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)
419 results
Margaret Kinsey
Historic (No Identified Response)
2021-0368 25 Oct 2021 Greater Manchester South
Department of Health and Social Care
Concerns summary (AI summary) Inadequate senior medical supervision for junior doctors in the Emergency Department, particularly at night, and inconsistent documentation of clinical discussions pose significant risks to patient care.
Serena Roberts
Historic (No Identified Response)
2021-0367 22 Oct 2021 Greater Manchester South
Department of Health and Social Care Tameside Clinical Commissioning Group
Concerns summary (AI summary) Significant delays in gynaecology referrals, poor understanding of NICE guidance in General Practice, inadequate GP referral documentation, and a lack of follow-up systems for referrals hindered effective patient care and risk identification.
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.
Jamie O’Connor
Partially Responded
2021-0363 21 Oct 2021 Leicester City and South Leicestershire
Care Quality Commission Department of Health and Social Care General Medical Council +2 more
Concerns summary (AI summary) Lack of a central medication tracking system, no mandatory GP contact, and insufficient consultation processes in online prescribing platforms risk over-prescription, drug interactions, and patient harm.
Noted (AI summary) The GMC updated its prescribing guidance in February 2021 to place greater emphasis on good practice principles regardless of consultation method and highlights the need for dialogue with patients and obtaining adequate history, including current medication use. The GPhC outlines its role in setting standards for registered pharmacies and pharmacy professionals and taking enforcement action when standards are not met, including actions against online pharmacies supplying high-risk medicines and referrals to Fitness to Practise process. CQC has been in formal discussion with DHSC and submitted proposals for legislative changes to improve risk management of online primary care providers, and is working with regulatory partners to ensure that gaps in regulation are mitigated. DHSC acknowledges the concerns and describes the regulatory framework for medicines, including the roles of MHRA and GPhC, without outlining specific actions beyond existing oversight.
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.
Henry Doll
Historic (No Identified Response)
2021-0351 20 Oct 2021 Surrey
Avenues Trust Group
Concerns summary (AI summary) Care home management demonstrated a significant misunderstanding of risk assessment processes, leading to inaccurate choking risk identification for residents, and staff provided ineffective CPR.
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.
Louie Johnston
Historic (No Identified Response)
2021-0342 14 Oct 2021 East London
Department of Health and Social Care Queen’s Hospital
Concerns summary (AI summary) The CTG trace monitoring equipment required staff to switch screens during delivery, meaning a graphic representation was not continuously visible, and an obstetric registrar was not up to date with mandated annual CTG training, with systems not ensuring all medical staff completed requisite training.
Murray Hyslop
Historic (No Identified Response)
2021-0339 14 Oct 2021 Nottinghamshire
My Care Ltd My The Orchards Ltd Nottinghamshire County Council +2 more
Concerns summary (AI summary) The care home failed to adequately prevent pressure damage for a vulnerable resident and identify their deteriorating condition. Frontline staff lacked crucial training, and senior management showed a culture of obfuscation.
Paul Barton
Partially Responded
2021-0338 14 Oct 2021 Nottinghamshire
Aviva Insurance Nottinghamshire Healthcare NHS Foundati… Nottinghamshire Police
Concerns summary (AI summary) The Crisis Resolution Home Treatment Team prioritized avoiding hospital admission over life protection and over-relied on the patient's denial of suicidal intent. The Trust's investigation was inaccurate and inadequate.
Action Planned (AI summary) The Trust plans to review CRHTT processes, update policies, and invest in centralised investigators and a family liaison service to improve serious incident governance and support for families.
Helena Opuku
Historic (No Identified Response)
2021-0341 12 Oct 2021 East London
Department of Health and Social Care London Borough of Redbridge
Concerns summary (AI summary) Social services struggled to properly investigate safeguarding referrals, appoint social workers within a reasonable timeframe, or conduct timely home suitability assessments for vulnerable residents.
Vivien Brunning
Partially Responded
2021-0340 12 Oct 2021 East London
Department of Health and Social Care Queen’s Hospital
Concerns summary (AI summary) Critical venous thromboembolism reviews and prescribed daily heparin injections were omitted. Furthermore, a noticed omission was not reported through the Trust's incident system.
Action Taken (AI summary) The practice held a meeting to discuss patient documentation workflow, agreeing that all DNA and Bardoc visit notifications will be date stamped and forwarded to the addressed GP; the amended policy will be updated by the practice manager and included in staff inductions.
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.