2021
PFD Reports
Reports: 419
Areas: 62
83% response rate (above 63% average).
Zainab Hashim and Tafaoul Abdulkarim
All Responded
2021-0205
16 Jun 2021
Stoke-on-Trent & North Staffordshire
Stoke-on-Trent City Council
Concerns summary (AI summary)
Residents in council-owned blocks of flats were unaware of the "Stay Put" fire policy, and communication methods have not changed despite this proven lack of awareness, risking future deaths.
Action Planned
(AI summary)
The Council already provides fire safety information in multiple languages and displays notices; they plan to increase targeted digital communication and explore displaying notices about requesting translated information and are piloting the provision of portable induction loops to assist tenants with hearing impairments.
Brian Mottram
All Responded
2021-0201
11 Jun 2021
Greater Manchester South
Tameside Clinical Commissioning Group
Concerns summary (AI summary)
GPs' predominant use of telephone appointments potentially missed COVID-19 symptoms, and there were no clear tools to identify high-risk cases or trigger in-person assessments for vulnerable patients.
Action Taken
(AI summary)
Tameside and Glossop CCG developed a COVID Oximetry @home service to monitor patients, providing safety netting information for low-risk patients and home oxygen monitoring for others, with escalation to hospital if needed. This service includes monitoring for 14 days and adapting to evolving pandemic circumstances.
Clive Rivers
All Responded
2021-0199
10 Jun 2021
Manchester South
Department of Health and Social Care
NHS England
Concerns summary (AI summary)
Hospital policy prevented inpatient COVID-19 vaccination, and discharge delays led to infection. The discharge assessment failed to consider the patient's rapid COVID-19 decline vulnerability, resulting in an unsafe return to isolated accommodation.
Noted
(AI summary)
NHS England explains that vaccinations were initially prioritized for staff, discusses discharge policies aligned with national guidance, and highlights the use of Criteria to Reside for discharge decisions, with efforts to expedite discharges where possible. The Department of Health and Social Care extends condolences and explains the JCVI's role in vaccine prioritisation, highlighting the initial focus on reducing mortality and protecting healthcare staff. It also mentions support for hospital discharge pathways and ongoing reviews of COVID-19 deaths.
Emiel Malinski
All Responded
2021-0198
10 Jun 2021
Manchester South
Home Office
Concerns summary (AI summary)
Miniature rifle ranges operate with minimal regulation, lacking essential safety measures such as secure weapon tethering, competent supervision, ammunition control, and first aid provisions.
Action Planned
(AI summary)
The Home Office is reviewing the firearms licensing exemption for miniature rifle ranges, prompted by the incident. They conducted a public consultation on tightening controls and will consider the responses before deciding on further measures.
Denton Duhaney
All Responded
2021-0200
9 Jun 2021
West Yorkshire Western Division
Mid Yorkshire Hospitals NHS Trust and S…
Concerns summary (AI summary)
Hospital failed to assess or treat a patient with psychiatric issues, did not follow discharge protocols for self-discharge, and neglected to inform external mental health teams, leading to a dangerous gap in care.
Action Taken
(AI summary)
Fieldhead Hospital updated their Standard Operational Policy to ensure consistency across Psychiatric Liaison Teams and disseminated guidance to community services for maintaining contact with service users awaiting discharge and the Psychiatric Liaison Team, providing a safety net for transition of care.
Nicholas O’Brien
All Responded
2021-0197
9 Jun 2021
Hampshire, Portsmouth and Southhampton
British Kite Surfing Association
Concerns summary (AI summary)
A kite-surfing radio device adhered to a helmet failed to detach when entangled, preventing depowering and leading to a fatal dragging incident. The device's attachment method was insecure, posing risks for similar helmet-mounted accessories.
Action Taken
(AI summary)
The British Kitesports Association issued recommendations to schools using BB-Talkin headsets or similar devices, including following manufacturer's instructions, checking equipment, making students aware of potential entanglement, and including guidelines in their Safety Management Systems.
