2021
PFD Reports
Reports: 419
Areas: 62
83% response rate (above 63% average).
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.
Dorothy Pegg
All Responded
2021-0358
22 Oct 2021
North Yorkshire Western District
Abbeyfields the Dales Ltd and North Yor…
Concerns summary (AI summary)
A resident was hoisted from her bed to a shower chair with a slip left underneath, then wheeled to the living room; prior to being hoisted to her living room chair, she slipped and suffered bilateral leg fractures that contributed to her death.
Action Planned
(AI summary)
NYCC has requested ICES to provide instruction leaflets for equipment and will include a dedicated module with examples and scenarios for completing moving and handling risk assessments and plans in future training for new or existing OTs (February/March 2022); a specialist moving and handling training event for NYCC OTs is scheduled for February and March 2022 and will incorporate a specific focus on instructions as to the purpose of equipment and moving and handling plans. Abbeyfield The Dales Ltd has introduced a new care plan format with images of mobility equipment and updated systems of work, launched a service delivery audit to check care delivery against the care plan, and plans to implement a new equipment process in January 2022 to ensure staff competency with new equipment.
Anthony Clacher
All Responded
2021-0356
22 Oct 2021
Dorset
Department of Health and Social Care
HM Prison and Probation Service
NHS England and NHS Digital
Concerns summary (AI summary)
A national lack of guidance for welfare checks and monitoring prisoners under the influence of psychoactive substances poses significant risks of physical and mental health deterioration, including death.
Noted
(AI summary)
NHS England highlights that the Digital Person Escort Record (DPER) has been live across the prison estate since November 2020, and all reception healthcare staff should have access to the DPER prior to arrival of persons at the site; further a review and update of the reception and secondary screening templates for healthcare is ongoing. NHS Digital is considering the coroner's concerns about SystmOne in prisons when developing the capabilities for the HJIS re-procurement in 2022/23 and will consider adopting GP IT related products such as GP2GP and the Primary Care Registration Management system in FY22/23. The Department of Health and Social Care acknowledges the concerns raised, highlights the National Partnership Agreement for Prison Healthcare, and notes actions NHS England is taking regarding substance misuse in prisons. HMPPS is considering a national rollout of local initiatives (including those from HMP Guys Marsh) to improve welfare checks on prisoners under the influence of psychoactive substances, and is developing a new version of the ACCT (Assessment, Care in Custody and Teamwork) processes with revised training modules being rolled out nationally for all staff involved in the delivery of ACCT.
David Walker
All Responded
2021-0357
21 Oct 2021
East London
North East London Foundation Trust
Concerns summary (AI summary)
Frequent changes in care coordinators and the failure to obtain critical collateral information from other healthcare trusts on admission resulted in a fragmented understanding of the patient's risks.
Action Taken
(AI summary)
The Trust has hired agency staff on a semi-permanent basis, approved budget for reduced caseloads, provided training and supervision for staff, and amended the electronic admission checklist to include prompts for obtaining collateral information from other Trusts.
Richard Franks
All Responded
2021-0355
21 Oct 2021
West Yorkshire Eastern
David Ake & Co Solicitors
Concerns summary (AI summary)
Critical information regarding a prisoner's suicidal intent expressed at court was not communicated to prison staff, leading to inadequate monitoring and a lack of necessary support measures.
Action Planned
(AI summary)
The solicitors will ensure that they remind appropriate organisations each time a threat to self-harm is repeated.
Freeda Glausiusz
All Responded
2023-0199
20 Oct 2021
Inner North London
East London NHS Foundation Trust
Concerns summary (AI summary)
A crisis line clinician failed to adequately assess risk, displayed a lack of empathy, and did not document a crucial call, exacerbated by management advising against proper record-keeping and a general lack of trust cooperation with the inquest.
