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)
Clear 215 results
Pauline Oakley
All Responded
2020-0304 18 Sep 2020 Inner North London
East End Homes, East London NHS Foundat…
Concerns summary (AI summary) There was no safety assessment of the patient's flat or appliances upon hospital discharge. Additionally, the fire alarm system was unmonitored, relying on residents who may have assumed it was.
Noted (AI summary) East London NHS Foundation Trust clarifies that responsibility for environmental risk assessments following the patient's discharge from hospital would lie with the Reablement Team, which falls within the remit of the London Borough of Tower Hamlets. However, they will discuss the case within their regular team meetings. East End Homes states that the smoke alarms were of an appropriate standard, properly installed, maintained, and operated when activated. They believe that residents do not expect domestic alarms to be monitored externally, and they offer general guidance on fire safety. The GP practice will ensure the multi-disciplinary team and Social Services are made aware of concerns raised about the adequacy or safety of a patient's home environment. Clinicians can prompt the Care Navigator or Social Worker at the monthly Integrated Care Multidisciplinary Meeting to ensure that appropriate fire safety checks are implemented.
Macloud Nyeruke
All Responded
2020-0177 18 Sep 2020 West Yorkshire (East)
Leeds Teaching Hospitals NHS Trust Reed Nursing Trust
Concerns summary (AI summary) Hospital failed to assess an agency support worker's immune status, assigning them to infectious wards without adequate PPE training, increasing infection risk to staff and patients. Nursing agencies failed to share health vulnerabilities.
Noted (AI summary) The Trust is providing additional 'fit testing' for PPE outside of usual provision and plans to standardise 'bank notes' on shifts in high risk areas specifying the need for fit testing, with audits to check implementation. They have also advised high risk staff to contact Reed to check the status of wards, and carry their risk assessments. Reed Specialist Recruitment states they have complied with their contractual obligations and notified relevant authorities (EAS, CCS, CQC). They suggest the report be re-addressed to ID Medical, the direct supplier of the worker in question. The Employment Agency Standards (EAS) Inspectorate explains its role in enforcing regulations for employment agencies, outlining the checks and authorisations required to ensure the suitability of work-seekers, including healthcare workers.
Isaac Newton
All Responded
2020-0174 14 Sep 2020 Blackpool & Fylde
Department of Health and Social Care
Concerns summary (AI summary) Despite guidance, young parents are continuing unsafe co-sleeping practices, often involving alcohol or drugs, and are not appreciating or following advice on safe sleeping environments, risking infant deaths.
Action Taken (AI summary) The Department of Health and Social Care detailed actions taken to raise awareness of co-sleeping risks, including releasing two short films with advice and incorporating safe sleeping advice into the Healthy Child Programme. Public Health England also plans to publish refreshed commissioning and delivery guidance for the Healthy Child Programme, including safer sleeping discussions and highlighting potential harms, in Q3 2020/21.
Frederick Terry
All Responded
2020-0173 9 Sep 2020 Essex
Mid and South Essex NHS Foundation Trust
Concerns summary (AI summary) Failures included inadequate risk assessment for delivery, incorrect forceps use due to insufficient training, excessive force, poor locum staff management, communication breakdowns, and unsuitable resuscitation equipment in maternity.
Action Taken (AI summary) Mid and South Essex Foundation Trust has strengthened processes, implemented a locum checklist, and added a self-assessment tool for obstetric skills. They employed an additional Obstetric Consultant, implemented a 24-hour bleep for the Senior Nurse in the Neonatal unit, and are driving the 'Below Ten Thousand Feet' initiative for communication in theatres.
Linda Phillipson
All Responded
2020-0172 8 Sep 2020 Brighton and Hove
Western Sussex Hospital Trust
Concerns summary (AI summary) Concerns arose from a significant delay in applying an external fixator and an apparent failure to mobilise the patient, indicating potential lapses in clinical care.
Action Taken (AI summary) Western Sussex Hospital Trust shared the PFD report with relevant staff, conducted an RCA, and confirmed a Trust Surgical Board ratified Transfer Policy is in place for complex trauma patients needing specialist surgery at the Major Trauma Centre. They also included the application of spanning external fixator, elevation, and early mobilisation within the protocol.
Peter Howarth
All Responded
2020-0171 8 Sep 2020 Greater Manchester South
Borough Care
Concerns summary (AI summary) The care home failed to conduct a robust investigation into a resident's fatal fall, missing crucial learning opportunities to prevent similar incidents for other residents.
Action Taken (AI summary) Borough Care implemented extra measures to review falls on a weekly/monthly basis after a previous PFD report, including weekly falls analysis, GP/falls clinic referrals for residents with more than 2 falls in 2 weeks, and monthly reviews. These measures have been discussed with CQC and their policy updated.