Susan Roberts
All Responded
2021-0195
7 Jun 2021
West Yorkshire Western Division
Bradford Royal Infirmary
Concerns summary (AI summary)
There was a lack of timely and effective handover between surgical specialties, compounded by an absence of formal protocols and a lack of engagement from plastic surgeons during and after an incident.
Action Taken
(AI summary)
Bradford Teaching Hospitals issued a protocol for Necrotising Fasciitis cases specifying contact procedures and involved specialties. The Trust also revised its Serious Incident Reporting policy to ensure attendance of all crucial staff at Round Table discussions.
Angela Best
All Responded
2021-0194
4 Jun 2021
Inner North London
Ministry of Justice
Concerns summary (AI summary)
A high-risk individual's critical discharge condition, requiring disclosure of intimate relationships, relied solely on his self-reporting despite known untruthfulness, with no independent verification mechanism.
Action Taken
(AI summary)
The MoJ is drafting discharge guidance for the Mental Health Casework Section (MHCS), identifying patients discharged prior to 2003 for MAPPA consideration, and revising court orders for new patients to highlight MAPPA responsibilities. They are also reviewing warrants issued in prison transfers to incorporate similar changes.
Pathushan Sutharsan
All Responded
2021-0193
4 Jun 2021
West Sussex
West Sussex County Council
Concerns summary (AI summary)
A road junction on the Downs Link remains hazardous for cyclists, pedestrians, and equestrians, lacking safe crossing infrastructure, such as a Pegasus crossing or bridge, and suffering from poor sight lines.
Action Taken
(AI summary)
West Sussex County Council formed a chicane, installed warning signs, and cleared vegetation at the collision site. They have also adjusted speed terminal sign heights for equestrians and plan to add red surfacing and additional hedge cutting this summer.
David Ormesher
All Responded
2021-0192
4 Jun 2021
City of Brighton and Hove
National Police Chiefs’ Council
Sussex Police
Concerns summary (AI summary)
Police protocols regarding the constant use of in-car radios and timely siren deployment were not followed, raising concerns about emergency response safety.
Noted
(AI summary)
The National Police Chiefs' Council acknowledges receipt of the letter and notes its contents. Sussex Police reviewed policies and procedures on radio use and found policy 594/2021 sufficiently robust. They have a Driver Behaviour Working Group reviewing trends and a point system for interventions. A training package is in development to remind staff of radio responsibilities.
Geoffrey Hutton
All Responded
2021-0191
4 Jun 2021
Worcestershire
HMP Long Lartin
Concerns summary (AI summary)
HMP Long Lartin lacked effective systems for social care referrals and allocating ACCT Case Managers, resulting in insufficient oversight of vulnerable prisoners and inadequate staff training.
Action Taken
(AI summary)
HMP Long Lartin reviewed its adult safeguarding policy, is working on a memorandum of understanding with Worcestershire County Council, and is developing a directory of interventions for staff. They are implementing a new database for allocating ACCT Case Coordinators and making SASH training mandatory for OSGs.
Geoffrey Hill
All Responded
2021-0262
2 Jun 2021
Black Country
National Institute for Health and Care …
Concerns summary (AI summary)
An elderly, confused patient in A&E spent over 7 hours without a falls risk assessment or trolley rail assessment, highlighting a lack of national guidelines for falls prevention in emergency departments.
Action Planned
(AI summary)
NICE will consider the issues raised in the report when they update their guideline on falls in older people (CG161).
Steven Allen
All Responded
2021-0190
2 Jun 2021
Greater Manchester South
Stockport Clinical Commissioning Group
Concerns summary (AI summary)
Strong pain medication was prescribed to a patient with a history of drug addiction and self-harm, often through remote consultations, with insufficient challenge or oversight regarding their chaotic lifestyle.
Action Planned
(AI summary)
Stockport CCG's Medicines Management Team is in discussion with Primary Care Network Leads to explore how the Stockport Integrated Pharmacy Service can support practices in medication reviews for vulnerable patients. Stockport GPs will be reminded of available resources for opioid prescribing support.
