2021
PFD Reports
Reports: 419
Areas: 62
83% response rate (above 63% average).
Ailsa Stewart
All Responded
2021-0110
15 Apr 2021
Manchester South
Department of Health and Social Care
Concerns summary (AI summary)
A lack of national guidance on suspending domiciliary care packages and coordinating information sharing for vulnerable patients discharged from urgent care poses a risk to continuity of care.
Action Taken
(AI summary)
North West Ambulance Services (NWAS) has introduced an additional question to prevent a journey until confirmation is received that a care package is either not required or is in place. Communications have also been sent to NWAS staff reminding them to ensure patients are left with a communication device or alarm facility.
Saima Hussain Mann
All Responded
2021-0109
15 Apr 2021
Manchester South
Greater Manchester Mental Health NHS Fo…
Concerns summary (AI summary)
The mental health service lacked a reliable system for direct, tailored communication with service users regarding their referral status and plan, failing to account for their specific needs.
Action Planned
(AI summary)
The Trust states that the Community Transformation Project will address referral processes between services and how service users are kept informed. In the interim, the Trafford Service Manager is updating the CMHT Standard Operating Procedure (SOP) to include the process of discharge from the CMHTs to ensure referrals into other services are actioned before case closure, to be completed by 9th July 2021.
Amy Chiverall
All Responded
2021-0178
14 Apr 2021
Manchester North
Rochcare
Concerns summary (AI summary)
The care home's business decision not to use pendant call alarms meant fixed call bells were often out of reach for falls-risk residents, increasing their injury risk.
Action Taken
(AI summary)
Rochcare states that it has introduced several improvements including staff training, review of policies, incident follow-up, a new record keeping system, and the installation of call bells that allow residents to summon help when needed.
Richard Dyson and Simon Midgley
All Responded
2021-0108
14 Apr 2021
West Yorkshire (East)
Dept. for Business, Energy and Industri…
Concerns summary (AI summary)
Hotels lack readily accessible and accurate guest/staff lists for emergency services, leading to critical delays in rescue efforts due to time lost establishing who was missing.
Action Planned
(AI summary)
The Scottish Government will work with SFRS to consider updating fire safety guidance for premises with sleeping accommodation, focusing on emergency fire action plans including procedures for checking evacuation and communicating with SFRS. SFRS will refresh prevention awareness internally, work with the hotel sector, engage with Dutyholders, and prepare a public education campaign on fire action plans.
Gary Day
All Responded
2021-0107
13 Apr 2021
Inner North London
Moorfields Eye Hospital NHS Foundation …
Concerns summary (AI summary)
Surgical consent forms failed to disclose death risk from air embolus. No post-operative check for embolus was done, and the patient was discharged too quickly without adequate monitoring.
Action Taken
(AI summary)
Moorfields Eye Hospital NHS Foundation Trust has completed an internal investigation, shared the report with the next of kin, and elected to not undertake further procedures of this nature due to lack of facilities for enhanced monitoring.
Anthony Wilkinson
All Responded
2021-0102
13 Apr 2021
South Yorkshire (West District)
Stars Social Support Ltd, Care Quality …
Concerns summary (AI summary)
The care provider demonstrated a lack of transparency, failed to update and communicate care plans effectively, and over-relied on an insecure WhatsApp group for critical service user information.
Action Taken
(AI summary)
The Trust has amended its Level 6 food consistency advice sheets by removing picture anomalies and amending statements to remove ambiguity, based on IDDSI Framework reviewed in May 2021. CQC has reviewed the concerns raised, contacted Stars Social Support Limited, and referred the report to CQC's policy team to review. The shorter report guidance was implemented in January 2019. The organisation has ceased trading and is liaising with the Local Authority and CQC to transfer service users.
Ann Coles
All Responded
2021-0101
13 Apr 2021
County of Surrey
Royal College of GPs
Royal College of Physicians
Concerns summary (AI summary)
A significant gap exists in patient oversight as there is no compulsory requirement for lung imaging when individuals are prescribed long-term amiodarone, despite known lung toxicity risks.
