2021
PFD Reports
Reports: 419
Areas: 62
83% response rate (above 63% average).
Matthew Mackell
Partially Responded
2021-0177
25 May 2021
North West Kent
Independent Office for Police Conduct
Kent Police
Concerns summary (AI summary)
Kent Police failed to train staff on new phone location software, leading to a critical delay in locating the deceased. Systemic gaps exist in staff knowledge, training, and record-keeping regarding suicide policy and call management.
Action Taken
(AI summary)
Kent Police provides continuous professional development training packages on a 5-week rotation to FCR teams and uses a database to track attendance. The default settings on the Northgate XC mapping system have been configured to ensure that the latest functionality is utilised, and briefings were delivered highlighting the enhanced functionality.
Ryan Taylor
All Responded
2021-0176
25 May 2021
Cornwall and the Isles of Scilly
Cornwall Council and CORMAC
Concerns summary (AI summary)
Converging surface water on the A390, exacerbated by heavy rainfall, creates a significant aquaplaning risk. Feasible drainage improvements have not yet been implemented despite a previous incident.
Action Planned
(AI summary)
Cornwall Council will erect signs warning of surface water, replace gully grids with larger capacity gratings in October, and undertake detailed drainage and topographical surveys. Further upgrades to the drainage system may be designed and implemented after the survey information is obtained.
Christopher Taylor
Historic (No Identified Response)
2021-0175
25 May 2021
Lincolnshire
Driver and Vehicle Licensing Agency
Concerns summary (AI summary)
An improperly placed, non-functional flat screen monitor in a crop sprayer cab created a dangerous blind spot, obstructing the driver's view of a cyclist.
Anastasia Uglow
All Responded
2021-0216
24 May 2021
Avon
Department for Education
Concerns summary (AI summary)
There is a critical need to raise sepsis awareness across all schools, as healthy teenagers can rapidly deteriorate, leading to tragic consequences if the condition is left untreated.
Action Planned
(AI summary)
The Department for Education noted the recommendations and is making progress by working with the Outdoor Education Advisers' Panel (OEAP) and the UK Sepsis Trust to update national guidance in relation to sepsis awareness, and intends to update its Health and safety responsibilities and duties for schools to reference the work of the OEAP.
Kenneth Smith
Historic (No Identified Response)
2021-0170
24 May 2021
Manchester West
Bolton Council Commissioning Services
NHS Bolton Clinical Commissioning Group
Shannon Court Care Centre
Roger Ballard
All Responded
2021-0168
24 May 2021
Manchester South
Tameside & Glossop Integrated Care NHS …
Concerns summary (AI summary)
Unclear scan reporting and inadequate documentation of clinical decisions, including those overriding specialist advice, prevented clinicians from appreciating critical findings and understanding the rationale.
Action Planned
(AI summary)
The trust plans to implement an electronic flagging system to identify when clinicians are not reviewing imaging reports in a timely manner, share the case at Clinician forums and has mandated personal learning and reflection for those involved in the care.
Dyllon Milburn
All Responded
2021-0167
21 May 2021
Manchester City
EMIS Health
National Institute for Health and Care …
Royal College of GPs
Concerns summary (AI summary)
The current repeat prescription system lacks automated alerts to remind patients to request and collect medication, contributing to non-compliance for those with mental illness.
Noted
(AI summary)
NICE acknowledges the concerns but states it cannot influence changes to the EMIS system. They highlight existing guidelines on medicines adherence (CG76) and depression management (CG90) that contain relevant recommendations. The RCGP will open a dialogue with the Royal Pharmaceutical Society to consider in more detail the issue of patients not collecting prescriptions, and recommends that much greater integration of pharmacy and GP IT systems will likely be needed. EMIS confirmed that their software was working as designed and complies with NHS Digital requirements and are presently considering a number of potential digital tools to aid further patient compliance; they welcome a discussion with stakeholders to create best practice for managing this risk. The practice uses EMIS Web software and outlines the three methods by which patients can request repeat prescriptions, also noting that there is no system to alert them if a patient is not requesting their repeat medications on a month-by-month basis and expressing concerns about the resources needed to respond to such alerts.
Martin Gibbons
All Responded
2021-0166
21 May 2021
Manchester South
Department of Health and Social Care
Greater Manchester Health and Social Ca…
Concerns summary (AI summary)
A lack of shared "high risk" patient definitions and national guidance for shared care plans between trusts led to inconsistent risk assessments. Prolonged mental health bed waits were also exacerbated by fragmented commissioning.
Action Planned
(AI summary)
Tameside and Glossop Integrated Care NHS Foundation Trust (TGICFT) and Pennine Care NHS Foundation Trust (PCFT) conducted a joint investigation and will present the learning to the Greater Manchester Quality Board and to commissioners of services to consider within the context of the services they commission. NHS England has asked all parts of the country to ensure that they have in place clear written protocols for escalation and actions to be taken when patients are waiting long periods, or a bed cannot be identified.