Mark Culverhouse
All Responded
2021-0189
2 Jun 2021
Milton Keynes
Ministry of Justice
Concerns summary (AI summary)
A prisoner was unlawfully detained due to a system failure where release dates were calculated after recall decisions, leading to unnecessary imprisonment, particularly over bank holidays.
Disputed
(AI summary)
HMPPS does not consider it possible to comply with the recommendation to calculate release dates prior to a recall decision due to complexities, staffing constraints and potential risks. They will however issue further communication to staff about using alerts on NOMIS to flag prisoners with unspent remand time.
Kesia Waller
All Responded
2021-0187
1 Jun 2021
Hampshire, Portsmouth and Southampton
A2Dominion of The Point
Concerns summary (AI summary)
Residential housing staff for vulnerable young people lacked adequate training and tools to respond to self-harm emergencies. Key policies were ineffectively communicated, failing to ensure staff understanding and practical application.
Action Taken
(AI summary)
The organisation has revamped first aid training to include suicide, self-harm and overdose, is providing ligature cutting kits in every office by the end of July 2021 and has implemented an interim solution to confirm staff have read and understood policy changes.
Samantha Gould
All Responded
2021-0186
28 May 2021
Cambridgeshire and Peterborough
Company Chemists’ Association
General Pharmaceutical Council
NHS England
+1 more
Concerns summary (AI summary)
There is a national gap in guidance for sharing mental health patient care plans and risk information with pharmacies, enabling vulnerable 16-17 year olds to access overdose medication.
Noted
(AI summary)
NHS E/I acknowledge a systemic weakness existed and is working with NHS Digital to allow information about local prescription plans to be added to Summary Care Records. They highlight existing NICE and GMC guidance on sharing information and safe medicine use. The RPS welcomes guidance/standards to ensure the NHS and other providers of care inform community pharmacies of patient safety plans. They highlight their existing guidance and campaigns on patient health records and safe transfers of care. The GPhC outlines its role in setting standards for pharmacies and pharmacists, noting that NHS England is better placed to provide information on national medication safety plans. They will share learnings from the case with stakeholders and encourage pharmacies to work more effectively with healthcare teams. The CCA will discuss the case at the next Community Pharmacy Patient Safety Group meeting to identify learnings and share best practice. They will also work with other organizations (GPhC, RPS, and NHS England) to consider how practice can be improved.
Christine Gould
All Responded
2021-0185
28 May 2021
Cambridgeshire and Peterborough
British Transport Police
Network Rail
Concerns summary (AI summary)
Investigations into railway suicides by BTP and Network Rail risk missing vital mitigating measures by too readily assuming a single point of access, rather than keeping an open mind about alternative routes.
Action Taken
(AI summary)
Network Rail is upgrading the fencing between Cherry Hinton and Teversham level crossings to 1.8m palisade fencing and has completed a significant portion of the upgrade. They are also reviewing their post-incident fence check process. The British Transport Police has created a single Fatality Investigation Team, trained frontline staff, and implemented procedures for Post Incident Site Visit (PISV) reports. They are working with Network Rail to establish regular meetings to discuss PISV reports and improvement considerations.
Angela Frost
All Responded
2021-0183
28 May 2021
Manchester North
Pennine Care NHS Foundation Trust
Concerns summary (AI summary)
The Trust lacks formal guidance for seeking second psychiatric opinions and consultants demonstrate poor understanding of confidentiality when communicating with family members regarding patient care and risk planning.
Action Planned
(AI summary)
The Trust has drafted a process for requesting second opinions from consultant psychiatrists, healthcare professionals, patients, families, and carers which will be submitted to the Trust's Quality Group for scrutiny and sign-off and implemented across Pennine Care NHS Foundation Trust's services. They are also working to improve adherence to the Triangle of Care standards, including surveys, workshops, and relaunching the program trust-wide.
Peggy Copeman
All Responded
2021-0182
28 May 2021
Norfolk
Premier Rescue Ambulance Services
Concerns summary (AI summary)
Patient transport staff failed to recognise a patient's respiratory distress, delayed calling emergency services, and performed ineffective CPR due to patient positioning. Only one staff member was CPR trained, violating policy.
