical decision unit (CDU), revised admission criteria for the CDU, reassessed safe staffing levels, increased senior nursing support, and is using RCEM/GIRFT recommendations for staffing. It has also re-opened the serious incident investigation and is creating a revised action plan.
Alfie Gildea
All Responded
2020-0242
18 Nov 2020
Greater Manchester South
Greater Manchester Police, Trafford Met…
Concerns summary (AI summary)
Suspects in domestic abuse cases were not placed on bail with conditions to protect alleged victims and there was a lack of understanding amongst police witnesses about the GMP policy in relation to serial/serious DA perpetrators and the actions that were required under GMPs policy.
Noted
(AI summary)
Greater Manchester Police has conducted a review into the triage process of district safeguarding teams, is developing a triage training course including guidance on information sharing, and has recruited a Domestic Abuse Coordinator to ensure a consistent approach to MARACs across the force. Trafford Council states it has already made significant improvements to policies and procedures since 2018 and believes the coroner's concerns are directed to central government. Greater Manchester Health and Social Care Partnership will present learning from the Serious Case Review to the Greater Manchester Quality Board and share it with commissioners of services for consideration. The CPS acknowledges differences in the definitions of a serial domestic abuser and explains the role of the prosecutor in relation to reasonable lines of enquiry. The Dept. of Health and Social Care notes the concerns raised, mentions a Serious Case Review and review of its action plan, and states that local authorities are responsible for commissioning health visitor services based on local needs. The Home Office describes national actions to manage perpetrators of abuse including College of Policing guidance, a review of the Domestic Violence Disclosure Scheme (Clare's Law), and the introduction of new Domestic Abuse Protection Orders (DAPOs) with associated training for police.
Michelle Turner
All Responded
2020-0240
18 Nov 2020
Blackpool and Fylde
Blackpool Clinical Commissioning Group
Concerns summary (AI summary)
Critical funding for peer support workers, who offer invaluable 'lived experience' and essential support for mental health and substance misuse, may be lost, jeopardizing vital services.
Action Planned
(AI summary)
The CCG has agreed to extend the current peer support worker provision until March 2022 and is transforming community mental health services as part of the Long-Term Plan, which includes peer support workers. The transformation model is due to be submitted to NHS England in January 2021.
Sylvia Griffiths
All Responded
2020-0238
17 Nov 2020
Staffordshire (South)
Staffordshire Fire and Rescue Service HQ
Concerns summary (AI summary)
Consideration should be given to fire and smoke alarms specifically designed for people with dementia, which could improve safety for this vulnerable group.
Action Planned
(AI summary)
Staffordshire Fire and Rescue Service will conduct a fatal fire review of the case with partner agencies, share learning nationally, and incorporate findings into Olive Branch training sessions.
Neil Barre
All Responded
2020-0237
17 Nov 2020
Staffordshire (South)
Staffordshire Fire and Rescue Service HQ
Concerns summary (AI summary)
Communication between Staffordshire Fire and Rescue Service and domiciliary care providers needs improvement to ensure awareness when clients are not using provided fire safety equipment.
Action Planned
(AI summary)
Staffordshire Fire and Rescue Service will conduct a fatal fire review involving key partner agencies, sharing any multi-agency learning. The learning will be used to review prevention and partnership activity, and shared nationally, and will also be incorporated into their Olive Branch training sessions.
Riley Holt, Keegan Unitt, Tilly-Rose Unitt and Olly Unitt
All Responded
2020-0236
17 Nov 2020
Staffordshire South
Housing of Vulnerable People (Building …
Concerns summary (AI summary)
Conventional smoke alarms may be ineffective for children under 16, particularly boys, suggesting mandatory fire suppression systems in all new properties, similar to Wales, should be considered.
Noted
(AI summary)
The Secretary of State acknowledges the deaths and states that the government is committed to building safety, including a review of smoke alarm standards.
Daniel Bancroft
All Responded
2020-0244
16 Nov 2020
Cumbria
Highways England Co. Ltd and Cumbria Co…
Concerns summary (AI summary)
Dangerous road conditions on the A66 include a lack of pedestrian warnings, rapid acceleration onto an unlit section, poor lighting, and national speed limit signs placed too close to a roundabout.
Noted
(AI summary)
Cumbria County Council stated that the Road Traffic Collision occurred on the Highways England Authority's road network. They regularly meet with Highways England to discuss road safety but Highways England will address the issues raised. Highways England will install 'no pedestrian' signs and bollards on the A66 Stainburn Bypass within 3-6 months and also install pedestrian direction signing during the same timeframe. They concluded no other actions are required regarding speed limit proximity to the roundabout and lighting.
Daniel Waite
All Responded
2020-0241
16 Nov 2020
Mid Kent and Medway
Highways Department Kent County Council…
Concerns summary (AI summary)
The A20 Ashford Road lacks parking restrictions and requirements for warning signage, allowing large vehicles to park unsafely and posing a significant risk to other road users.
Action Taken
(AI summary)
Kent County Council has installed 'clearway' signs and implemented a temporary traffic regulation order prohibiting parking on the section of dual carriageway. A permanent traffic regulation order with permanent posts and signage will replace the temporary order.
Jean Williams
All Responded
2020-0239
16 Nov 2020
Manchester (West)
NHS England, Blackpool Teaching Hospita…
Concerns summary (AI summary)
Bed levers are improperly fitted by untrained staff without patient assessment, and policy gaps hinder reporting concerns. Miscommunication prevents trained professionals from fitting them, and there is a risk of supplying levers without essential safety straps for Divan beds.