Wilfred Breakell
All Responded
2021-0165
20 May 2021
County of Dorset
BCP Council
Concerns summary (AI summary)
A lack of safety barriers between the highway and a storm drain at a road exit poses a significant risk of cyclists and vehicles falling into it.
Disputed
(AI summary)
BCP Council investigated the incident and concluded that it is not appropriate to introduce additional fencing to the inside of the bend on the slip road, but will continue to monitor the site in conjunction with the police.
Neil Challinor-Mooney
All Responded
2021-0164
20 May 2021
East London
North East London Foundation Trust
Concerns summary (AI summary)
The Trust's risk assessment policy was not consistently followed by nursing staff. Electronic medical records showed significant validation delays and unapparent post-death amendments, compromising their integrity.
Action Planned
(AI summary)
NELFT has agreed to take a number of actions in addition to actions already taken and provided an action plan detailing the Trust’s efforts to prevent future deaths and to improve the safety and quality of care provided by the Trust.
Richard Burgess
All Responded
2021-0163
19 May 2021
Sunderland
Cumbria, Northumberland, Tyne and Wear …
Department of Health and Social Care
Concerns summary (AI summary)
Dementia care was undermined by insufficient multidisciplinary skills, a lack of proactive prevention, inadequate comprehensive assessments, poor family engagement, and a failure to implement person-centred policies effectively.
Noted
(AI summary)
The Trust states that all staff working with dementia patients have received appropriate training, and policies and guidelines are put into practice with staff receiving information and/or training on their implementation, and audits in place to monitor compliance. The Minister acknowledges the concerns, describes existing training frameworks and personalized care approaches, and mentions the Health and Care Bill's aim to improve integration of health and social care services.
Liam Kenyon
Historic (No Identified Response)
2021-0161
19 May 2021
Manchester North
Adullam Homes Housing Association
Concerns summary (AI summary)
Supported housing showed a lack of clarity in their duty of care, failed to conduct agreed hourly checks, and did not follow procedures for drug checks or risk assessment updates. Welfare checks were inadequate due to staff shortages and poor escalation.
Todd Salter
All Responded
2021-0281
18 May 2021
South Yorkshire East
National Probation Service
Concerns summary (AI summary)
A probation officer's inadequate knowledge of mental health services and poor inter-agency collaboration forced the deceased to seek treatment by committing criminal acts.
Action Taken
(AI summary)
The identified lack of knowledge and training gaps have been and continue to be dealt with at an individual level, briefing sessions on suicide prevention and processes have been updated in EQUIP. The Probation Service developed a new Target Operating Model (published in February 2021) which includes the implementation of the commitments set out in the Health & Social Care Strategy.
Bruce Houghton
All Responded
2021-0160
18 May 2021
Manchester North
Department of Health and Social Care
Manchester Health and Social Care Partn…
Uplands Medical Practice
Concerns summary (AI summary)
The deceased missed an annual medication review, and such reviews fail to inquire about patients' over-the-counter medication use, risking adverse drug interactions.
Noted
(AI summary)
The GMCA will share learning from the case with the Greater Manchester Quality Board, communicate advice and guidance to relevant providers to increase staff awareness, cascade shared learning to professionals through relevant governance and learning forums, and subject potential safeguarding issues/care concerns to further review. The practice participates in monthly multidisciplinary team meetings. Standardised medication review template will be introduced that includes a prompt to routinely trigger an enquiry as to whether the patient is taking any over-the-counter medicine. High risk mental health patients will be invited for a health check and medication review, all patients with known mental health conditions will complete by March 2022. The response acknowledges the concerns raised and mentions existing guidance and requirements for medication reviews within GP practices and Primary Care Networks, and notes that the Uplands Medical Practice has introduced a standardised medication review template.
Callum Evans
All Responded
2021-0159
18 May 2021
Hampshire, Portsmouth and Southampton
Network Rail
Concerns summary (AI summary)
A lack of visible and prominent signage regarding the live electrified third rail at the railway station meant individuals were unaware of its presence and life-threatening danger.
Action Taken
(AI summary)
Network Rail has installed additional safety measures at stations, including Hinton Admiral, such as platform end gates, yellow hatching warning lines and anti-trespass matting and conducts campaigns to warn of the dangers and target people at risk and high-risk areas.
Juliet Saunders
All Responded
2021-0157
18 May 2021
East London
Queen’s Hospital
Concerns summary (AI summary)
Multiple failures included poor weekend ED support for learning disability patients, inadequate record-keeping, lack of junior doctor supervision, and repeated diagnostic overshadowing leading to missed acute conditions.
Action Taken
(AI summary)
The Learning Disability Team provides an advisory service to support clinical teams during the hours of 09:00 - 17:00, Monday to Friday and Safeguarding Oncall Manual has been created. The Trust commissioned an external thematic review in March 2021, into Serious Incidents {Sis) from the period of January 2019 to December 2020.
Lynne Lawrence
All Responded
2021-0158
17 May 2021
Gwent
Blaenau Gwent County Borough Council
Concerns summary (AI summary)
An uneven pedestrian pavement creates a future fall risk, particularly for elderly individuals with reduced mobility.