Action Taken
(AI summary)
Premier Rescue Ambulance Service Ltd. has trained all staff, including drivers, in CPR, with one member of staff now authorized to train others internally. The company has also implemented a policy to no longer transport patients who are not awake and responsive at the start of the journey and requires a qualified medical practitioner confirming a patient's fitness to travel.
Kevin Fitton
All Responded
2021-0169
28 May 2021
City of Brighton and Hove
Brighton and Hove Clinical Commissionin…
Brighton and Hove Council
Brighton and Hove Health and Adult Soci…
+1 more
Concerns summary (AI summary)
There was an over-reliance on assumed capacity, failure to assess for Acquired Brain Injury (ABI) and its impact on substance use, alongside poor inter-team communication and lack of coordination, all compounded by inadequate staff training.
Action Planned
(AI summary)
Sussex NHS Commissioners have shared the report with commissioners to consider how long term service delivery can be improved for people with acquired brain injuries. Brighton & Hove City Council has designed and implemented a non-engagement policy, will develop a training course on mental capacity assessments and will continue to provide training courses on Acquired Brain Injury and self-neglect.
Zeyna Partington
All Responded
2021-0181
27 May 2021
Manchester North
Greater Manchester Police
National Police Chiefs Council
Concerns summary (AI summary)
GMP officers lack understanding of ACT markers and policies cause delays in missing person investigations. A national ANPR system for vehicle tracking is not fully implemented, leading to missed alerts.
Action Planned
(AI summary)
Greater Manchester Police acknowledges concerns about the use of PNC markers and ANPR data. They are reviewing the use of high priority markers for vulnerable missing persons and are working to connect to the new National ANPR Service.
James Devenny
All Responded
2021-0179
25 May 2021
Mid Kent and Medway
HMP Elmley and Director General – Priso…
Concerns summary (AI summary)
Prisoners lack direct access to Samaritans, relying on staff, which is especially difficult for those with violence risks. Prison officers are not routinely briefed on prisoners' significant self-harm history.
Action Taken
(AI summary)
HMP Elmley has equipped nearly all cells with in-cell phones and ensures access to Samaritans. ACCT version 6 has been rolled out across the male estate and training modules and awareness materials have been made available to all staff. The prison also operates a Key Worker scheme and uses an updated safety diagnostic tool.
Ryan Taylor
All Responded
2021-0176
25 May 2021
Cornwall and the Isles of Scilly
Cornwall Council and CORMAC
Concerns summary (AI summary)
Converging surface water on the A390, exacerbated by heavy rainfall, creates a significant aquaplaning risk. Feasible drainage improvements have not yet been implemented despite a previous incident.
Action Planned
(AI summary)
Cornwall Council will erect signs warning of surface water, replace gully grids with larger capacity gratings in October, and undertake detailed drainage and topographical surveys. Further upgrades to the drainage system may be designed and implemented after the survey information is obtained.
Anastasia Uglow
All Responded
2021-0216
24 May 2021
Avon
Department for Education
Concerns summary (AI summary)
There is a critical need to raise sepsis awareness across all schools, as healthy teenagers can rapidly deteriorate, leading to tragic consequences if the condition is left untreated.
Action Planned
(AI summary)
The Department for Education noted the recommendations and is making progress by working with the Outdoor Education Advisers' Panel (OEAP) and the UK Sepsis Trust to update national guidance in relation to sepsis awareness, and intends to update its Health and safety responsibilities and duties for schools to reference the work of the OEAP.
Roger Ballard
All Responded
2021-0168
24 May 2021
Manchester South
Tameside & Glossop Integrated Care NHS …
Concerns summary (AI summary)
Unclear scan reporting and inadequate documentation of clinical decisions, including those overriding specialist advice, prevented clinicians from appreciating critical findings and understanding the rationale.
Action Planned
(AI summary)
The trust plans to implement an electronic flagging system to identify when clinicians are not reviewing imaging reports in a timely manner, share the case at Clinician forums and has mandated personal learning and reflection for those involved in the care.