2021
PFD Reports
Reports: 419
Areas: 62
83% response rate (above 63% average).
Trevor Smith
All Responded
2021-0387
17 Nov 2021
Birmingham and Solihull
College of Policing
West Midlands Police
Concerns summary (AI summary)
Critical mental health information from MARAC was not accurately recorded or cascaded to police, leading to officers being unaware of the deceased's EMD status. There was also confusion and a lack of coordination during CPR efforts.
Action Planned
(AI summary)
The NPCC First Aid Forum will formally raise the issue of establishing a first aid (CPR) coordinator at its next meeting. The College of Policing will send out a national circular to raise awareness of the Coroner's concerns so that forces can consider a coordinator role in appropriate circumstances while the associated national guidance and training is considered. West Midlands Police have updated team briefing sheets to include reference to the CPR coordinator role and updated the Medical Plan to include direction regarding the coordination of care. All Strategic and Tactical Firearms Commanders (S&TFCs), Operational Firearms Commanders (OFCs), Firearms Tactical Advisers (FTAs) and all Authorised Firearms Officers (AFOs) are aware of this recommendation.
Victoria Harrild-Jones
All Responded
2021-0386
17 Nov 2021
Suffolk
Ministry of Defence
Concerns summary (AI summary)
Military personnel and dependents treated overseas receive post-operative care, specifically regarding prophylactic anti-coagulation medication, that does not comply with UK NICE guidance.
Action Planned
(AI summary)
The Defence Professor of General Practice has committed to add this case and reflective discussion to the mandatory course for all Defence GP trainees held in Cyprus each June. The DMS Overseas Assurance Working Group is reviewing the assurance process to create supporting policy and a common framework.
Joseph Martin
Historic (No Identified Response)
2021-0389
16 Nov 2021
Inner North London
Police Service of Northern Ireland Belf…
Concerns summary (AI summary)
Systemic and individual failures in police information sharing meant critical concerns from a psychiatrist about a vulnerable missing person's psychotic relapse were not recorded or relayed to other officers or agencies.
Sharon Robinson
All Responded
2021-0385
16 Nov 2021
West Yorkshire Western
Bradford Teaching Hospitals NHS Trust
Concerns summary (AI summary)
There is a concern that patient sensitivities to antibiotics are ignored, leading to medication being administered despite potential risks.
Action Planned
(AI summary)
The Trust is working to align its approach to antimicrobial policy with Bradford Teaching Hospitals, overseen by the Drug and Therapeutics Committee, including a revision of the Antimicrobial Policy. The Trust is also engaging with other healthcare providers to understand how they manage the risk of prescribing medication to patients with documented allergies.
Emma Burbury
All Responded
2021-0382
11 Nov 2021
Cornwall and Isles of Scilly
Cornwall Council
Kernow Clinical Commissioning Group
Concerns summary (AI summary)
There was a missed opportunity to caseload a dual diagnosis patient, alongside systemic communication issues between agencies regarding record access. Patients were also discharged too readily for missed appointments without considering other support services.
Action Planned
(AI summary)
The Trust is contributing to the implementation of a system-wide Dual Diagnosis policy and will explore improvements to information sharing between partner organisations. Community Mental Health transformation work is underway to address collaborative working between the ICMHT and other partners. NHS Kernow will provide funding for read-only access to We Are With You (WAWY) notes for CMHT staff at CFT. They are engaging with CFT regarding discharge processes and will ensure WAWY staff complete specific training modules.
Daniel Hall
All Responded
2021-0381
10 Nov 2021
South Wales Central
University of South Wales
Concerns summary (AI summary)
University students face lengthy delays accessing mental health support, even when expressing suicidal ideation and having known risk factors like ASD.
Action Taken
(AI summary)
The University has commissioned an independent external review of wellbeing policies and procedures. Since October 2021, it has worked to improve understanding of support services and has improved and extended its training program for students and staff.
Philip Ellis
All Responded
2021-0380
10 Nov 2021
County Durham and Darlington
Free the Way
Concerns summary (AI summary)
The deceased was able to leave service premises unsupervised and obtain drugs in breach of rules, with no serious incident review conducted into these supervision failures.
