2020
PFD Reports
Reports: 309
Areas: 57
83% response rate (above 63% average).
Andres Roberts
All Responded
2020-0182
23 Sep 2020
Swansea and Neath Port Talbot
Department of Health and Social Care
Welsh Ambulance Services NHS Trust
Concerns summary (AI summary)
Delays in emergency department arrival for acute stroke patients may delay critical treatment, raising concerns about stroke patient categorisation, specific time targets, and ambulance service resources.
Action Planned
(AI summary)
The Trust disagrees with the need for action regarding stroke patient grading and resource allocation. However, it describes several ongoing actions to reduce hospital delays, including expanding clinical desk staff, developing out-of-hospital pathways, supporting patient discharge, and recruiting Advanced Paramedic Practitioners. The Welsh Government describes ongoing efforts to improve ambulance response times for stroke patients and wider improvements to urgent and emergency care services, including the establishment of a Ministerial Ambulance Availability Taskforce and additional funding for transformation projects.
Christine Forbes
Partially Responded
2020-0181
23 Sep 2020
Derby and Derbyshire
NHS Derby & Derbyshire Clinical Commiss…
NHS England
Primary Care Support England
Concerns summary (AI summary)
Patients registering at new GP surgeries lack their complete medical history, leading to doctors treating and prescribing medication without full and necessary information.
Action Planned
(AI summary)
NHS Derby and Derbyshire Clinical Commissioning Group will offer additional GP2GP/ Record Transfer training to Ashbourne Medical Practice, offer additional training Note Summarisation to Ashbourne Medical Practice, circulate information about available training to all practices, include information about training into the GP Membership Bulletin and within DDCCG Clinical Governance leads meetings.
Jane Jowers
All Responded
2020-0180
23 Sep 2020
East London
Disclosure and Barring Service
Concerns summary (AI summary)
The absence of statutory international criminal background checks allows unsuitable individuals with foreign convictions to work with vulnerable adults and children, posing a significant risk.
Noted
(AI summary)
The DBS acknowledges the coroner's concern about the lack of statutory international criminal conviction checks and explains its role in providing DBS checks for employment in England, Wales, the Channel Islands, and the Isle of Man. It outlines the types of DBS checks available and directs the coroner to existing guidance for employers regarding applicants who have lived or worked outside the UK.
Brett Marrs
Historic (No Identified Response)
2020-0179
23 Sep 2020
Lancashire and Blackburn with Darwen
HMP Wymott
Concerns summary (AI summary)
Prison officers lacked essential first-aid and resuscitation training, and welfare checks during cell unlocks were routinely neglected despite clear instructions, indicating systemic safety failures.
Paul Reynolds
All Responded
2020-0178
21 Sep 2020
Plymouth, Torbay and South Devon
Derriford Hospital
Concerns summary (AI summary)
Incomplete patient medical records led to an inadequate understanding of underlying conditions, resulting in an incorrect anaesthetic choice and monitoring, risking patient safety during procedures.
Action Taken
(AI summary)
The trust confirms that all three recommendations regarding the availability of patient records and understanding of patient's underlying conditions have been fulfilled.
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.
Joseph Nihill
Historic (No Identified Response)
2020-0175
18 Sep 2020
West Yorkshire (East)
Department of Health and Social Care
Concerns summary (AI summary)
Online platforms actively promoted suicide methods and dangerous substances to vulnerable young men, undermining mental health support and posing a foreseeable risk of drawing individuals into self-harm.
Yugal Limbu
Historic (No Identified Response)
2020-0176
14 Sep 2020
Central and South East Kent
Ashford Borough Council
Kent County Council
Concerns summary (AI summary)
A hazardous gap and sloped surface by a footbridge in a public park pose a danger to users, especially at night, with unclear responsibility between local authorities.
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.
Alyn Rees
Historic (No Identified Response)
2020-0190
9 Sep 2020
Gwent
Aneurin Bevan University Health Board
Welsh Ambulance Services NHS Trust
Concerns summary (AI summary)
Excessive ambulance waiting times (2 hours) without informing the family of estimated arrival, coupled with significant hospital patient transfer delays, prevented ambulances from being released for other emergencies.
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.
Carlington Spencer
Historic (No Identified Response)
2020-0167
28 Aug 2020
Lincolnshire
Morton Hall Immigration Removal Centre
Nottingham Healthcare NHS Foundation Tr…
Concerns summary (AI summary)
Prison discipline and healthcare staff exhibited confirmation bias regarding drug use, leading to inadequate investigation, poor record-keeping, insufficient training on new psychoactive substances, and a lack of clear escalation protocols for medical emergencies.
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.