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
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.
Hannah Royle
Partially Responded
2021-0327 4 Oct 2021 West Sussex
Health Education England NHS Digital NHS England +1 more
Concerns summary (AI summary) The 111 service failed to appropriately handle a complex case involving a disabled child due to non-compliant call handlers and an inadequate system for disabilities. The public is also misled about the service's diagnostic capabilities.
Noted (AI summary) SECAmb issued a "Hot Topic" learning update to all 111 call handling staff in October 2021, emphasising the need to identify and refer complex cases to clinicians and provided training and guidance to ensure staff fully understand the diverse needs of patients. NHS Digital provides background information on the NHS Pathways clinical decision support software and its governance, deferring to other organisations to address specific concerns raised in the report.
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.
Stephen Barton
Historic (No Identified Response)
2021-0326 1 Oct 2021 Staffordshire South
Department of Health and Social Care
Concerns summary (AI summary) The NHS lacks a system for tracking non-cancer outpatient appointments, unlike cancer cases. Implementing such a system could prevent unnecessary deaths and improve administrative efficiency.
Stephen Cope
Partially Responded
2021-0332 30 Sep 2021 Inner London South
Department of Health and Social Care HMP Belmarsh Ministry of Justice +1 more
Concerns summary (AI summary) The rapid closure of an ACCT for newly transferred prisoners, often based on minimal review, poses a risk as it fails to allow adequate time for staff to assess and understand the individual's needs.
Action Planned (AI summary) HMPPS implemented a revised version of ACCT in July 2021 that focuses on a person-centred approach, information sharing, improved case reviews and a strengthened post-closure period and shared a learning bulletin about transferring prisoners on an open ACCT which emphasises the importance of good communication and information-sharing. The Department of Health and Social Care is working with partners on the next version of the National Partnership Agreement (NPA) for Prison Healthcare, due in April 2022. NHS England is also reviewing the ACCT process in prisons and healthcare attendance, with findings anticipated in early 2022.
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.
Richard Boateng
All Responded
2021-0335 28 Sep 2021 South London
College of Policing London Ambulance Service NHS England
Concerns summary (AI summary) Untrained non-clinicians are triaging urgent GP calls without guidance, ambulance service protocols for inter-agency information sharing are unclear, and police lack practical guidance for safely conveying patients in emergencies.
Noted (AI summary) The College of Policing acknowledges the concerns and refers to existing APP guidance on dynamic risk assessment. The NPCC will discuss ambulance availability with colleagues and the NPCC First Aid Forum will consider practical advice to forces. The London Ambulance Service has issued staff bulletins for frontline and control room staff detailing actions for 'no trace' calls, and is updating policies OP14 and OP23 to include a step-by-step process. Policy OP14 is expected to be finalised by the end of 2021, and OP23 in early 2022. NHS England details existing guidance, clinical safety officer forums, and hazard logs for digital triage. They also highlight that practices should not rely on online access for all clinical triage.
Robert Walaszkowski
Historic (No Identified Response)
2021-0325 27 Sep 2021 East London
Patient Transport UK Ltd
Concerns summary (AI summary) A patient in extremely poor physical and mental health was unsafely transported on the floor of a secure vehicle without restraints, a practice accepted by the transport company, likely contributing to respiratory arrest.
Antony Schofield
All Responded
2021-0324 27 Sep 2021 Manchester City
Greater Manchester Mental Health NHS Tr…
Concerns summary (AI summary) Inadequate risk assessments, poor communication during patient transfer, and a lack of professional curiosity by community mental health staff led to missed opportunities to address escalating suicidal risk, compounded by poor audit and flawed investigation.
Action Taken (AI summary) Greater Manchester Mental Health NHS Foundation Trust has updated its process for obtaining staff statements following a Serious Incident, and has addressed factual inaccuracies with the RCA investigation author. They ensure all Serious Incidents are reviewed by a team supported by a Patient Safety Practitioner and that the final draft is shared with senior managers.
Clay Wankiewicz
Historic (No Identified Response)
2021-0321 24 Sep 2021 South Yorkshire (East)
Doncaster and Bassetlaw NHS Foundation … Healthcare Safety Investigation Branch Switalskis Solicitors
Concerns summary (AI summary) Staff failed to understand and address confirmation bias, hindering practice changes. Inadequate and slow training on this issue leaves mothers and babies at continued risk.
Hamish Howitt
All Responded
2021-0320 23 Sep 2021 West Sussex
Avon and Somerset Police College for Policing Home Office +1 more
Concerns summary (AI summary) Police officers, lacking medical training, failed to ensure an injured, seemingly inebriated person was taken to hospital, leading to a missed traumatic brain injury. Training needs to mandate hospital referral for such individuals.
Action Planned (AI summary) Avon and Somerset Constabulary circulated a memorandum to all officers with guidance on head injury risk, sent guidance to first aid trainers, and added guidance to first aid training modules. They also incorporated training on head injury response into Taser, Public Safety, and Public Order training, all completed in October 2021. The Home Office has consulted with the College of Policing and NPCC, and the College will address the coroner's concerns about police first aid training through its formal governance routes. The College of Policing and NPCC will raise concerns about alcohol's impact and head injury assessment in first aid training at the next First Aid Forum meeting in December to assess feasibility of addressing them within the FALP licence scope. The College is also reviewing high-level learning outcomes within the FALP to emphasize life-saving elements, considering acute alcohol intoxication, intentional overdoses, and extending head injury learning to Module 2.
Anthony Preston
Historic (No Identified Response)
2021-0319 23 Sep 2021 Essex
Essex Police National Police Chiefs’ Council
Concerns summary (AI summary) The police Missing Person Policy requires review to ensure it is fit for purpose and adequately addresses risks.