Action Taken
(AI summary)
Free the Way has introduced measures including escorting clients returning from relapse to collect belongings, searching all property, and restricting unaccompanied leave. Clients entering treatment will be monitored closely and subject to regular room checks and urine screening.
Mared Foulkes
All Responded
2021-0378
10 Nov 2021
North West Wales
Cardiff University
Concerns summary (AI summary)
The university's examination results system is complex and misleading, with provisional passes and pending marks causing confusion. There is also no system for personal tutors to proactively contact vulnerable students before releasing failed results.
Action Taken
(AI summary)
The University has reviewed its process for releasing in-year resit results to ensure all available results are ratified at the Main Examining Board in June. The practice of using notional marks where a student has not met a competency standard has been stopped.
Mollie Dimmock
All Responded
2021-0379
9 Nov 2021
Buckinghamshire
National Institute for Health and Care …
Concerns summary (AI summary)
NICE Guidance NG121 lacks a clear definition for "large-for-gestational-age" babies, leading to inconsistent interpretation and application of delivery mode guidance. This creates uncertainty in crucial obstetric care decisions.
Noted
(AI summary)
NICE acknowledges the coroner's concerns regarding the lack of a standard definition for "large for gestational age" in its guideline on intrapartum care, but argues that providing a specific cut-off would convey inappropriate certainty.
Ethel Beaumont
Historic (No Identified Response)
2021-0377
9 Nov 2021
Cambridgeshire and Peterborough
North West Anglia NHS Foundation Trust,…
Concerns summary (AI summary)
There is a lack of clarity between hospital and primary care regarding responsibility for monitoring antibiotic prescriptions, risking patient safety where GPs prescribe at hospital request.
Susan Merton
Partially Responded
2021-0375
9 Nov 2021
North Wales (East and Central)
Betsi Cadwaladr University Health Board
Ysbyty Gwynedd
Concerns summary (AI summary)
The Health Board consistently fails to implement its own action plan recommendations and address concerns within set timeframes, leading to ongoing risks to patient lives.
Action Taken
(AI summary)
BCUHB changed its serious incident process in April 2021, requiring all investigation reports to be submitted for scrutiny and approval at an Incident Learning Panel. The Health Board is tracking actions and auditing compliance through its Datix patient safety system.
Katrina Makunova
All Responded
2021-0388
5 Nov 2021
London Inner South
University of Gloucestershire, Universi…
Concerns summary (AI summary)
Knife possession and gang affiliation were not consistently recognized as risk factors in contextual abuse assessments by police or social services. Additionally, police Child Safety Units face significant workload pressures impacting safeguarding effectiveness.
Action Planned
(AI summary)
The MPS will share the report with relevant departments and review training programmes to include expert evidence-based advice on knife carrying and gang membership in domestic abuse risk assessments. A review of CSU resourcing is underway, with findings to be presented to the MPS Management Board in January 2022.
Christian Hinkley
All Responded
2021-0376
4 Nov 2021
Mid Kent and Medway
Minister of State for Prisons and Proba…
Concerns summary (AI summary)
Prison fire detection systems are inadequate and unable to reliably detect cell fires early enough to save lives. Despite repeated warnings and notices issued since 2015, in-cell automatic fire detectors remain uninstalled.
Action Taken
(AI summary)
HMPPS is investing £315m to improve fire safety, including in-cell fire detectors, portable fire detection devices, water mist firefighting equipment, and smoke ventilation fans. Cell fire response training was revised in December 2021 to include scenarios for obstructed inundation ports.
Robert Wright
All Responded
2021-0374
4 Nov 2021
South Wales Central
Cwm Taf University Health Board
Concerns summary (AI summary)
Internal hospital referrals were paper-based and not promptly integrated into patient notes, leaving busy clinicians without immediate access to complete patient referral information.
Action Planned
(AI summary)
CTM UHB is exploring implementing electronic referrals and triaging, and is benchmarking practice with a neighbouring Health Board. A future project would be to consider an electronic patient pathway.
Steven Evans
All Responded
2021-0372
3 Nov 2021
Gwent
Civil Aviation Authority and British Gl…
Concerns summary (AI summary)
A lack of mandatory radio communication between ground crew and glider pilots meant observed glider problems before launch were not communicated. This ongoing absence of mandatory radio use poses a future risk to lives.