Action Taken
(AI summary)
East London NHS Foundation Trust has implemented changes to the Crisis Line, including a revised supervision structure, training for call handlers, and improved record-keeping. They have hired four new SI investigators to clear the backlog of reports and agreed to hire an additional solicitor to increase the Legal Affairs Team’s capacity.
Jane Bush
All Responded
2021-0353
20 Oct 2021
Norfolk
Hellesdon Hospital
Concerns summary (AI summary)
Persistent delays in mental health assessments and access to psychological therapy are driven by ongoing staff recruitment and retention issues, hindering the Trust's ability to manage increased demand for complex cases.
Action Taken
(AI summary)
Hellesdon Hospital has implemented several actions including increasing capacity of the Central Youth Team, developing a locality model, developing a transition service, and recruiting senior nurses and consultant psychologists. They have also added relocation incentives to recruitment adverts and are offering remote working where appropriate.
Donna Constantine
All Responded
2021-0350
19 Oct 2021
Greater Manchester South
National Police Chiefs’ Council, Home O…
Concerns summary (AI summary)
Police encouraging vulnerable individuals to use unmonitored work mobile phones creates risks due to a lack of off-duty response, clear escalation procedures, and proper audit trails for communication.
Noted
(AI summary)
The Home Office acknowledges the concerns and states that police forces are operationally independent and it is for Greater Manchester Police, the NPCC and the College of Policing to address the issues raised. The NPCC and College of Policing note the concerns and explain that the Victims Code was updated in April 2021. They state that forces are not encouraged to give out mobile phone numbers and provide guidance for officers receiving emergency calls.
Mohammed Salam
All Responded
2021-0348
18 Oct 2021
Manchester North
Northern Care Alliance NHS Trust
Concerns summary (AI summary)
The Root Cause Analysis for a medication omission lacked rigor, failing to investigate causal factors or consequences, which raises concerns about organizational governance and learning from deaths.
Action Taken
(AI summary)
Northern Care Alliance has implemented consultant countersignatures on ward round outcomes, updated grand round and weekend handover proformas to include an ePMA review checkbox, and updated the junior doctors' handbook with information on tumour lysis syndrome.
Sky Rollings
All Responded
2021-0354
16 Oct 2021
Stoke-on-Trent & North Staffordshire Coroner’s Court
NHS England
North Staffordshire Combined Healthcare
Concerns summary (AI summary)
The absence of dedicated in-patient mental health provision for young people aged 14-25, and the immediate application of adult services at 18, poses risks by not acknowledging developmental needs.
Noted
(AI summary)
NHS England acknowledges concerns about transitioning young people from CAMHS to adult mental health services, explains the current policy, and notes work has commenced regarding community transformation and development of a 14-25 Transition service. North Staffordshire Combined Healthcare NHS Trust will review the Transition of Young People to Adult Mental Health Service Policy, and explore options for a designated in-patient service or unit for young adults.
Darren Lawrence
All Responded
2021-0349
15 Oct 2021
Manchester City
Prestwich Hospital and The Droylsden Ro…
Concerns summary (AI summary)
Inadequate communication and follow-up between mental health teams and the GP led to a patient disengaging and not receiving crucial medication. The Trust's internal investigation was also flawed and incomplete.
Action Taken
(AI summary)
The practice has developed a pathway for managing patients with suicidal tendencies and implemented changes to their template. They have also nominated leads for suicide prevention and will start recruiting a mental health worker. The Trust has implemented daily multi-disciplinary zoning meetings in CMHT, attended by HBTT staff twice weekly to improve communication; also, an Assistant Director for Quality has been appointed to address concerns raised in recent inquests.
Harbans Singh
All Responded
2021-0345
15 Oct 2021
Warwickshire
Warwick Hospital
Concerns summary (AI summary)
The discharge process experienced a system failure, and significant hypothyroidism identified by blood tests was not flagged or acted upon, posing a risk to patient safety.
Action Planned
(AI summary)
A working group reviewed discharge processes and thyroid blood test flagging. A new 'Discharge to Assess' process will be rolled out across the trust by April 2022, with compliance audits to follow.
