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
Stanislaw Zielinski
All Responded
2021-0277 20 Aug 2021 Greater Manchester South
Department of Health and Social Care NHS England Secretary of State of Health +1 more
Concerns summary (AI summary) COVID-19 restrictions significantly impacted care delivery, leading to insufficient face-to-face GP consultations and delayed mental health support, preventing early recognition of deteriorating health.
Noted (AI summary) Tameside and Glossop CCG acknowledges the concerns, explains the challenges faced during the pandemic, and states it will work with providers to optimise access times to mental health services. The response expresses condolences and acknowledges the concerns regarding the impact of COVID-19 restrictions on healthcare delivery. It notes that general practice has been delivering services according to national Standard Operating Procedures, and provides a list of support services. The Minister acknowledges the concerns raised and highlights existing NHS England guidance for general practices, including offering face-to-face appointments and managing mental health patients. It also mentions a consultation on new waiting time standards for community-based mental health services.
Sheldon Marshall
All Responded
2021-0276 20 Aug 2021 Surrey
Mayday Group
Concerns summary (AI summary) Insufficient senior clinical oversight at Mayday Assistance Limited and a lack of clear responsibility for patient medical management during air ambulance repatriations pose risks of future deaths.
Action Taken (AI summary) Mayday Assistance now employs two doctors, has implemented an internal escalation process for seriously ill patients, holds weekly virtual ward rounds to review patient management and has an Air Ambulance Support Agreement in place with providers to clarify responsibilities.
Steven Kirkham
All Responded
2021-0280 18 Aug 2021 South Yorkshire (East)
Instastop Ltd
Concerns summary (AI summary) A "blind spot" in door alarm systems for vulnerable people creates a potential danger, and other users may be unaware of this significant safety flaw.
Action Planned (AI summary) Intastop identified a 'blind spot' on the door mechanism, confirmed timing delay was between 5-6 seconds, recommends checking thoroughly all alarms and re-setting the sensors and to inspect their testing protocol prior to dispatch.
Roland Stannard
All Responded
2021-0274 17 Aug 2021 Suffolk
Department of Health and Social Care
Concerns summary (AI summary) Care home staff lacked adequate training in operating specialist pressure sore equipment, resulting in its incorrect use. This highlights a broader concern regarding the appropriate assessment for nursing care needs.
Noted (AI summary) The Minister acknowledges the concerns and outlines the responsibilities of CQC registered providers regarding staff training and care delivery. It also mentions NHS England support for care homes and the upcoming statutory inquiry into the Government’s response to the Covid-19 pandemic.
Steven Regoli
Historic (No Identified Response)
2021-0273 17 Aug 2021 Essex
Essex Partnership University NHS Founda… NHS England
Concerns summary (AI summary) Inadequate systems existed for providing in-depth mental health support to patients with anxiety and non-engagement issues, leaving families as the sole caregivers and preventing necessary intervention.
Kumbulani Mtombeni
All Responded
2021-0272 16 Aug 2021 West London
Grassy Meadow Care Centre
Concerns summary (AI summary) Methadone prescribed to a care home resident was found in a staff member's possession, raising serious concerns about medication management, security, and auditing protocols.
Action Taken (AI summary) Care Outlook has implemented a digital care planning and monitoring system, will ensure all medication auditors and managers understand their obligation and have introduced a training program.
Stuart Tokam
Partially Responded
2021-0271 13 Aug 2021 East London
Department of Health and Social Care St Pancras Hospital
Concerns summary (AI summary) There was an unacceptable delay in clinical assessment, and no system existed to triage referral acuity, preventing expedited assessment for urgent cases.
Action Taken (AI summary) The Trust is undertaking quality improvement work, increased clinical involvement in referral screening, introduced consolidated waiting lists and has a 'Duty clinician system' to respond to escalation of risk.