Ellie Isaacs
All Responded
2020-0169 7 Sep 2020 East London
Havering Highways
Concerns summary (AI summary) Obstructed driver views, a Pelicon crossing located after a high-speed zone, and high non-compliance with traffic signals at the crossing create a dangerous environment for pedestrians.
Noted (AI summary) TfL renewed the 30mph signs, resurfaced the Gallows Corner roundabout including renewal of surfacing and markings, and liaised with the Gallows Corner Retail Park to request maintenance of vegetation and trees. They will undertake a further safety review and address any further actions identified by 31 March 2021. Havering Council acknowledges the incident location is on the A12, for which Transport for London is the Highway Authority. While they undertook a site inspection, they do not feel that there are any actions Havering Council can take.
Zoe Knight
All Responded
2020-0168 4 Sep 2020 South Manchester
National Institute for Health and Care …
Concerns summary (AI summary) Acute aortic dissection is difficult to diagnose due to symptom overlap. A critical recommendation to add "aortic pain" to the Manchester Triage System to improve awareness and earlier diagnosis has not been implemented.
Noted (AI summary) NICE acknowledges the concerns and notes that existing guidance (CG95) flags points where healthcare professionals should consider aortic dissection. They note that topic experts decided against including more detailed guidance, but that they will engage with professional bodies to improve use of their guidelines.
Laura Parsons
All Responded
2020-0170 3 Sep 2020 County Durham & Darlington
Department of Health and Social Care
Concerns summary (AI summary) A patient with a recent morphine overdose history received a repeat prescription for a fatal amount of liquid morphine. Electronic systems failed to flag the overdose history during repeat prescription authorization, lacking critical scrutiny.
Noted (AI summary) The Department for Health and Social Care acknowledges the concerns and outlines existing NICE guidance and CQC recommendations regarding the safe use and management of controlled drugs. They highlight the need for regular monitoring of patients before repeat prescriptions are issued.
Dereck John Chapman
All Responded
2020-0165 27 Aug 2020 Blackpool & Fylde
Rossendale Nursing Home
Concerns summary (AI summary) Nursing home staff provided an insufficient response to a high-fall-risk dementia patient, failing to account for his communication difficulties. Additionally, poor and unreliable record-keeping compromised accurate care narrative and incident review.
Action Taken (AI summary) Rossendale Nursing Home has implemented Person Centred Software, walk around handovers, pre-admission falls risk assessments, motion sensors, staff presence in communal areas, a post-fall protocol, referrals to the Falls team, CCTV, and monthly environmental audits to reduce falls risk.
Toby Nieland
All Responded
2020-0164 26 Aug 2020 Lincolnshire
Lincolnshire County Council Lincolnshire Partnership NHS Foundation… South Lincolnshire Clinical Commissioni… +1 more
Concerns summary (AI summary) Agencies failed to engage with family concerns for a patient with complex dual diagnosis. There was inadequate care coordination, poor evaluation of relapse signs, and a lack of assertive community outreach for his advanced addiction and mental health needs.
Action Planned (AI summary) Lincolnshire County Council plans to implement a working protocol for mental health and substance misuse services, take into account best practice when re-commissioning drug and alcohol services, review dual diagnosis provision, and consider partnership commissioning with the CCG. We Are With You charity has jointly agreed to review Dual Diagnosis pathways, embedded information sharing expectations, and reviewed staff structures to introduce specialist Dual Diagnosis roles. They have also enhanced reciprocal training to LPFT and regularly attend interface meetings and provide opportunities for staff from various organisations to spend time within their teams. The Trust plans to update training programmes to focus on dual diagnosis, reinforce the role of carers, review the Care Programme Approach, and engage with commissioners to ensure appropriate funding for patients with dual diagnoses. They also aim to remove barriers to information sharing and promote data gathering and benchmarking.
Daniel Coleman
All Responded
2020-0166 25 Aug 2020 Inner North London
Camden Council First Response Group
Concerns summary (AI summary) Managers and security failed to detect a resident living illicitly on a demolition site, exhibiting inconsistent patrols, poor record-keeping, and failing to recognise intoxication. Ineffective drug and alcohol policies for high-risk environments were also noted.
Action Planned (AI summary) Camden Council is revising its Drug and Alcohol Policy, consulting with Hampton Knight and Trade Unions, with a planned testing regime rollout in the new year, dependent on the ongoing consultation and impact of the coronavirus pandemic.
Malyun Karama
All Responded
2020-0162 21 Aug 2020 Inner North London
Royal Free Hospital
Concerns summary (AI summary) There is a lack of national learning regarding the increased risk of uterine rupture in multi-gravida mothers from misoprostol. Additionally, the absence of computers in delivery suites hinders contemporaneous observation recording.