Noted
(AI summary)
The RCGP acknowledges the concerns, provides background on amiodarone, and recommends that the coroner request the MHRA comment on the matter as regulatory responsibility lies with them. The RCP recommends that no new monitoring systems are required for amiodarone, but that strict adherence to existing NICE and local shared care guidelines will provide for safe and monitored practice. MHRA will take forward the PEAG's recommendations to improve product information on pulmonary toxicity and consider additional risk minimisation measures, such as a Patient Alert Card, and issue a reminder to healthcare professionals via the Drug Safety Update.
Janet Willcock
All Responded
2021-0105
9 Apr 2021
City of Brighton & Hove
University Hospitals Sussex NHS Foundat…
Concerns summary (AI summary)
Crucial opportunities were missed to auscultate the patient's chest in A&E and before surgery, leading to a missed new heart murmur that should have triggered an urgent cardiology referral.
Action Planned
(AI summary)
The hospital will present the case at the next Governance Meeting to highlight the importance of auscultation and rationale documentation, and will audit Emergency Department documentation.
Steven Costello
All Responded
2021-0095
31 Mar 2021
West Sussex
Brighton and Sussex University Hospital…
Concerns summary (AI summary)
Accident and Emergency patient notes, particularly for mental health concerns, were not regularly updated or reviewed, indicating a need for improved documentation processes and staff training.
Action Taken
(AI summary)
The Royal Sussex County Hospital has updated the Emergency Department documentation to include clear guidelines for assessing the risk of self harm and suicide, with prompting questions and a traffic light system; training on the updated documentation has been delivered to all Emergency Department staff.
Roy Morris
All Responded
2021-0094
29 Mar 2021
Buckinghamshire
Oxford Health NHS Foundation Trust
Concerns summary (AI summary)
Inadequate application of the Care Programme Approach (CPA) policy and untimely allocation of care coordinators for patients discharged from inpatient mental health settings.
Action Planned
(AI summary)
The trust will strengthen the understanding and application of the CPA policy through a task and finish group of clinicians, who will review the role of the Care Coordinator and review standard operating procedures. They are also embedding the six principles of the Triangle of Care, using better lives assessments and carers’ assessments.
Raymond Powell
All Responded
2021-0089
29 Mar 2021
Birmingham and Solihull
Cole Valley Care Ltd
Concerns summary (AI summary)
The nursing home failed to investigate a resident's fall, did not record a preceding fall or update the falls risk assessment, and provided misleading observation records, indicating systemic safety failures.
Action Taken
(AI summary)
The nursing home has implemented a new post falls protocol folder, a new manager’s report/handover for nurses, and a Daily Walkabout Form. They have also promoted an RGN to Deputy Manager and implemented a new daily task folder for nurses to complete audits.
Nicholas Rousseau
All Responded
2021-0087
28 Mar 2021
Milton Keynes
Milton Keynes University Hospital
Concerns summary (AI summary)
Senior A&E consultants held conflicting views on managing elevated lactate levels and sepsis, with one disregarding NICE guidelines due to perceived inconvenience, indicating a lack of standardized care.
Action Planned
(AI summary)
The hospital will update the MKUH sepsis policy for November 2021, repeat an audit of the management of patients with suspected sepsis, and consider designating a sepsis lead within the department.
Clara Freeman
All Responded
2021-0085
26 Mar 2021
Plymouth Torbay and South Devon
Hart Care Nursing and Residential Home
Concerns summary (AI summary)
Concerns were raised about the proficiency of care staff in managing falls, specifically their interaction with ambulance services, accurate medical recording, and awareness of post-fall complications.
Action Taken
(AI summary)
All staff members in charge of shifts have attended First Aid Training, which included calling the emergency services, managing falls, fractures, choking, bleeding, dressings, CPR, anaphylaxis, the recovery position and monitoring the patient while awaiting help.
Lee Marsden
All Responded
2021-0084
26 Mar 2021
Manchester North
Highways England
North West Motorway Police Group
Concerns summary (AI summary)
A significant delay in activating motorway warning signals and communication failure between agencies, combined with the lack of an internal review, indicate a missed opportunity for learning.