Hadley Savory
Historic (No Identified Response)
2022-0402 11 Aug 2021 North East Kent
East Kent Hospital University NHS Found… Kent and Medway NHS and Social Care Par… Forward Trust
Concerns summary (AI summary) There was no multi-agency planning or established procedures for the safe discharge of patients with complex concurrent mental health, substance misuse, social care, and physical health needs.
Adam Forrester
All Responded
2021-0268 11 Aug 2021 Stoke-on-Trent and North Staffordshire Coroner’s Court
WISH and Health and Safety Executive
Concerns summary (AI summary) A single-crewed bin lorry operated in hazardous conditions, and safety guidance for waste collection did not adequately address checking bins for persons, creating a risk for vulnerable individuals.
Action Planned (AI summary) HSE and WISH have reviewed the guidance and drafted some modified text to WISH INFO 3, including adding "Crew check all large, four wheeled bins" to the checklist.
Alice Pettersson
Historic (No Identified Response)
2021-0267 10 Aug 2021 Inner West London
Department of Health and Social Care
Concerns summary (AI summary) The lack of a designated referral pathway and national guidelines for achondroplasia means general paediatric teams are often unaware of associated sudden infant death risks, such as foramen magnum stenosis.
Terence Tuttle
Partially Responded
2021-0265 9 Aug 2021 Norfolk
Hellesdon Hospital Queen Elizabeth Hospital
Concerns summary (AI summary) Failures included inadequate dietician and mental health assessments, inaction on weight loss, poor mental capacity assessment, and insufficient care for mentally unwell patients refusing food, excluding family expertise.
Noted (AI summary) NSFT expresses condolences and explains their limited involvement in Terrence Tuttle's care, stating they can only respond to one part of the coroner's concerns related to mental health liaison. They provide details of the mental health liaison team's involvement, assessments, and medication adjustments during his admission, highlighting communication and planned reviews.
Steve Cooke
All Responded
2021-0266 8 Aug 2021 Mid Kent and Medway
South East Coast Ambulance Service
Concerns summary (AI summary) Critical communication failures by emergency operations control, including dispatching an ambulance to the wrong address and inadequate follow-up with contacts, led to a severely unwell patient not being located.
Action Planned (AI summary) South East Coast Ambulance Service is updating its processes for 999 and 111 calls to ensure call handlers ask for the address instead of suggesting it, and improving the process for when crews cannot locate a patient by escalating to a team leader who will verify the address and search for additional information; these changes will be implemented via operational bulletins expected to be in force within 1-2 weeks.
Adam Brunskill
All Responded
2021-0384 3 Aug 2021 Black Country
Wayne Clarey Roofing & Cladding Ltd and…
Concerns summary (AI summary) An unqualified and inexperienced employee worked on a roof without proper training, a CSCS card, or designated supervision, indicating a lack of structured training programs and adequate supervisory arrangements.
Action Taken (AI summary) HSE reports that Proclad Developments Ltd has appropriate systems in place and are extending them to their subcontractors, including Wayne Clarey Roofing & Cladding Ltd where appropriate; Proclad's revised Contract For Services document states that their subcontractors must appropriately supervise their workers and their training matrix system will be available to subcontractors including appraisals and training needs analysis. Wayne Clarey Roofing Cladding Ltd states they now have a clear designated structured training programme for new and unqualified employees using the Pro-Clad training structure, and supervisors appraise workers daily and recommend them for further qualification which is tested by outside agencies.
Cpl Ryan Lovatt
All Responded
2021-0373 3 Aug 2021 Oxfordshire
Ministry of Defence
Concerns summary (AI summary) The alcohol policy for Op Cabrit is unrealistic and poorly understood, potentially promoting binge drinking, while the critical "shark watch" role for sober supervision lacks formalization and clear communication.
Action Taken (AI summary) The Ministry of Defence has amended its Sharkwatch policy to include written orders for the nominated sober individual, requiring them to keep the group together, ensure safe return, and report deviations, with signed orders retained by the commander; also Part 1 Orders are issued daily containing repeats of all aspects of the Force Protection policy, including alcohol restrictions and actions for duty personnel.
