2021

PFD Reports
Reports: 419 Areas: 62

83% response rate (above 63% average).

Response Status
Responded 347 Historic 72
AI Classification
Action Taken 43%
Action Planned 38%
Noted 18%
Disputed 2%
Based on 518 classified responses
Top Categories
Hospital Death (Clinical Procedure… (189) Mental Health related deaths (109) Other related deaths (99) Suicide (from 2015) (89) Community health care and emergenc… (77)
419 results
Maziellie Mackenzie
All Responded
2022-0005 31 Dec 2021 Lancashire and Blackburn with Darwen
Lancashire and South Cumbria NHS Founda…
Concerns summary (AI summary) The mental health unit lacked a written policy for granting group leave, mandatory risk assessments, and clear staff-to-patient ratios, creating significant safety risks for patients.
Action Taken (AI summary) The Trust developed a written procedure regarding group leave from The Cove, approved it on 3 February 2022, and shared it with staff, suspending group leave until ratification. They also shared the procedure with other North West of England Tier 4 CAMHS providers.
Jos Tartese-Joy
All Responded
2021-0435 31 Dec 2021 Greater Manchester South
Department of Health and Social Care
Concerns summary (AI summary) A combination of poor communication regarding high-risk pregnancy, lack of clear national guidance for CTG monitoring, and inadequate support and escalation policies for student midwives contributed to critical care gaps.
Action Planned (AI summary) DHSC notes that £52 million was announced to fast track the provision of online maternity records and NHSE has updated the maternity early warning score (NEWS2) chart and the updated element seeks to focus more attention on pregnancies at high-risk of fetal growth restriction. A standardised risk assessment tool that all trust should use at the onset of labour has been developed.
Yousef Makki
All Responded
2021-0434 31 Dec 2021 Greater Manchester South
Department for Education
Concerns summary (AI summary) The coroner notes a culture among some teenagers of viewing knife possession as impressive without understanding the risks, and that the knife used in the stabbing was easily purchased during school break time, highlighting the vital role of schools and education in addressing attitudes towards knife carrying.
Action Planned (AI summary) The Department for Education is investing in educational resources to address knife crime and serious youth violence, and investing £45 million in two new programmes including Alternative Provision Specialist Taskforces and the SAFE Taskforces programme.
Gregory Barber
All Responded
2021-0429 24 Dec 2021 West Yorkshire (Eastern)
Network Rail
Concerns summary (AI summary) Network Rail failed to implement recommended mitigation measures to curtail access to railway tracks at a specific high-risk location, leaving a vulnerability unaddressed despite police warnings.
Action Planned (AI summary) Network Rail is procuring the installation of 8 metres of 2.4m palisade fencing behind a parapet wall and will close off gaps at either end of the new fence, with work expected to commence the week of March 7, 2022 and be completed within two weeks.
Margaret Toye
Historic (No Identified Response)
2022-0004 23 Dec 2021 East London
Department of Health and Social Care Royal London Hospital
Concerns summary (AI summary) Failure to assess malnutrition risk using the MUST score and erroneous documentation meant necessary nutritional interventions were not implemented, despite known widespread non-compliance on the ward.
William Doleman, Anita Burkey, Peter Sellars and Carol Cole
All Responded
2021-0432 23 Dec 2021 Nottingham City and Nottinghamshire
Nottingham University Hospitals NHS Tru…
Concerns summary (AI summary) There was a lack of robust patient pathways, inadequate vetting, and non-personalised consent for ERCP procedures, coupled with insufficient accountability among professionals.
Action Planned (AI summary) The hospital has taken or planned actions to improve ERCP patient pathways, vetting, consent, and accountability, including a specialist HPB endoscopy team and a meeting to design pathways for complex HPB cases scheduled for March 9, 2022.
Sameena Javed
Historic (No Identified Response)
2021-0430 23 Dec 2021 Manchester North
Croft Shifa Health Centre
Concerns summary (AI summary) The GP practice lacked written procedures for administrative staff to escalate critical incoming correspondence to medical staff, risking important actions being overlooked.
Dilys Etchells
All Responded
2021-0428 23 Dec 2021 West Yorkshire Western
Aden Nursing Home
Concerns summary (AI summary) The care home showed inadequate provision and documentation of safety equipment, poor note-taking, insufficient staff training in visual checks and handover, and deficient wound management protocols.
Action Taken (AI summary) Aden Court Care Home implemented several changes, including a new Registered Manager, review of crash and sensor mat provision with improved documentation, and amended admission procedures, with ongoing reviews and hospital staff producing initial care plans for residents returning with casts.
Mark Castley
All Responded
2021-0427 22 Dec 2021 London Inner South
HM Prison and Probation Service
Concerns summary (AI summary) The coroner suggests the risks of recurrent impulsive self-harm were not fully assessed in light of the circumstances, specifically concerning the period after sentencing, and that a notification form might have been completed had the risks been fully considered.