Noted
(AI summary)
The council investigated the footway condition outside Alma Street and concluded that it does not meet the standard for intervention based on their inspection regime, which exceeds national minimum standards for safety and maintenance defects intervention.
Lola Sheldrake
Historic (No Identified Response)
2021-0156
17 May 2021
Cambridgeshire and Peterborough
National Institute for Clinical Excelle…
Concerns summary (AI summary)
There are no national guidelines for monitoring and treating infants at risk of haemolytic disease of the newborn, especially regarding post-treatment and discharge care.
Stephen Thurm
All Responded
2021-0155
17 May 2021
Manchester South
Greater Manchester Mental Health NHS Fo…
NHS England
Concerns summary (AI summary)
Family information regarding self-harm risk was disregarded when denied by the patient, and care coordinators lacked dedicated time for contemporaneous note-taking. Carers' mental health needs were also not integrated into long-term plans.
Action Planned
(AI summary)
NHS England and Improvement has set out clear expectations for systems to provide support for carers of people with severe mental health problems and to better involve carers in care and support planning from April 2021. Long Term Plan funding will be used to develop and implement plans to improve the lives of carers of people with severe mental health problems and to also look at specific inequalities’ carers may face. The trust will ensure families/carers are identified and involved in care planning where possible, and offered carers' assessments. They are also undertaking a quality improvement project regarding staff supervision.
Steven Oscroft
All Responded
2021-0162
12 May 2021
Nottingham City and Nottinghamshire
Driver and Vehicle Licensing Agency
Paul Wainwright Construction Services L…
Concerns summary (AI summary)
Unsafe industry practice of 'mounding' tipper lorry loads above side height, combined with inadequate sheeting systems that fail to cover the load, increases the risk of materials falling from vehicles.
Action Planned
(AI summary)
DVSA will work with HSE to amend load security guidance on GOV.UK to include specific narrative on bulk loads, aiming to have it ready by September 2021. They will arrange special road checks focused on bulk trailer skip lorries, starting in September, and produce dedicated communications highlighting the revised guidance. The company has upgraded its sheeting and restraint systems for all vehicles to increase load cover and security, and is having its Health and Safety Consultants design ongoing training criteria and schedules for drivers.
Mary Mellor
All Responded
2021-0153
12 May 2021
Manchester South
Medica Reporting Ltd and Liverpool Hear…
Concerns summary (AI summary)
Critical aortic stent leaks were missed on CT scans due to the lack of 3D reconstruction. An external reporting service, Medica, has not committed to implementing this essential practice, leaving patients at risk.
Action Planned
(AI summary)
Medica will share the learning from this case with their radiologists, highlight the importance of good MPR technique, and remind case reviewers of the importance of using MPRs. The hospital has reviewed relevant patient scans and established no further incidents occurred, written a formal policy requiring multi-planar view reporting for this type of image, and set up a Liverpool Cardiovascular Surgery Clinic. They will also perform and report in-house for this type of image, no longer outsourcing to Medica.
Charlotte Swift
All Responded
2021-0150
11 May 2021
West Sussex
NHS England
Concerns summary (AI summary)
A national shortage of inpatient beds at specialist eating disorder units meant a patient could not receive urgent treatment, highlighting a systemic risk of serious harm and death to vulnerable individuals.
Noted
(AI summary)
NHS England and Improvement acknowledges the concerns about waiting times for specialist eating disorder inpatient beds. They describe the optimal service model and ongoing transformation work, including investment in community services and early intervention models.
John Lott
Historic (No Identified Response)
2021-0149
10 May 2021
City of Brighton and Hove
Nuffield Hospital
Concerns summary (AI summary)
Inadequate management of a patient's deteriorating condition, including unmanaged hypoglycaemia and failure to transfer to critical care, was exacerbated by poor escalation of care when the primary consultant was unavailable.
Parys Lapper
All Responded
2021-0148
10 May 2021
West Sussex
NHS England
Concerns summary (AI summary)
A fragmented prescription system, lacking central records, allowed a patient to obtain excessive medication from multiple providers, enabling abuse and increasing the risk of fatal overdose.
Noted
(AI summary)
NHS England and NHS Improvement acknowledge concerns about individuals obtaining excess medications and checking prescriptions across providers. They cite GMC guidance on prescribing practices and describe ongoing programs to improve information sharing and mental health services.
Eva Hayden
All Responded
2021-0147
9 May 2021
Liverpool and Wirral
Southport and Ormskirk Hospital NHS Tru…
Concerns summary (AI summary)
No specific concerns were detailed in the provided text.
Action Taken
(AI summary)
The trust has reported the incident as a Serious Incident to the Strategic Executive Information System (StEIS) and is undertaking a full Serious Incident investigation, reviewing ongoing processes. They are amending the local induction for staff in paediatrics to ensure that staff are provided with important information about communication with families and other organizations, and what to do when children aren't brought to their appointments.