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
Helen Sheath
All Responded
2020-0107 27 Jan 2020 Bedfordshire and Luton
Association of Ambulance Chief Executiv… Emergency Call Prioritisation Advisory … National Association of Ambulance Medic…
Concerns summary (AI summary) Ambulance services incorrectly coded an initial emergency call for a suicidal patient, delaying the dispatch of appropriate urgent response teams and potentially altering the outcome.
Noted (AI summary) The Association of Ambulance Chief Executives (AACE) outlines the triage process for 999 calls, the role of the Emergency Call Prioritisation Advisory Group (ECPAG), and references a letter sent to ambulance trusts in April 2019 from NHS England regarding clinical oversight for self-harm and suicidal patients. NASMeD previously encouraged all ambulance trusts to implement clinical review of these cases.
Gary Sloan
All Responded
2020-0009 22 Jan 2020 Sunderland
Sunderland City Council
Concerns summary (AI summary) A specific section of the A690 has a high incidence of collisions, including two fatal incidents at the same location, necessitating a review of safety restrictions and drainage.
Action Planned (AI summary) Sunderland City Council will include a scheme in its 2020-2021 capital programme to mitigate the risk of serious injury to drivers on the A690. The council will replace a side entry gully with a top entry gully in the spring.
Jason Devoti
All Responded
2020-0017 21 Jan 2020 Worcestershire
West Midlands Police
Concerns summary (AI summary) West Midlands Police failed to address numerous P2 incident logs due to overwhelming backlogs, insufficient officers, and inadequate control room staffing, leading to significant response delays.
Action Taken (AI summary) West Midlands Police details steps taken to improve emergency call response, including involving the Force Incident Manager during busy periods, implementing a "Log Closure Doctrine," and reducing the number of logs held by each dispatcher. They are also working on a record of missing person logs managed and overseen by supervisors until resolved.
Aston McLean
All Responded
2020-0015 20 Jan 2020 Berkshire
JRCALC
Concerns summary (AI summary) Guidelines for declaring death on scene (ROLE) need urgent clarification, especially regarding assumptions about imminence or difficulty of extraction. Ambulance crews also lacked awareness of fire service capabilities for vehicle lifting, hindering decision-making.
Action Planned (AI summary) The Association of Ambulance Chief Executives is reviewing the JRCALC clinical practice guidelines in relation to recognition of life extinct (ROLE). They will amend the wording to clarify what to do when access to the patient is not possible and to clarify the need to work with other agencies.
Deborah Lamont
All Responded
2020-0008 20 Jan 2020 South Wales Central
College of Policing South Wales Police
Concerns summary (AI summary) Police misinterpreted Section 136 of the Mental Health Act, believing they lacked power to detain a suicidal individual in a hotel room. This highlights a need for clearer guidance on how such temporary accommodations are classified under the Act.
Action Planned (AI summary) The College of Policing will amend its guidance in respect of the use of s136 powers, circulate a summary of the issue to all police force mental health leads, and work with the Home Office to assess the need for changes to national guidance regarding the use of s136 and hotel rooms. The Chief Constable of South Wales has asked that the Force Mental Health Lead fully consider the use of hotel rooms and s.136, subject to a specific note upon force guidance and within training. The College of Policing will circulate a summary of the issue to all police force mental health leads and has raised the issue with the Home Office to assess the need for changes to national guidance.
Matthew Willoughby
All Responded
2020-0016 19 Jan 2020 Blackpool & Fylde
Landlord
Concerns summary (AI summary) A landlord failed to ensure safety adaptions, such as window restrictors, remained in place after a tenant removed them, despite prior safety advice. This created a serious ongoing risk to tenants.
Action Taken (AI summary) The landlord confirms the adaptations to the windows in flat 10 have been replaced and all top floor flats windows have been checked for safety.
Janet Jasper
All Responded
2020-0014 17 Jan 2020 Rutland and North Leicestershire
Cadent Gas Ltd Gas Safe Network Institution of Gas Engineers +2 more
Concerns summary (AI summary) Hundreds of properties face a risk of floor failure, and there is inconsistency across gas distribution networks regarding protocols for inspecting adjoining properties after an incident.
Action Planned (AI summary) Following a review, Gas Distribution Networks (GDNs) have agreed on a revised EM72 policy for responding to gas leak callouts, particularly "no trace" declarations. HSE also undertook communication with residents and gas engineers in the local area, including hosting a residents meeting and providing leaflets to explain potential risks and actions. Gas Distribution Networks (GDNs) clarified procedures for checking adjoining properties during internal gas escape investigations, focusing on external sources. The GDNs will brief operational teams on the revised requirements, expected to be in place across all networks by mid-summer 2020.
Shneur Kaye
All Responded
2020-0013 17 Jan 2020 Manchester (North)
Bury Council
Concerns summary (AI summary) Safeguarding referrals were closed without parental contact, and referral information was not shared with other agencies due to data protection concerns. This practice potentially deprives social workers of vital context and undermines child protection.
Action Taken (AI summary) North Manchester Care Organisation outlines changes implemented after the incident, including revised discharge processes for children presenting to A&E with overdoses, new referral pathways for children with mental health needs, and mandatory safeguarding training for staff. Bury Council conducted a service review of the Multi Agency Safeguarding Hub (MASH) in early 2022, reinforcing strength-based practices and parental involvement unless safeguarding or legal reasons prevent it. The MASH also consults with referrers to clarify information and consider alternative support pathways.
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.
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.