Alexandra Tolley
All Responded
2021-0344
14 Oct 2021
West Yorkshire (East)
Leeds and York Partnership NHS Foundati…
Concerns summary (AI summary)
The care plan's instruction not to restrain or follow a high-risk patient absconding under Section 2 was incompatible with safety duties. Informal decisions for ground leave lacked criteria and proper risk assessment.
Action Planned
(AI summary)
The Trust will update its procedure for patients who go missing, including external feedback, aiming for ratification by January 2022; it will also communicate clear timescales to external organizations for procedure input.
Kirsty Doodes
All Responded
2021-0343
14 Oct 2021
Cornwall and Isles of Scilly
Cornwall Partnership (Foundation) Trust
Concerns summary (AI summary)
Poor note-keeping and a lack of clear future care planning during discharge, coupled with insufficient family involvement and unavailable crisis support for the carer, exposed the patient to significant risk.
Action Planned
(AI summary)
The Trust is taking measures to expand the mental health workforce, including international nurse recruitment, increasing apprentice roles, and improving staff retention.
Michael Jaggs
All Responded
2021-0333
6 Oct 2021
Inner North London
MedPure Healthcare
Concerns summary (AI summary)
An agency nurse provided suboptimal care, but the agency failed to provide additional training or encourage reflective learning, unlike the hospital, raising concerns about safety improvements.
Action Taken
(AI summary)
The agency has outsourced complaints to a clinical team, implemented a policy for reflective statements upon complaint, and can offer immediate additional training; they have also assisted the nurse in self-referring to the NMC.
Charlotte Duffield
All Responded
2021-0334
5 Oct 2021
Cumbria
Cumbria County Council
Concerns summary (AI summary)
Adult Social Care failed to take appropriate safeguarding action despite significant police concerns, only attempting telephone contact and sending a letter, without making any physical visit to a vulnerable individual.
Action Taken
(AI summary)
The Council has reviewed self-neglect policies, revised operational practice guidance, implemented a countywide operational Safeguarding Adults service, and is delivering training sessions; a practice learning session will be undertaken with the team directly involved in this case.
Aaron Fretwell
All Responded
2021-0331
5 Oct 2021
West Yorkshire (East)
Bailey Trailers Ltd
Concerns summary (AI summary)
An agricultural trailer lacked a required propping device and warning signs, failing to meet safety regulations. Many similar trailers remain in use without these critical safety features, posing a risk of future accidents.
Action Taken
(AI summary)
The company now fits a mechanical body support to secure the body in a high position during maintenance to all applicable trailers; its revised operation and maintenance manual states how to deploy it and warns users to never work under a raised body unless propped, and has emailed dealers to explain the design does not require the trailer to be raised for routine maintenance.
Leon Briggs
All Responded
2021-0330
4 Oct 2021
Bedfordshire and Luton
Association of Ambulance Chief Executiv…
Bedfordshire Police
EEAST
+1 more
Concerns summary (AI summary)
The local S136 Multi-Agency Policy is unclear and lacks streamlining. There is insufficient training for first responders on recognizing medical emergencies, the effects of restraint, and monitoring detainees.
Noted
(AI summary)
EEAST has approved (November 2021) the National Ambulance s.136 Guidance, is developing and implementing a new mental health care service model, and has developed a specific training session in relation to Acute Behavioural Disorder, including positional asphyxia for frontline staff. Bedfordshire Police is updating its local section 136 multi-agency policy, with a revised version due to be signed off this year and is incorporating guidance from a national ABD policy review into existing guidance for relevant policing areas. AACE confirms that the national S136 guidance has recently been revised, updated, and issued nationally and that on 1st February 21 they updated the acute behavioural disturbance guidance with wording to emphasise the need for close monitoring of a patient when restraint is used.