Action Taken
(AI summary)
The BGA reviewed launch signalling, clarified requirements with subject matter experts and gliding clubs, and revised rules and guidance on signalling. The AAIB confirmed the BGA's actions adequately addressed their recommendation. The BGA has clarified launch signalling requirements, including guidance on back-up signalling, through revised rules and guidance. All clubs required pilots and instructors to review safety information, and the AAIB confirmed the BGA's actions adequately addressed their recommendation.
Rhian Rose
All Responded
2021-0371
3 Nov 2021
Worcestershire
Worcestershire Acute Hospitals NHS Trust
Concerns summary (AI summary)
There is insufficient emphasis on maternal wishes and informed consent regarding mode of delivery. Additionally, there's a lack of specific guidance for managing infection risks associated with a retained deceased foetus following feticide.
Action Planned
(AI summary)
Worcestershire Acute Hospitals Trust is planning to adopt the National I Decide tool and introduce a Personalised Care Plan into BadgerNotes App to support informed consent. They also plan to establish a robust process to manage 'in labour' requests for Caesarean Section.
Angela O’Donnell
Partially Responded
2021-0370
3 Nov 2021
Berkshire
Department of Health and Social Care
Frimley Park Hospital
Concerns summary (AI summary)
High reliance on agency nursing staff raises concerns about consistent training and continuity of care. The national shortage of nursing staff contributes to these systemic challenges.
Action Taken
(AI summary)
Frimley Park Hospital has taken several steps to address staffing shortages and improve the support for agency staff including proactive recruitment of nurses, improved retention schemes, and relaunched induction training for all staff. Agency staff are appointed through suppliers party to the NHS Workforce Alliance Framework Agreement and are trained in accordance with the UK Core Skills Training Framework Agreement.
Fishmongers’ Hall Inquests
All Responded
2021-0362
3 Nov 2021
London City
College of Policing
Department for Education
Home Office
+7 more
Concerns summary (AI summary)
This document is a questionnaire for the jury, intended to determine the means and circumstances by which Jack Merritt and Saskia Jones died, focusing on identifying any errors, omissions, or circumstances that may have caused or contributed to their deaths.
Noted
(AI summary)
The Learning Together Network CIC states it cannot take steps on the recommendations as it did not employ staff or run partnerships, and will be dissolved in January 2022. CTPHQ now has CT Nominal Management specialist trained officers who will attend all future CT MAPPA (Category 4) cases and are responsible for designing and delivering a risk management plan (RMP). West Midlands Police exceeds national guidance for visits to Registered Terrorist Offenders/Pathfinders. The Office for Students will write to all registered higher education providers in England, making them aware of the report and asking them to consider changes to their approach to risk assessment of events, programmes, and information sharing. The College of Policing acknowledges the concerns raised and states its commitment to supporting other bodies in achieving improvements in terrorist offender management. They provide broader offender management training products and guidance and will work with partners to ensure they are updated. CTPHQ now has CT Nominal Management specialist trained officers who will attend all future CT MAPPA (Category 4) cases and are responsible for designing and delivering a risk management plan (RMP). West Midlands Police exceeds national guidance for visits to Registered Terrorist Offenders/Pathfinders and now feed this into the MAPPA panel. The Secretary of State will engage with the higher education sector to encourage action to implement the recommendations and officials have spoken to the Office for Students to encourage them to take action. Officials have also engaged with HMPPS to design a new framework to define roles and responsibilities of prisons and higher education providers. The University of Cambridge has created a new policy and guidance for staff and students working with people who have offended, and the Institute of Criminology has developed a Risk Assessment Form for all activities. The University has also stopped delivering the Learning Together programme. The government is legislating a new power of personal search through the Police, Crime, Sentencing and Courts Bill, allowing police to stop and search terrorist offenders on license under certain circumstances. MoJ accepted recommendations relating to the Fishmongers' Hall attack. A new framework is being designed for Learning Together activity in prisons. Statutory guidance on MAPPA meetings will be strengthened, and the Police, Crime, Sentencing and Courts Bill includes a power for police to search terrorist offenders on licence.
Shaun Mansell
All Responded
2021-0383
1 Nov 2021
Stoke-on-Trent and North Staffordshire Coroner’s Court
Royal Stoke University Hospital and NHS…
Concerns summary (AI summary)
Excessive and prolonged patient handover delays at the hospital severely impacted ambulance response times, highlighting a critical national issue in emergency care.