Action Planned (AI summary) HMCTS is updating Security and Safety Operating Procedure 4b across all crime courts by the end of May, including publicising random searches and implementing a new Safeguarding policy with training for front line court staff to identify and escalate safeguarding concerns. The 'Working with Suicide & Self-Harm' guide was reviewed, changing a question about suicide risk, and the Probation EQUiP process map was updated for court staff; all London probation staff were reminded to adhere to the 'probation risk to self' EQUiP process maps. London Probation published a new thematic Suicide and Self-Harm Performance and Quality Newsletter on 19 January 2022.
Kyle Nel
All Responded
2021-0426 22 Dec 2021 Dorset
HMP Guy’s Marsh and Prisons and Probati…
Concerns summary (AI summary) The prison failed to adequately respond to family concerns, lacked structured record-keeping for prisoner welfare, and had known security flaws with fences enabling drug transfers between units.
Action Taken (AI summary) HMPPS replaced the Custodial Violence Management Model with the Challenge, Support and Intervention Plan (CSIP), a violence reduction case management model, and HMP Guys Marsh has a dedicated drug strategy manager in place since Autumn 2021 as part of the accelerator project.
Louise Cooper
Historic (No Identified Response)
2021-0431 21 Dec 2021 Blackpool & Fylde
Department of Health and Social Care
Concerns summary (AI summary) The healthcare system lacks sufficient provision for sustained supported eating for anorexia nervosa patients, leading to ineffective hospital admissions and hindering patient improvement despite clinical recommendations.
Eva Wheeler
All Responded
2021-0424 21 Dec 2021 South Wales Central
Cwm Taf Morgannwg University Health Boa…
Concerns summary (AI summary) Communication errors led to delayed ambulance calls and incorrect patient preparation. The hospital lacks robust processes for documenting/chasing emergency ambulances, clear NBM protocols, and joint registrar consultation for common conditions like bowel obstructions.
Action Taken (AI summary) The Health Board has taken action to address communication errors and review procedures for escalating concerns about deteriorating patients, primarily through computerisation of notes, NEWS audits, and practice development sessions. They concluded there was no need for an on-call shared discussion protocol.
Saul Thomas
All Responded
2021-0423 21 Dec 2021 Worcestershire
HMP Birmingham
Concerns summary (AI summary) A third of prison staff lack up-to-date ACCT training, and critical psychiatric assessment information was not consistently included in handovers between prisons, posing a risk of future deaths.
Action Planned (AI summary) HMP Birmingham plans to train 80% of staff in suicide and self-harm (SASH) over the next six months, prioritizing high-risk areas and ensuring new staff receive SASH training; a new handover process is in place for prisoners transferring with healthcare needs. HMP Hewell delivered training to 205 staff in the latest version of ACCT in December 2021 and is working to train a larger percentage of staff.
Maria McGauran
All Responded
2022-0098 20 Dec 2021 Derby and Derbyshire
Alvaston Medical Centre
Concerns summary (AI summary) The surgery failed to conduct a medication review or consider alternative pain management, despite long-standing family concerns about the patient's excessive use and hoarding of codeine.
Action Taken (AI summary) Alvaston Medical Centre recruited two clinical pharmacists to conduct patient medication reviews, particularly for controlled drugs, and ensures high-risk scheduled drugs are not part of repeat prescriptions, with a robust system to prevent medications being ordered too far in advance.
Oliver Weston
Historic (No Identified Response)
2021-0422 20 Dec 2021 Lancashire & Blackburn with Darwen
OFSTED
Concerns summary (AI summary) An OFSTED inspection of a children's home was deficient, failing to consider relevant safeguarding information and misinterpreting evidence. Lack of guidance for publishing reports in "exceptional circumstances" led to arbitrary decisions.
Nichola Lomax
Partially Responded
2021-0433 17 Dec 2021 Manchester North
Academy of Medical Royal Colleges Department of Health and Social Care Greater Manchester Mental Health NHS Fo… +7 more
Concerns summary (AI summary) Doctors lacked training on eating disorder guidance (MARSIPAN) and pathways to specialist advice. Restrictive referral criteria for community services led to inadequate monitoring by non-specialist GPs.
Action Planned (AI summary) The Greater Manchester Health and Social Care Partnership (GMHSCP) will present learning from the case at the Greater Manchester Quality Board and cascade it to professionals through governance and learning forums. They commit to establishing clear MARSIPAN pathways and protocols with associated training.
Ziggy Mitchell-Stagg
Historic (No Identified Response)
2021-0425 17 Dec 2021 Inner North London
Homerton University Hospital NHS Trust
Concerns summary (AI summary) Inconsistent terminology for meconium, incomplete medical records, lack of centralised CTG monitoring policy, and a trust policy for "fresh eyes" review that deviates from national guidance are concerns.
Joan Wright
All Responded
2021-0420 17 Dec 2021 Manchester West
Royal Bolton Hospital
Concerns summary (AI summary) Insufficient and unreliable IT facilities hinder timely electronic record-keeping, forcing staff to rely on memory or paper notes, which results in unrecorded or omitted crucial clinical information.