Jude Lloyd
All Responded
2021-0329
4 Oct 2021
Manchester City
Greater Manchester Mental Health NHS Tr…
Concerns summary (AI summary)
Inadequate care planning and communication between inpatient, CMHT, and GP services led to unmanaged diabetes and missed mental capacity assessments. The Trust's internal investigation was also flawed and incomplete.
Action Taken
(AI summary)
Following a Root Cause Analysis Investigation, recommendations were made and implemented to address concerns regarding diabetes monitoring and management. An eLearning training package is in place for CMHT staff regarding supporting and monitoring physiological health needs and to raise awareness and education on monitoring for signs of diabetic ketoacidosis.
Caden Stewart
All Responded
2021-0328
4 Oct 2021
Mid Kent and Medway
HMYOI Cookham Wood
Concerns summary (AI summary)
Prison staff were unaware of relevant policies, and there was a critical lack of communication among officers regarding a prisoner's unwell status and need for healthcare, leading to missed checks and handovers.
Action Taken
(AI summary)
In September 2021, HMP Cookham Wood issued a Notice to Staff reminding PE staff of PSI 58/2011 requirements and introduced daily roll books to record time spent in activities and healthcare requests. The logs provide for comments to be added and ‘guidance prompts’ are now in place which outline the importance of providing this information so that it is available to all staff.
Stephen Verrall
All Responded
2021-0336
1 Oct 2021
South London
Care Quality Commission
St John’s Nursing Home
Concerns summary (AI summary)
The CQC's failure to routinely check window restrictors, combined with a nursing home's un-manned weekend reception, allowed residents without capacity to leave unaccompanied, posing a significant risk.
Action Taken
(AI summary)
St Johns Nursing Home has implemented several measures, including advising all staff of the potential problem of residents leaving through the front door, ensuring all staff securely closes the door behind them, fitting all windows in the building with window restrictors in line with guidance, and introducing a 'Herbert Protocol' for any resident that poses a risk of absconding. Following the inquest, the CQC carried out a responsive “targeted” inspection of St John’s Nursing Home on 13 October 2021 and are progressing regulatory action in relation to their concerns.
Mohammad Farhan
All Responded
2021-0323
29 Sep 2021
West Yorkshire Western
Harden & Bingley Park Ltd
Concerns summary (AI summary)
Safety signs prohibiting swimming were obscured by vegetation and were old, making them less noticeable and explicit about the dangers of the water.
Action Planned
(AI summary)
Harden & Bingley Park Ltd will erect more signs around the Goit Stock waterfall area, and has provided photos of the proposed signs.
Mary Land
All Responded
2021-0322
29 Sep 2021
West Yorkshire (East)
Department of Health and Social Care
Mid Yorkshire Hospitals NHS Trust
Philips Respironics
Concerns summary (AI summary)
The Philips Respironics AF 541 mask uses an insecure 'push-on' connection to the ventilator, prone to detaching, especially with a filter. A more robust docking mechanism is needed to prevent inadvertent disconnections.
Disputed
(AI summary)
The Mid Yorkshire Hospitals NHS Trust has already completed four actions identified in an RCA investigation, including scoping improvements for securing tubing circuit connections. They continue to use filters per BTS guidance, and note the manufacturer is addressing all-in-one circuit availability. The MHRA will agree an investigation plan with Philips Respironics, engage with them on standards compliance, and discuss updating guidance with the British Thoracic Society and NICE. They will also continue to assess incoming data and take action as needed. Philips Respironics argues that the AF541 mask design meets standards, is not intended to prevent disconnection, and is contraindicated for life support. They state the facility failed to follow instructions and incorrectly used an unapproved filter, leading to the incident, therefore no action is proposed. The Department of Health and Social Care acknowledges the MHRA's actions, including requesting a final investigation report from Phillips Respironics and discussions with the British Thoracic Society and NICE on updated guidance. It also mentions the Care Quality Commission (CQC) is monitoring the Mid Yorkshire Hospitals NHS Trust action plan.