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
REDACTED
Partially Responded
9 Nov 2020 Surrey
Domestic Abuse Management Board Surrey … Surrey County Council
Concerns summary (AI summary) The deceased's general practitioner was not invited to MARAC meetings, nor informed of domestic violence allegations or care proceedings, hindering effective mental health treatment.
1 response from Response to Surrey coroner area Prevention of future deaths report dated
Joseph Hargreaves
All Responded
2020-0227 9 Nov 2020 Greater Manchester South
Department of Health and Social Care
Concerns summary (AI summary) Reduced information sharing from the care home to hospital clinicians, partly due to family visiting restrictions, hindered the provision of accurate baseline health data, risking treatment delays for vulnerable patients.
Noted (AI summary) The Department acknowledges concerns about the impact of COVID-19 restrictions on vulnerable people in hospitals and care homes, and outlines the national guidance and measures in place to manage visiting safely and support care home residents, including testing and updated guidance based on tier restrictions.
Joey Walker
All Responded
2020-0226 9 Nov 2020 Manchester South
Ministry of Housing, Communities and Lo…
Concerns summary (AI summary) Residential landlords are not required to inspect window coverings in private rental properties to ensure only safety cords are used, posing a risk of entanglement.
Action Planned (AI summary) The BBSA, working with Trading Standards and RoSPA, has produced specific guidance for Landlords on window blind safety and updated its child safety website to include landlords and signpost the guidance; the National Residential Landlords Association is supporting the dissemination of this guidance. The Secretary of State acknowledges the risks of looped blind cords, reiterates the legal obligations for safe products, and will ask officials to further publicise RoSPA's safety campaign through newsletters to landlords and local authorities and guides for the private rented sector.
Christopher Murfet
All Responded
2020-0273 6 Nov 2020 Lincolnshire
United Lincolnshire Hospitals Trust
Concerns summary (AI summary) Procedures for considering sectioning the deceased under the Mental Health Act were unclear or potentially absent, despite a risk of suicide.
Noted (AI summary) The Consultant and Clinical Lead for A&E reviewed Mr Murfet's previous attendances at Pilgrim Hospital A&E Department and stated that on both occasions, Mr Murfet was seen and referred to the appropriate psychiatric service from the A&E Department; and subsequently discharged by them.
Stanley Babbs
All Responded
2020-0225 6 Nov 2020 East London
Queen’s Hospital
Concerns summary (AI summary) Contrast media, a prescription-only medicine, was administered without a formal prescription, careful dose consideration, or a clearly identified responsible clinician, particularly for high-risk patients.
Action Taken (AI summary) The Trust has implemented several actions to improve the safe use of IV contrast in CT scans, including communicating a new IV Contrast protocol, emphasizing the importance of personalized evaluations for patients with eGFR less than 30, recording radiologist authorization decisions, providing specific training for radiographers and admin staff, and creating a new radiology request form to incorporate safeguards for patients with abnormal renal function.
Ann Smith
All Responded
2020-0223 5 Nov 2020 Essex
Princess Alexandra Hospital
Concerns summary (AI summary) There was no local protocol for managing anticoagulated patients over 65 who suffer head trauma, especially when also receiving treatment-dose Clexane.
Action Planned (AI summary) The Trust has established a multi-disciplinary Anticoagulation/Falls Tasking Group to develop an Action Plan addressing the management of anticoagulation in patients over 65 who sustain a head trauma; an update is promised by the end of March 2021. The Trust has completed updates to the Falls Prevention policy, quick reference guides, and Nerve Centre software; mandatory questions have been added to the Datix incident management system, and the action has been formally added to the Trust's Strategic Quality Improvement Programme and Corporate Risk Register.
Linda Doherty
All Responded
2020-0224 5 Nov 2020 Surrey
Surrey and Sussex Healthcare NHS Trust
Concerns summary (AI summary) Failures included lack of colorectal follow-up, inaccurate malnutrition scoring, incomplete food charts, delayed recognition of weight loss, and an end-of-life decision made without full multidisciplinary team consultation.
Action Planned (AI summary) The Trust's response includes an action plan with actions such as the Nutrition Steering group overseeing an audit to assess the impact of MaST nutrition training, appointing a professional lead and a lead dietician, and agreeing funding for an additional nutritional nurse specialist, all with deadlines for completion.
Clara Moniatis
All Responded
2020-0221 3 Nov 2020 Essex
Barts and Whipps Trust
Concerns summary (AI summary) Concerns included lengthy waiting times between chest x-rays and image review, and the absence of a system ensuring prompt clinical review after a PEWS alert.
Noted (AI summary) The Trust states that early senior review of deteriorating patients is critically important and they have shared learning widely among clinical staff; however, they believe that nothing could have prevented the patient's outcome.