Action Taken
(AI summary)
Blackpool Teaching Hospitals addressed concerns about bed lever fitting at Thornton House by clarifying that Occupational Therapists, now correctly trained, will prescribe and fit them after a full assessment. The intermediate care team and LCC were informed of updated processes at a meeting on December 2, 2020, and the Trust shared findings with senior Allied Health Professionals across the Lancashire and South Cumbria Integrated Care System. Lancashire County Council updated their 'Bed Rail and Bed Lever Policy and Procedure' to clarify the escalation process for concerns, effective January 8, 2021, with a further review planned for April 2021. They also rectified a miscommunication regarding bed lever usage at Thornton House, agreeing with Blackpool Teaching Hospitals that bed levers can be used when appropriate and fitted only by trained Occupational Therapy staff. Mobility 2000 Ltd has carried out further training with staff on fitting bed levers and straps, and will now supply a hard copy of the manufacturer's instructions with every bed lever.
Imane Bouasbia
Partially Responded
2020-0234
12 Nov 2020
East London
Home Office
Metropolitan Police Service
Concerns summary (AI summary)
Police failures included inadequate communication of suicidal ideation during handover, absence of a risk assessment for self-harm, and a limited, non-expedited response to a direct suicidal text message.
Action Taken
(AI summary)
The MPS emailed all SOIT officers and Public Protection Department managers with the instruction that SOIT and investigating officers must inform a supervising officer if they receive any contact from a victim that causes them concern. Continuous Professional Development events for SOIT officers will include suicide awareness and a contribution from Hostage and Crisis negotiator regarding how to more effectively engage with a person in a mental health crisis.
Amarbai Bhudia
Partially Responded
2020-0232
12 Nov 2020
East London
Department of Health and Social Care
Royal London Hospital
Concerns summary (AI summary)
Poor communication of medical instructions, inadequate training for nursing and agency staff on NG tube management, and a failure to properly escalate concerns about its function were identified.
Action Taken
(AI summary)
Barts Health NHS Trust implemented a structured ward round template to improve communication and a teaching session on Nasogastric Tube Placement was delivered to teams on the wards. A comprehensive local induction pack was developed to ensure that all temporary workers have a robust induction to the clinical area.
Chelsie Greatorex
All Responded
2021-0018
11 Nov 2020
East London
Home Office
Metropolitan Police Service
Concerns summary (AI summary)
The police investigation into a child sexual assault lacked specialist officer involvement, experienced significant delays, and provided insufficient support to the complainant.
Action Planned
(AI summary)
The Home Office is conducting a review of the criminal justice response to rape, consulting on a new Victims’ Law, and investing in rape support centers and Independent Sexual Violence Advisers (ISVAs). The MPS is developing a Suicide Prevention Policy Document and Toolkit, including information on suicide prevention, support services, risk indicators, contacts and best practice, with a draft expected by the end of December 2020; they are also improving training and guidance for officers and staff, including an investigative standards document and meeting with other forces to share good practice.
Margaret Sales
All Responded
2020-0233
11 Nov 2020
Norfolk
Queen Elizabeth Hospital
Concerns summary (AI summary)
Records were not always completed as required, nurses had difficulty contacting on-call medical staff, and a referral to the Home Enteral Nutrition service was not placed with the GP after a previous discharge.
Action Taken
(AI summary)
The Queen Elizabeth Hospital Kings Lynn provided a medical records audit across the Trust's wards. They also have updated falls risk assessments and management plans to include contacting Mental Health Liaison. A review of the QEH guidelines for those on Fresnuis is underway and due by the end of February 2021.
Carolyne Senior
All Responded
2020-0231
11 Nov 2020
South Yorkshire (West)
Barnsley Hospital NHS Foundation Trust
Concerns summary (AI summary)
Hospital staff lacked sufficient specialist mental health advice to properly assess and mitigate falls risks for patients with mental health needs, leading to inadequate care plans.
Action Taken
(AI summary)
The Trust updated falls risk assessments to consider mental health, including a direct reference to contacting Mental Health Liaison. They have also informed nursing staff of these changes and shared learning from the case with the Mental Health Strategy Implementation Group.
Xuanze Piao
All Responded
2020-0230
11 Nov 2020
Coventry
Coventry University
Concerns summary (AI summary)
The university failed to hold a face-to-face meeting or contact the guardian/parents of an under-18 overseas student before sending a critical email indicating course removal risk, revealing a lack of clear communication policy.
Action Planned
(AI summary)
Coventry University is undertaking a full review of its policy and procedures relating to students who are under the age of 18, expected to be complete by January 31, 2021. They have also put in place an additional process for responding when international students under 18 fail to engage with their course, including a face-to-face meeting with a welfare advisor.
Ewan Brown
Historic (No Identified Response)
2020-0235
10 Nov 2020
Newcastle upon Tyne and North Tyneside
Northumbria Police, Newcastle City Coun…
Concerns summary (AI summary)
A lack of joint police-health policies for vulnerable missing persons, absence of multi-agency meetings, inadequate police mental health training, and poor information sharing protocols hindered effective risk assessment and search efforts.
Leslie Clewarth
All Responded
2020-0229
10 Nov 2020
West Yorkshire
Mid Yorkshire Hospitals NHS Trust
Concerns summary (AI summary)
Inadequate record-keeping of care provided and medication dosage made it impossible to corroborate staff actions and risked erroneous or duplicated patient care.
Action Planned
(AI summary)
The Trust is revising its Syringe Pump Policy and combined prescription/administration chart to provide clearer guidance on medication recording and syringe changes; further training will be delivered following appropriate governance routes.