Pauline Allison
All Responded
2021-0269 3 Aug 2021 West Sussex
British Medical Association and Sussex …
Concerns summary (AI summary) Insufficient awareness among patients, families, and carers about the increased fire risk from flammable emollient creams, especially when combined with air mattresses, poses a significant safety concern.
Noted (AI summary) NHS Brighton & Hove CCG, NHS East Sussex CCG, and NHS West Sussex CCG have reviewed preventable deaths messaging related to flammable products and are raising awareness of the risks from emollient creams, including publishing warnings and providing information to GPs, care homes, and patients about the fire risks associated with these products, based on previous alerts from the MHRA. The BMA acknowledges the concern about patient awareness of risks associated with emollient creams, but states they are not the appropriate organisation to address it. They suggest contacting the MHRA, NHS England, the Royal College of General Practitioners, and medical defence bodies instead.
Emma Day
Partially Responded
2021-0263 3 Aug 2021 London Inner South
Department for Work and Pensions HM Courts and Tribunals Service Home Office +2 more
Concerns summary (AI summary) The Gaia Centre did not record the details of protective orders, Lambeth Children’s Social Care lacked knowledge of the orders, and the Metropolitan Police Service's Merlin Report did not mention the Non-Molestation Order, highlighting a potential system failure regarding protective orders and information sharing; the Child Maintenance Service of Department of Work and Pensions also exhibited a system failure in handling reports of domestic violence.
Action Taken (AI summary) The Metropolitan Police Service now records non-molestation orders on both the Police National Computer (PNC) and Criminal Intelligence System (CRIMINT), ensuring they are identified during background checks in safeguarding incidents; also, a review of the Multi-Agency Safeguarding Hubs (MASH) was commenced in June 2021, to improve risk identification.
Mary Lincoln
All Responded
2021-0275 2 Aug 2021 West Yorkshire (East)
Pinderfields General Hospital
Concerns summary (AI summary) The hospital lacked a policy for overnight checks on vulnerable fall-risk patients, causing delayed discovery of injury. Furthermore, the bedrails policy was not adequately circulated or understood by all relevant staff.
Action Taken (AI summary) Mid Yorkshire Hospitals NHS Trust has shared learning from the serious incident review and from other Trusts regarding bed rail management; they have also updated the falls policy and incorporated learning into an addendum published in July 2021 and individualised counselling/training will be undertaken with staff members in relation to the assessment and use of bed rails.
Amanda Dunn
All Responded
2021-0261 30 Jul 2021 Staffordshire South
Staffordshire Police
Concerns summary (AI summary) Police repeatedly failed to act on reports of neighbour harassment, suggesting incidents are not taken seriously enough and leading to missed opportunities to intervene and potentially prevent future deaths.
Noted (AI summary) Staffordshire Police has commenced a criminal investigation into potential offences committed against Mrs. Dunn and is reviewing repeat cases of anti-social behaviour involving vulnerable people. They have also written to the Staffordshire and Stoke on Trent Adult Safeguarding Partnership Board to understand if further information was known by partner agencies. Staffordshire Police provides an update that the case has been referred to the Independent Office for Police Conduct (IOPC) for an independent investigation.
James Nowshadi
All Responded
2021-0260 29 Jul 2021 Cambridgeshire and Peterborough
Department of Health and Social Care Public Health England Royal College of Psychiatrists
Concerns summary (AI summary) Mental health practitioners lack national guidance on specific suicide method risks and their antidotes, while Serious Incident Reviews fail to adequately learn lessons, risking future fatalities.