Michael Robert Collins
All Responded
2021-0092 30 Oct 2020 East London
Royal London Hospital
Concerns summary (AI summary) The CERNER system's flaw in consistently sending results to the correct clinician and radiologists' inability to confirm critical report delivery poses a significant communication risk.
Action Taken (AI summary) The respiratory team developed a Standard Operating Procedure to ensure all investigation results are reviewed promptly. The trust Divisional Director for Imaging has reviewed the processes and has improved the system, which is now formally incorporated within the trust Standard Operating Procedure.
Sarah Gibbs
All Responded
2020-0220 29 Oct 2020 Norfolk
Norfolk and Norwich University Hospital
Concerns summary (AI summary) Inadequate communication between staff teams, especially during night handovers, and uncertainty regarding the consistent use of effective communication tools like SBARD were identified.
Action Taken (AI summary) SBARD is integrated into the patient handover used by the wards at every handover, with a template document used. EObs has been introduced. The Recognise and Response Team (RRT) has been expanded to provide their services 24/7 and teaches SBARD on all new staff inductions.
Darrell Sharples
All Responded
2020-0219 28 Oct 2020 Cornwall and the Isles of Scilly
Devon and Cornwall Constabulary Kernow Clinical Commissioning Group
Concerns summary (AI summary) A mental health clinician conducting telephone triage was unfamiliar with key Trust policies and guidance, resulting in an inadequate assessment of a high-risk patient.
Action Planned (AI summary) The Trust has introduced a 24-hour response telephone line and is developing an Initial Response Service (single point of access for people presenting with mental distress). All new staff members are required to attend a corporate welcome day induction and complete statutory training depending on their role. A former Police Superintendent has been recruited as Mental Health Liaison Officer. A trigger process to identify escalating risk in adults has been launched, including a more focused letter to GPs, with draft letter to be subject to a process of consultation. The Trust launched the Initial Response Service as a single point of access for people in mental distress. A standardised triage tool has been developed for adult mental health services throughout the Trust, and the Trust is involved in a national project to improve access to patient information.
Martin Barrett
All Responded
2020-0222 27 Oct 2020 North East Kent
Priory Group
Concerns summary (AI summary) When internal referrals are declined, patients are not directly informed or given safety netting advice, particularly with insurance funding, leaving high-risk individuals without immediate alternative treatment or support.
Action Taken (AI summary) The Corporate Client Team now makes direct contact with all newly referred clients. Guidance has been put in place for the CCT on actions to take if a client is experiencing an immediate crisis. An appointment with a consultant psychiatrist is now booked to take place in the same week as the therapy assessment, and therapists have been given guidance on the advice that they should give to any newly referred clients who they feel are higher risk.
Reggie-Jay Payne
Historic (No Identified Response)
2020-0218 27 Oct 2020 Milton Keynes
Milton Keynes University Hospital
Concerns summary (AI summary) Group B Strep infection risks were not discussed during pregnancy, screening was not offered, and antibiotics were not administered, potentially contributing to the baby's death.
Sean Owen
All Responded
2020-0215 23 Oct 2020 Manchester North
Pennine Care NHS Foundation Trust
Concerns summary (AI summary) Medication compliance was not monitored after discharge, care coordinator contact was insufficient, and there were significant delays in arranging a psychiatrist appointment despite the patient's deteriorating mental state.
Action Taken (AI summary) The Clinical Director for the Borough has established a process that ensures that all new medical trainees receive a presentation regarding the standards expected and process of writing admission/discharge summaries and a senior doctor checks the documentation. Pennine Care NHS Foundation Trust has issued all new trainees with laptops, and documentation review is now incorporated in trainees’ weekly supervision.
Benjamin Popovach
All Responded
2020-0214 23 Oct 2020 Plymouth, Torbay and South Devon
Devon Partnership NHS Trust
Concerns summary (AI summary) Risk assessments for patients going on leave were not consistently completed, failing to identify community risks and define staff actions for potential plan breakdowns.
Action Taken (AI summary) The Trust undertook a Serious Incident Investigation and developed an action plan. Risk assessments are completed and include contingency plans, and guidance is available for staff on leave arrangements. The learning has been shared with medical staff, Senior Nurse Managers, and at the Eastern Locality Learning from Experience meeting and the Adult Directorate Governance Board meeting.
Karen Jane Winn
All Responded
2020-0213 22 Oct 2020 Suffolk
West Suffolk Hospital
Concerns summary (AI summary) Failure to escalate a rare blood condition to specialists, an unrobust VTE assessment system, and unclear flagging of anticoagulation decisions on records posed significant risks.