Noted
(AI summary)
NHS England reiterates national policy on 15-minute ambulance handover times and highlights actions taken to address delays, including alternative patient pathways, improved hospital flow, and additional funding for Hospital Ambulance Liaison Officer staff. On 13 December, NHS England and NHS Improvement reiterated the need to eliminate ambulance handover delays. University Hospitals of North Midlands NHS Trust (UHNM) highlights measures to reduce ambulance delays including a focus on patient flow, admission avoidance, and improved discharge processes. They developed a Standard Operating Procedure (SOP) to manage ambulance arrivals when there is a necessity to hold WMAS crew and patients on ambulances. UHNM considers this a system-wide issue requiring a system response.
Neil Bastock
All Responded
2021-0365
1 Nov 2021
West Yorkshire (East)
Leeds and York Partnership NHS Foundati…
Concerns summary (AI summary)
The decision to rescind the section was made by a responsible clinician who had only been in the role for two weeks.
Action Planned
(AI summary)
Leeds and York Partnership NHS Foundation Trust will formalize support and supervision arrangements for locum medics, review their clinical handover process, and ensure families are involved in decisions about rescinding sections. The Trust will also disseminate an updated Missing Service User Procedure and audit compliance against it.
Jane Bruce
Historic (No Identified Response)
2021-0366
29 Oct 2021
Leicester City and South Leicestershire
Department of Health and Social Care
Concerns summary (AI summary)
Inconsistent district nurse assignments, lack of photographic wound documentation, and inability to access electronic patient records at home hindered proper assessment of changing patient conditions.
Lorraine Karat
All Responded
2021-0364
29 Oct 2021
Inner North London
Clarion Housing Group
Concerns summary (AI summary)
Lack of a risk assessment for an unsafe, accessible balcony, inadequate communication regarding its use, and absence of safety barriers or window restrictors created a significant fall risk in housing properties.
Action Planned
(AI summary)
Clarion Housing Group is informing tenants that access to flat roofs is unauthorised and unsafe and issuing guidance to staff to identify flat roofs where unauthorised access might occur. Additional measures such as window locks and restrictors can be installed where a risk of unauthorised access to a flat roof has been identified.
Christopher Collinson
All Responded
2021-0361
26 Oct 2021
Birmingham and Solihull
University Hospitals Birmingham NHS Fou…
Concerns summary (AI summary)
A manual patient allocation system risks unassessed patients, and the electronic prescribing system lacks a secondary check, increasing the danger of incorrect medication being administered.
Action Taken
(AI summary)
The Trust has rolled out its in-house electronic system, PICS, to Birmingham Heartland’s Hospital AMU to provide a paper-free electronic patient record. However, they will not be introducing a secondary check for enoxaparin prescribing due to concerns about alert fatigue, arguing existing systems are sufficient.
Kyle Hurst
All Responded
2021-0359
26 Oct 2021
North Wales (East and Central)
Betsi Cadwaladr University Health Board
Concerns summary (AI summary)
The Health Board failed to implement a beneficial medical protocol and delayed approving critical risk mitigation procedures for diagnostic results, despite setting their own deadlines, thereby putting lives at risk.
Action Planned
(AI summary)
BCUHB is considering adopting the SNAP protocol for paracetamol overdose treatment but requires local review and approval. The Health Board is reviewing historic action plans from serious incident investigations and tracking actions through their Datix patient safety system.
Alan Hunter
All Responded
2021-0369
25 Oct 2021
Greater Manchester South
Stockport NHS Trust
Concerns summary (AI summary)
Poor documentation, incorrect BMI calculation, and failure to follow NICE guidance on weight monitoring led to an inaccurate assessment of the patient's nutritional risk and status.
Action Taken
(AI summary)
The Trust had already begun improvement work related to MUST, nutrition and hydration prior to the inquest, including monthly steering group meetings, training (90.76% compliance), ward audits, and nutrition/hydration information boards. Quality assurance checks and daily safety huddles now include a review of nutrition and hydration concerns and weight completion where appropriate; the Trust also participated in Malnutrition Awareness Week in October 2021.