Action Taken (AI summary) The Royal Free London NHS Foundation Trust has shared learning from the case at the North Central London Local Maternity System Quality and Safety Meeting, communicated with the national maternity risk/governance managers, and reviewed workstations on wheels available on the Labour ward, sending a memo to staff on 2nd September 2020.
Viktor Scott-Brown
All Responded
2020-0163 18 Aug 2020 County Durham and Darlington
Informa Healthcare National Institute for Health and Care … Oxleas NHS Foundation Trust +2 more
Concerns summary (AI summary) A psychiatrist failed to inform a patient about Lamotrigine's self-harm/suicide side effect due to a lack of awareness, exacerbated by inconsistent or absent warnings in reputable pharmacological guidelines, posing patient safety risks.
Noted (AI summary) Oxleas NHS Foundation Trust states they no longer have any involvement in the authorship or editing of the Maudsley Prescribing Guidelines since April 2015. Tees Esk & Wear Valley NHS Foundation Trust is developing a Medication Safety Series document regarding prescribing resources and sources of patient information, aiming to have a draft ready for approval on 24th September 2020 and complete dissemination by 2nd October 2020. NICE has passed the concerns regarding lamotrigine to the BNF publishers and will consider moving a footnote about the risk of suicidal thoughts and behaviour into the recommendation of their guideline on epilepsies, currently being updated. BNF Publications will add suicidal ideation as a side effect to the lamotrigine monograph and the important safety section of the lamotrigine monograph in the BNF.
Ian Allen
All Responded
2020-0161 17 Aug 2020 Birmingham and Solihull
Birmingham and Solihull Mental Health F… Department of Health and Social Care
Concerns summary (AI summary) The Trust failed to act on high clozapine levels due to poor monitoring systems and a lack of understanding regarding its importance. National guidance is needed for monitoring frequency and practitioner education on clozapine.
Action Taken (AI summary) Birmingham and Solihull Mental Health Trust has provided pharmacists with additional training on Clozapine, will build further education into the Post Graduate Medical Education programme and is drafting a safety alert to all clinicians; also reviewing and updating Trust Clozapine guidelines to reflect updated MHRA guidance in August 2020, to be approved in November 2020. The Department of Health and Social Care notes that Birmingham and Solihull Mental Health NHS Foundation Trust has responded to the report by undertaking a review and update of its guidance on the use of clozapine, and have taken additional measures such as additional training and education and an audit of patients.
Brenda Elmer
All Responded
2020-0159 14 Aug 2020 West Sussex
NHS England Public Health England
Concerns summary (AI summary) Discharged patients were not effectively informed about a hospital-acquired Listeria outbreak, delaying diagnosis. Additionally, there are no legal requirements for private labs or hospitals to share Listeria isolates, hindering timely outbreak identification.
Action Taken (AI summary) PHE implemented an Incident Management Team following listeria cases, inspected the sandwich manufacturer, and wrote to national microbiological standards to update the SOP for identification of Listeria. The updated SOP advises hospital laboratories to refer all isolates from patients to PHE.
Sylvia Scully
All Responded
2020-0156 11 Aug 2020 Greater Manchester South
Royal College of Radiologists Tameside and Glossop Integrated Care NH…
Concerns summary (AI summary) The hospital failed to conduct a Serious Untoward Incident investigation, and its emergency department lacked a rapid assessment model, causing significant delays in senior doctor assessment and critical treatment for walk-in patients.
Action Planned (AI summary) The RCR has invited its Radiology Informatics Committee to revisit its guidelines to double check that they are clear and unambiguous in their specifications regarding IT equipment standards. The Trust is developing an Abdominal Pain Pathway aiming for CT scans within 2 hours for Emergency Department patients with abdominal pain, expecting it to be in place by the end of October 2020. They have also created an Escalation Handovers Pack for junior doctors, with the Royal College of Emergency Medicine planning to host it on their website.
Francis Cooney
All Responded
2020-0154 10 Aug 2020 Birmingham & Solihull
University Hospitals Birmingham NHS Fou…
Concerns summary (AI summary) Critical medication changes for a patient with cognitive impairment were not communicated to the next of kin, causing confusion. A lack of clear policy and systemic investigation into this communication breakdown risks future harm to vulnerable patients.
Action Planned (AI summary) The Trust will reinforce with staff the requirement to record sight of a registered LPA, review the 'Communication with Relatives Procedure', and explore options for implementing electronic flagging of patients lacking capacity.