Charlie Todd
All Responded
2021-0318 21 Sep 2021 County Durham and Darlington
HMP Durham
Concerns summary (AI summary) A lack of supervisory oversight, inadequate staffing, and a manual, untracked system for hourly checks in the SACU led to incomplete observations and a failure to ensure prisoner safety.
Action Taken (AI summary) HMP Durham has provided additional officer and administrative resources to the Separation and Care Unit (SACU). A "Know Your Job" sheet will be provided to staff working on the unit, and a SACU pilot will consider operational processes and health support.
Uyapo Theodore Hayunga-Macha
All Responded
2021-0314 20 Sep 2021 Liverpool and Wirral
Cheshire Wirral Partnership North West Ambulance Service Wirral University Teaching Hospital
Concerns summary (AI summary) A mentally unwell patient left the emergency department unattended while awaiting triage, raising concerns about inadequate supervision and leaving vulnerable individuals unwatched during assessment.
Action Planned (AI summary) Following an investigation into a patient death, the trust has developed and delivered an action plan addressing failures in mental health pathway commencement, risk assessment, triage delays, recognition of high-risk patients, and implementation of missing person policy; additionally, a Mental Health Transformation Group has been established. The Trust is participating in the Wirral University Teaching Hospital's Mental Health Transformation Group, addressing mental health strategy, escalation processes, training on the Mental Capacity Act, paediatric mental health, and contract monitoring.
Frankie Macritchie
Partially Responded
2021-0315 17 Sep 2021 Cornwall and Isles of Scilly
Devon and Cornwall Police Constabulary Dog Legislation Office
Concerns summary (AI summary) Dog attacks require thorough investigation and, where appropriate, euthanasia of the dangerous animal to mitigate risks of future serious incidents.
Noted (AI summary) Devon and Cornwall Police are assured that they are dealing with reports appropriately where a dog poses a risk of serious harm, and will explore with the Police and Crime Commissioner the opportunities for enhanced public communication, potentially with our farming community and Local Authority partners in respect of dangerous dogs.
Heike Mojay-Sinclare
All Responded
2021-0313 17 Sep 2021 Derby and Derbyshire
Department for Transport
Concerns summary (AI summary) Lack of mandatory standards and inspection for river ford depth gauges, combined with poor inter-agency information sharing on previous incidents, creates significant safety risks, especially with increasing severe rainfall.
Noted (AI summary) The Department for Transport clarified that local authorities are responsible for hazard signage and highway maintenance, and that existing guidance is available but not mandatory.
Colin Blackburn
Partially Responded
2021-0311 17 Sep 2021 Worcestershire
HMP Hewell Practice Plus Group
Concerns summary (AI summary) Prison staff demonstrated numerous failings in managing the ACCT process, including missed reviews, incomplete care plans, and insufficient observations, exacerbated by high demands and inadequate training, leading to significant risks of suicide/self-harm.
Action Taken (AI summary) Practice Plus Group, in conjunction with MPFT, has taken several actions including ensuring all staff at HMP Hewell are aware of processes to ensure prisoners receive urgent mental health care at weekends, an Out of Office message has been added to the mental health team’s generic email inbox at weekends and an answer phone has been purchased for the mental health team.
Tripta Bhanote
Historic (No Identified Response)
2021-0347 16 Sep 2021 Black Country
Manor Court Healthcare on behalf of Ans…
Concerns summary (AI summary) Care staff demonstrated a lack of clarity regarding escalation procedures for acutely unwell patients, the role of enhanced care teams, and accurate identification of Do Not Attempt Resuscitation (DNAR) status.
Maya Zab
All Responded
2021-0316 16 Sep 2021 West Yorkshire Western
Department of Health and Social Care NHS England
Concerns summary (AI summary) The report notes an increased incidence of severe nutritional anaemia in children in the Yorkshire & Humber region in 2020, potentially linked to factors arising indirectly from the pandemic such as reduced consultations, limited social contact, and widening socio-economic inequalities.
Noted (AI summary) NHS England is integrating care with a focus on addressing inequalities and supporting vulnerable children and families, and will work to raise the profile and uptake of the Healthy Start programme which is in the process of transferring from paper vouchers to digital cards. The Department of Health and Social Care acknowledges the concerns, states that national data does not show a significant increase in diagnoses of iron deficiency anaemia, and outlines existing schemes such as the Healthy Child Programme and Healthy Start scheme aimed at promoting healthy diets. They do not plan to introduce new policies specifically targeting nutritional anaemia.
Eldine Lashley
Historic (No Identified Response)
2021-0308 16 Sep 2021 East London
Cherry Orchard Nursing Home
Concerns summary (AI summary) The patient's mobility care plan was not updated to reflect increased observation needs, and staff progress notes inaccurately recorded the frequency of checks performed.
Chloe English
All Responded
2021-0317 15 Sep 2021 West Yorkshire Western
Calderdale Council
Concerns summary (AI summary) Existing suicide prevention measures at a known high-risk location proved ineffective, as the deceased was able to jump within minutes of arrival, indicating current safeguards are insufficient.
Action Taken (AI summary) Calderdale Council installed anti-climb mesh, steeple coping, and Samaritan signs on North Bridge in 2019 and improved CCTV coverage. Following a death at the bridge, temporary fencing was installed, a suicide prevention group was convened, and a design for further safety measures costing £1.5M has been agreed with Historic England.
Diana Reay
Historic (No Identified Response)
2021-0309 15 Sep 2021 Stoke-on-Trent &  North Staffordshire Coroner’s Court
Royal Stoke University Hospital
Concerns summary (AI summary) Multiple doctors misread scans, mistaking a fluid-filled cyst for a full bladder, which resulted in unnecessary and repeated catheterisations of the patient.