Action Planned
(AI summary)
Highways England and the NWMPG have agreed to add a free text description to the log to clearly identify the source of information. Police operators and supervisors within NWMPG will be briefed to add this plain language to logs, with a briefing note circulated to staff. Highways England will brief North West Highways England Regional Operations Centre staff and police officers on using 'free text' entries in incident logs, shared with all Regional Control Centres as best practice nationally. They maintain their existing policy for activating warning signals is robust and appropriate, and will not take further action on it.
Azra Hussain
All Responded
2021-0082
25 Mar 2021
Birmingham and Solihull
Birmingham and Solihull Mental Health N…
Concerns summary (AI summary)
Critical family concerns about a suicide attempt were not recorded or escalated, and known ligature points in en-suite bathrooms remained unmitigated, indicating failures in risk assessment and safety.
Noted
(AI summary)
The Trust has taken steps to reduce risk from ligatures, including installing pressure sensor alarms on en-suite bathroom doors, removing door furniture, and establishing a rolling capital programme for ligature works. They are also reviewing therapeutic observational practice, staffing levels, and care plans. HSE states that the safety of the environment for patients, including management of ligature points, falls within the remit of CQC, not HSE, according to a Memorandum of Understanding. NHS Birmingham and Solihull ICB provides supplementary information to the Coroner, in support of the information provided by Birmingham and Solihull Mental Health Foundation Trust, in response to the Regulation 28 Report. The CQC has asked for weekly reports on ward improvements, sought an independent review from NHS England, and will share learning from the inquest with inspectors and registered persons. They are monitoring the trust and will use enforcement powers if regulations are not met.
Sheldon Farnell
All Responded
2021-0081
25 Mar 2021
City of Sunderland
Department of Health and Social Care
Concerns summary (AI summary)
Revision of sepsis recognition guidance, mandatory, up-to-date sepsis training, and a review of overly cautious antibiotic prescribing are needed to prevent future deaths.
Action Taken
(AI summary)
The Department of Health and Social Care notes that the South Tyneside and Sunderland NHS Foundation Trust has taken action to improve the identification and management of sepsis, particularly in children, including improvements to processes and policies, and introduced multidisciplinary training.
Jamie Poole
All Responded
2021-0075
15 Mar 2021
Stoke-on-Trent & North Staffordshire Coroner’s Court
NHS England
Concerns summary (AI summary)
It is not standard practice across all trusts to regularly test magnesium levels in transplant patients on immunosuppressive medication, despite a known life-threatening side effect, posing an inconsistent risk.
Action Planned
(AI summary)
NHS England will issue a National Patient Safety Alert (Level 2) on the risk of severe hypomagnesemia in transplant recipients using Tacrolimus and PPIs, and send out a Reminder Alert on Magnesium monitoring in patients on PPI. An Expert Clinical review will make recommendations on magnesium monitoring in patients on Immunosuppression.
Lesley Powell
All Responded
2021-0282
12 Mar 2021
City of Brighton and Hove
East Sussex County Council
Concerns summary (AI summary)
Pedestrian safety on the A2100, Battle Hill, needs review following a fatal road traffic collision, highlighting concerns about highway safety for those crossing the road.
Action Planned
(AI summary)
East Sussex County Council is developing a potential pedestrian crossing scheme on the A2100 Battle Hill, with preliminary design completed and funding allocated in the 2021/22 Capital Programme for further development, subject to consultation and legal agreements.
Elizabeth Robinson
All Responded
2021-0072
12 Mar 2021
Gwent
Aneurin Bevan University Health board
Concerns summary (AI summary)
Inadequate nursing staff levels and an unreviewed internal investigation meant nurses were unable to deliver safe care, assess patient fall risk correctly, and were unaware of learning opportunities.
Action Taken
(AI summary)
Aneurin Bevan University Health Board has established a Ysbyty Ystrad Fawr (YYF) Health Care Support Worker (HCSW) pool in September 2020 to support enhanced care levels. The Corporate Serious Incident Team is implementing a training programme for Investigating Officers and trialling standardised template agendas for use at Serious Incident investigation meetings.