Action Planned (AI summary) A flow pathway for Autoimmune Haemolytic Anaemia has been established and published in the Trust’s ‘Pink Book’ and will be included in the ‘Heads Up book’ (HUB), which is currently under development. The VTE assessment tool will be updated to include a prompt for haemolytic anaemia.
Raymond Woodhouse
Historic (No Identified Response)
2020-0217 21 Oct 2020 Cornwall and the Isles of Scilly
Royal Cornwall Hospital
Concerns summary (AI summary) Inadequate staffing led to staff not listening to family, poor cleanliness, delayed antibiotics, and multiple failures in administering time-critical Parkinson's medication.
Roger Wood
Historic (No Identified Response)
2020-0212 21 Oct 2020 East London
Clinisys UK Maylands Health Care Public Health England +1 more
Concerns summary (AI summary) A critical AAA scan result was not acted upon by the GP, and the updated referral policy still relies on GP action rather than direct automatic referral, risking similar failures.
Siân Hewitt
Historic (No Identified Response)
2020-0208 21 Oct 2020 Milton Keynes
NHS England
Concerns summary (AI summary) The NHS lacks appropriate safe placements for patients with Asperger's or autism who also have co-occurring mental health conditions.
Douglas Owens
All Responded
2020-0210 19 Oct 2020 Blackpool & Fylde
Blackpool Teaching Hospitals NHS Founda…
Concerns summary (AI summary) Lack of formal transfer agreements and speciality doctor reviews in ED, coupled with widespread failures in vital signs observation, documentation, and medication recording, jeopardised patient safety.
Action Taken (AI summary) The Trust has developed a protocol for handover from Spire Fylde Coast Hospital to the Emergency Department and then ophthalmology and has reminded ED staff that variable doses of medication should be written on the PRN section of the chart. Morphine elixir has been treated as a restricted drug since November 2018, with all doses recorded in the restricted drugs register.
William Turner
Partially Responded
2020-0209 15 Oct 2020 County Durham and Darlington
Department for Transport Secretary of State for Transport's Hono…
Concerns summary (AI summary) Current DVLA regulations for driving licences following epileptic seizures may need review, as a driver potentially experiencing a seizure lawfully held a licence, leading to a fatal incident.
Action Planned (AI summary) The DVLA will ask the Secretary of State for Transport’s Honorary Medical Advisory Panel on Disorders of the Nervous System to review the period of time required off driving before someone who has suffered a seizure can regain their driving licence.
Thomas King
All Responded
2020-0207 15 Oct 2020 Essex
Essex Partnership University NHS Founda…
Concerns summary (AI summary) Incompatible software used by the Health and Justice Team prevented crucial mental health information sharing with other teams, risking inaccurate risk assessments and patient harm.
Action Taken (AI summary) The Trust has implemented Tiani Health Information Exchange (HIE), an interoperable application that allows clinicians to view patient data from across systems, including the Health and Justice Service's Exelicare system. All clinical staff in the Trust now have access to the HIE.
Avis Addison
All Responded
2020-0216 14 Oct 2020 Cornwall and the Isles of Scilly
Care Quality Commission
Concerns summary (AI summary) Concerns about ensuring GP practices have robust domestic violence and safeguarding policies/training, and implementing "early warning systems" for suspicious missed appointments or uncollected prescriptions.
Action Taken (AI summary) Following the regulation 28 notice, CQC contacted the registered person of the GP practice, and were assured about the management of safeguarding and vulnerable patients; learning from the inquest will be shared with inspectors.
Edward Cowey
Partially Responded
2020-0205 14 Oct 2020 Derby and Derbyshire
NHS England University Hospital of Derby and Burton
Concerns summary (AI summary) Fragmented patient information across multiple systems, inconsistent head injury policies, inadequate anticoagulation guidelines, and insufficient falls form guidance created significant safety risks.
Action Taken (AI summary) Since the incident, a doctor now checks all ISBAR handovers, medications and VTE status of patients. The Trust will be explicit in their guidance that any patient receiving low-molecular weight heparin for prophylactic or therapeutic reasons are included in NICE guidance CG176 and have suggested that NICE updates CG176 to reflect this advice. Staff will receive training regarding updating electronic handovers, revisiting handovers, and countersigning entries made by student nurses.
Piotr Kierzkowski
All Responded
2020-0204 12 Oct 2020 Suffolk
Department of Health and Social Care
Concerns summary (AI summary) A critical lack of available mental health beds prevented the deceased from informal admission despite mutual desire from patient and staff, leading to his tragic death.
Action Planned (AI summary) Norfolk and Suffolk NHS Foundation Trust has increased capacity through the opening of four crisis house beds in Norwich, with plans to open two additional crisis houses in the coming months, as well as extra ward capacity for older people. The Trust has reviewed its bed management processes to ensure clinically-led admissions.