Action Planned (AI summary) NHS England and NHS Improvement will send a communication to mental health trusts to bring their attention to the risks associated with sodium nitrate as a means of suicide and the need to seek advice from the National Poisons Information Service (NPIS). The Department of Health and Social Care is working with other government departments, health bodies, and experts to tackle the use of sodium nitrate and similar chemicals in suicides. The Royal College of Psychiatrists will look for opportunities to reinforce key risk advice around sodium nitrate and other substances to psychiatrists and will ask those responsible for treatment in Emergency Departments to consider adding mention of sodium nitrate to toxicology sites used by clinicians.
Jacob Owczarek
Partially Responded
2021-0259 28 Jul 2021 Nottinghamshire
Care Quality Commission Doncaster and Bassetlaw Teaching Hospit…
Concerns summary (AI summary) Concerns include low compliance with paediatric sepsis screening, lack of consultant review prior to discharge, and absent alert systems for test results, along with poor recording of radiology discussions.
Action Planned (AI summary) The Trust is updating its Sepsis Action Plan and has created a detailed action plan in response to the coroner's report, which will be monitored by the Children & Families and Medical Division with the oversight of the Quality and Effectiveness Committee.
Carl Walters
All Responded
2021-0256 28 Jul 2021 Exeter and Greater Devon
HMP Exeter
Concerns summary (AI summary) The failure to preserve key evidence hindered the inquest, raising concerns that dangerous conditions could go undiscovered and preventative measures overlooked.
Action Taken (AI summary) HMP Exeter created a local operating policy for deaths in custody, including a list of essential documents to retain (cell bell records, CCTV, body-worn video). A new CCTV system has been installed, and all deaths in custody are subject to a quick-time learning review by the Head of Safety and Regional Groups Safety Lead.
Albert Rowlands
All Responded
2021-0253 26 Jul 2021 North Wales (East & Central)
Gwern Alyn House Residential Home
Concerns summary (AI summary) Falls prevention measures were inconsistently implemented, and staffing pressures led to errors in care. The resident's room placement also increased the risk of falls during toilet access.
Action Planned (AI summary) Pendine Park will introduce a programme of testing door pressures where mobile residents encounter doors and will continue to work with GPs and other health professionals to support any resident that has a history of falls using the North Wales Prevention and Management of Falls in Care Homes Pathway. They also aim to continue to be suitably staffed.
John Dickinson
All Responded
2021-0310 22 Jul 2021 West Yorkshire Eastern
Care Quality Commission Sunnyside Nursing Home
Concerns summary (AI summary) Inconsistent and insufficient record-keeping, coupled with assumptions about food refusal, prevented a holistic view of the patient and delayed the recognition of deterioration.
Action Planned (AI summary) Sunnyside Nursing Home attached an action plan to the response and has shared the action plan with the Care Quality Commission. The CQC contacted Bluebell Care Services Limited to request written confirmation and evidence of the action they have taken to date following this death and any additional action they intend to take in response to the prevention of future death report; they are assured with the actions taken by the registered provider to address the specific concerns found during the inquest.
Oscar Seaman
All Responded
2021-0252 21 Jul 2021 Norfolk
Norfolk County Council
Concerns summary (AI summary) High collision rates persist on a road where speeding is ignored, compounded by an unsafe junction lacking stop signs and adequate visibility, necessitating speed cameras and mirrors.
Action Planned (AI summary) Norfolk County Council reduced the speed limit to 50mph in response to this incident and will undertake speed surveys to measure driver compliance, and will undertake a further review to reassess the visibility approaching the A134 from the northeast arm of the junction.
Sarah Lewis
All Responded
2021-0251 20 Jul 2021 County of Dorset
Department for Transport
Concerns summary (AI summary) The absence of mandatory rear cameras on Large Goods Vehicles creates critical blind spots, contributing to collisions with pedestrians during reversing manoeuvres.
Action Planned (AI summary) The DfT is developing a new approval system for vehicles after leaving the EU and plans a call for evidence later this year to gather views on technologies like reversing detection systems, which will inform future legislation on mandatory fitting of these technologies.