Emma Dorman
All Responded
2021-0071
11 Mar 2021
West Yorkshire, Western Division
South West Yorkshire Partnership
Concerns summary (AI summary)
Non-clinical staff inappropriately influenced patient leave decisions, overriding clinical judgment. Additionally, the ward lacked psychologist input for over three years due to persistent recruitment failures.
Action Planned
(AI summary)
The Trust is reviewing its Patient Flow Procedure, skill-mix for vacant psychology posts, and will update the Job Description and Person Specification for the vacant part-time Psychologist post in Ward 18, anticipating completion in June 2021 and in the interim a Clinical Psychologist will provide in-reach support.
Edward Bilbey
All Responded
2021-0068
10 Mar 2021
Derby and Derbyshire
Department for Culture, Media and Sport
England Boxing
Concerns summary (AI summary)
England Boxing lacked adequate child protection policies, enforcement, and up-to-date records for welfare officers, leaving clubs vulnerable and compromising child safety measures.
Noted
(AI summary)
DCMS acknowledges the concerns, describes existing safeguarding measures and engagement with sports bodies, but states they do not intend to introduce further sport-specific legislation at this time. They will work with Sport England and England Boxing to review the specific concerns raised. England Boxing had already implemented remedial actions to increase safety and awareness, including revising the Rule Book to make safeguarding responsibilities clear, introducing mandatory DBS checks, and implementing safeguarding training. Following the inquest, they are setting up an independent inquiry to investigate adherence to regulations.
Rodney Gates
All Responded
2021-0070
8 Mar 2021
Mid Kent and Medway
Medway Maritime Hospital
Concerns summary (AI summary)
Critical patient observations were missed due to low numbers of nursing staff, heavy reliance on agency nurses with limited experience, and a lack of essential equipment on the ward.
Action Taken
(AI summary)
Medway Maritime Hospital has implemented electronic observation recording with a red-flagging system, delivered MHLS training to nurses, trained Band 6 nurses in ALERT and Advanced Life Support, established an acute response team, improved shift handovers, increased A&E staffing, reduced reliance on agency nurses, enhanced the nursing team in Pembroke Ward, and invested in an after-hours equipment store.
Yvonne Copland
All Responded
2021-0067
8 Mar 2021
Isle of Wight
Highways – Isle of Wight Council and Ri…
Concerns summary (AI summary)
The road junction has a history of serious collisions due to poor visibility, deceptive road layout, and inadequate signage/safety measures, despite being a high-traffic route.
Action Planned
(AI summary)
The Isle of Wight Council will commission junction designs in May 2021, conduct a design review and consultation in July 2021, commit to a design option in September 2021, tender for a delivery contractor in November 2021, and commence works in February 2022 to improve the junction. Ringway Island Roads will commission junction designs in May 2021, conduct a design review and consultation in July 2021, commit to a design option in September 2021, tender for a delivery contractor in November 2021, and commence works in February 2022 to improve the junction.
Paula Speirs
All Responded
2021-0064
4 Mar 2021
Inner North London
Weymouth Street Hospital
Concerns summary (AI summary)
There was a lack of formal observations or monitoring for an intoxicated patient, and nurses were untrained in recognising or preventing positional asphyxia in a hospital setting.
Action Taken
(AI summary)
Phoenix Hospital Group has reviewed and revised policies/procedures at Weymouth Street Hospital, conducted root cause analysis meetings, scheduled a Managing a Deteriorating Patient workshop, and is highlighting the Coroner's concerns to nurses through regular briefings and a final reflection and learning session.
Grazyna Walczak
All Responded
2021-0063
4 Mar 2021
Inner North London
St Pancras Hospital
Concerns summary (AI summary)
The iCope service failed to involve family in mental health assessments, and a critical 72-hour investigation report was severely delayed, hindering urgent learning.
Action Planned
(AI summary)
The iCope service has reviewed its policy on contact with clients’ families and is implementing a new system reporting process to enable easier reporting and monitoring of 72-hour reports, including a training programme for divisional staff to support the implementation of the new system.