Anthony Williamson
All Responded
2020-0153 7 Aug 2020 Cornwall & Isles of Scilly
Maritime Coastguard Agency Royal National Lifeboat Institution
Concerns summary (AI summary) Concerns persist regarding reduced coastguard and lifeguard cover on the Cornish coastline, with no transparent, published plan on mitigation strategies or current service levels available to the public.
Noted (AI summary) The MCA confirms its search and rescue services were maintained during the pandemic, describes collaboration with Surf Life Saving GB, and states responsibility for beach safety lies with landowners. The RNLI details the impact of Covid-19 on its lifeguard service, outlines its role in beach safety, and describes a joint publicity campaign with HM Coastguard and co-authored guidance for local authorities.
Jan Klempar
All Responded
2020-0152 7 Aug 2020 Cornwall & Isles of Scilly
Maritime Coastguard Agency Royal National Lifeboat Institution
Concerns summary (AI summary) Reduced lifeguard cover on Cornish beaches lacks a clear, publicly available plan detailing coverage levels or how shortfalls will be mitigated by other emergency services, increasing safety risks for bathers.
Noted (AI summary) The MCA outlines its role in coordinating search and rescue missions, clarifies it has no responsibility for beach lifeguards, and describes publicity campaigns with the RNLI to encourage personal responsibility for safety. The RNLI details the impact of Covid-19 on its lifeguard service, outlines its role in beach safety, and describes a joint publicity campaign with HM Coastguard and co-authored guidance for local authorities.
Alana Cutland
All Responded
2020-0151 5 Aug 2020 Milton Keynes
Medicines and Healthcare Products Regul…
Concerns summary (AI summary) The drug information leaflet for doxycycline failed to highlight the possibility of a psychotic reaction, which the deceased experienced, hindering early intervention by her family.
Action Planned (AI summary) The MHRA reviewed evidence on doxycycline and psychotic reactions. Based on expert advice, they will request that the lead marketing authorisation holder submit a proposal by 30 November 2020 to gather further data on the risk of psychotic reactions following doxycycline.
Pauline Russell
All Responded
2020-0149 4 Aug 2020 Norfolk
James Paget University Hospital
Concerns summary (AI summary) Hospital staff did not check if the deceased could read, impacting her ability to understand menus and discharge instructions; this practice remained unchanged eight months after her death.
Action Taken (AI summary) The hospital trust has amended admission and discharge documentation to include additional checks regarding literacy support, shared updated documentation with ward managers, and will carry out monthly audits to ensure compliance. The pharmacy department also implemented a new system which communicates patient's discharge letter to their usual community pharmacy.
Samuel Garner
All Responded
2020-0145 27 Jul 2020 Greater Manchester South
Department of Health and Social Care Greater Manchester Health and Social Ca…
Concerns summary (AI summary) An elderly, vulnerable patient received inadequate care in an overcrowded Emergency Department, including being treated in a corridor. Significant delays for critical procedures and surgical ward transfer were caused by bed capacity issues.
Action Taken (AI summary) The Department of Health and Social Care acknowledges the poor care received by Mr. Garner and highlights regulatory action taken by the CQC at Stepping Hill Hospital. The response also mentions national initiatives to improve patient flow, including funding for winter pressures and enhanced discharge arrangements. The GMHSCP highlights actions taken to address ED pressures including implementation of a GM Discharge Pathway, use of a single GM Discharge to Assess Referral Form with triage within 30 minutes, adherence to COVID-19 testing guidance and PPE requirements, supply of two weeks of medication on discharge, and next-day follow-up processes.
Kobi Wright
All Responded
2020-0143 16 Jul 2020 Norfolk
James Paget University Hospital RadcliffesLeBrasseur LLP
Concerns summary (AI summary) No specific concerns were detailed in the provided text for this report.
Action Planned (AI summary) The Trust is reviewing its recruitment process for doctors to ensure appropriate training and induction, with changes to be implemented by the end of September 2020. The trust also describes existing processes for assessing locum doctors, offering substantive contracts after frequent employment, and encouraging staff to raise concerns. Dr. referred himself to the General Medical Council following the inquest. He has also been proactive in his efforts to improve his knowledge and partake in training for obstetric emergencies including completing the K2 Training Program.
Luiz Anjos
All Responded
2020-0259 13 Jul 2020 Essex
Highways Agency Essex County Council
Concerns summary (AI summary) Easy access over the footbridge parapet and sides at the location remains a significant safety concern, despite other identified issues having been remedied.
Action Planned (AI summary) Essex Highways has identified three potential options to improve safety at the St Dominic Road Footbridge and prefers installing full-height corrugated steel parapets. A full structural assessment is estimated to be completed by the end of January 2021, with design and refurbishment works to follow, subject to Network Rail approval.