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)
Clear 304 results
John Berrow
All Responded
2021-0080 7 Jan 2021 Gwent
Specsavers UK
Concerns summary (AI summary) An optometrist failed to recognize a critical sign of intracranial pressure, lacked proper reference tools, and there was no system for disseminating clinical incident learning.
Action Planned (AI summary) Specsavers will commission a specialist optometrist or neuro-ophthalmologist to deliver training materials (concentrating on this topic) which will be recorded and disseminated via an online webinar available to all professional staff within the Company. They also hope to make the training available for the wider optical community.
Arthur Johnson
All Responded
2021-0003 5 Jan 2021 Hampshire, Portsmouth and Southampton
Hampshire County Council and Oakridge H…
Concerns summary (AI summary) Care home's "Post-Falls" policy lacked clarity on when to call emergency services for possible head injuries, and staff training on recognising intracranial injury was insufficient.
Action Taken (AI summary) Hampshire County Council updated its "falls protocol" in line with current NICE guidance, clarifying that staff should contact 999 or 111. Additionally, staff will now participate in a standalone learning module on falls management, including head injury risk.
Hariharan Harichandra
All Responded
2021-0001 5 Jan 2021 Inner North London
Royal Free Hospital
Concerns summary (AI summary) A CT scan error was not noticed by a consultant radiologist, the Falls Assessment Tool was not properly completed, staff lacked training on external wheelchairs and safety features, and an adverse reaction to a Naso-Gastric tube was not recorded.
Action Taken (AI summary) The response details multiple actions regarding radiology reporting, NG tube insertion, and documentation, including reviews of policies, training enhancements (including simulation training for NG tube insertion), audits, and equipment changes (such as new manometry equipment). The hospital has also provided additional support to staff involved in the incident.
Pardeep Plahe
All Responded
2021-0061 4 Jan 2021 Birmingham and Solihull
Ashfield Surgery Sutton Coldfield Birmingham and Solihull Clinical Commis… EMIS +1 more
Concerns summary (AI summary) A technical fault in the EMIS system caused GP consultation lists to not update, leading to a missed appointment. Reliance on manual workarounds creates a risk of further missed appointments.
Noted (AI summary) NHS England notes that EMIS is developing a solution, expected in September 2021, to address the intermittent EMIS system issue which resulted in a booked telephone consultation for Mr Plahe not taking place. NHS Digital will jointly review the solution with EMIS clinicians. The CCG's IT Team worked with EMIS and GP practices to address appointment refreshing issues, issuing guidance after identifying the cause. In response to reoccurring issues after the Windows 10 upgrade, the CCG communicated potential problems and resolution information to all GP practices. Ashfield Surgery updated its induction pack to highlight EMIS issues and steps to address them, shared this information with nursing staff and term locums, and cascaded to Primary Care Networks using EMIS. A Significant Event Analysis was completed and shared. EMIS investigated the reported issue of the appointment book not refreshing, advised the practice to check UDP ports, and states they are investigating potential solutions to improve functionality given the increase in remote working, but offered no concrete actions.