Action Taken (AI summary) The Informatics Team is conducting ward spot audits to monitor IT equipment, a topic discussed at Ward Managers meetings in December 2021 and January 2022. A Steering Group was established to review ward round processes and competing demands on IT equipment, with expected completion by May 2022. Agency staff also now receive training on the EPR system before booking shifts.
David O’Brien
Partially Responded
2022-0068 16 Dec 2021 Newcastle upon Tyne and North Tyneside
Care Quality Commission Springfield Health Care Services
Concerns summary (AI summary) Poor record-keeping and inter-agency communication in the care home resulted in critical wheelchair safety advice being ignored, leading to the deceased's excessive and unsafe use of the mobility aid.
Action Planned (AI summary) The CQC conducted reviews and found no reasonable grounds for criminal investigation, but identified areas where Springfield should improve. They will hold an internal management review to consider further action, including an inspection focusing on the coroner's concerns, and will inform the coroner of the proposed action.
Martin Brown
All Responded
2021-0417 15 Dec 2021 Lancashire and Blackburn with Darwen
HMP Lancaster Farms
Concerns summary (AI summary) Prison staff lacked training for medical emergencies and the ERIC system. There was poor liaison between healthcare and ambulance services, and communication between emergency responders and the control room was inadequate.
Action Taken (AI summary) Spectrum has developed an Emergency Response in Custody (ERIC) presentation and has been delivering training sessions to prison staff since January 2022. They have also implemented a system using a spare radio net for healthcare staff to communicate directly with the prison's communications room during medical emergencies, which went live on January 31st after a successful trial. The prison has distributed ERIC cards to all staff and commenced additional ERIC training delivered by the Head of Healthcare, with new staff receiving this training as part of their induction. A new radio channel process has been implemented for healthcare staff to communicate with the control room and ambulance service during emergencies.
Hedley Robinson
Historic (No Identified Response)
2021-0421 14 Dec 2021 Milton Keynes
CNWL and Chief Constable
Concerns summary (AI summary) A S.136 Mental Health Act assessment was conducted without critical information or discussion with relevant police, indicating an urgent need to review S.136 procedures.
Hurrun Maksur
All Responded
2021-0418 13 Dec 2021 East London
Resuscitation Council UK and Royal Coll…
Concerns summary (AI summary) Failure to perform a recommended Point-of-Care Ultrasound scan on a collapsed woman led to inappropriate thrombolytic treatment for undiagnosed intra-abdominal bleeding. Obstetricians also lack specific training in identifying such bleeding.
Noted (AI summary) The Resuscitation Council UK (RCUK) will emphasize the need to exclude major bleeding as the cause of collapse before giving fibrinolytic drugs for suspected PE in pregnancy. They will review and update the next print run of the RCUK Advanced Life Support Manual, teaching materials on the ALS course concerning pregnancy, and the Obstetric Cardiac Arrest Quick Reference Handbook. The RCOG outlines existing training and guidance related to ultrasound assessment in early pregnancy and the management of gynecological emergencies, emphasizing that excluding ectopic pregnancy is a routine part of the first scan. They state that competencies are outlined in CiP 9 and 11 and detailed knowledge criteria appears in knowledge areas 3, 13, 10, 11, 12, 14 and 15 in their MRCOG membership examination.
James McKeough
All Responded
2021-0414 9 Dec 2021 West Sussex
Department for Transport
Concerns summary (AI summary) The positioning, brightness, and color of rear flashing LED lights on trailers can mask or be misinterpreted as turn indicators, hindering other drivers' ability to discern turning intentions.
Action Planned (AI summary) The Department for Transport will write to the National Police Chiefs’ Council, Driver and Vehicle Standards Agency, Society of Motor Manufacturers and Traders, Agricultural Engineers Association, National Farmers’ Union of England and Wales, and the National Farmers Union of Scotland to provide guidance and raise awareness of requirements for amber warning beacons on agricultural vehicles.
Rebecca Begg
Partially Responded
2021-0416 8 Dec 2021 Nottinghamshire
Care Quality Commission Heathcotes Group
Concerns summary (AI summary) The care home failed to monitor care plan compliance, conducted inadequate incident reviews, and lacked inclusion of support workers in client meetings, with no dedicated time for staff to read care plans.
Action Taken (AI summary) Full incident reviews are implemented and the Clinical team now has involvement to understand the root cause and offer different support methods. The internal governance and quality assurance procedures have been reviewed and physical items used to tie ligatures are now stored with the incident report to be sure what was used and how it was removed.
Jonathan Bayliss
All Responded
2021-0413 7 Dec 2021 North West Wales
Ministry of Defence
Concerns summary (AI summary) Urgent investigations into an artificial stall warning for the Hawk Mk 1 aircraft, which can stall without warning, are stalled. The training simulator also inaccurately models the aircraft with a smoke pod.
Action Planned (AI summary) The MOD is undertaking investigations into incorporating an artificial stall warning capability in the Hawk T Mk1, with a decision expected in summer 2022. The RAF is developing options for a RAFAT-focused Hawk Synthetic Training Facility, expected to be in place by 2025, and will update the current Hawk Synthetic Training Facility software to reflect a RAFAT aircraft by 2023.