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
Brooke Martin
All Responded
2021-0299 2 Jul 2021 Milton Keynes
Department of Health and Social Care
Concerns summary (AI summary) Incompatible electronic patient record systems across the NHS lead to significant difficulties in healthcare providers accessing full patient histories. This lack of information sharing compromises risk assessments and specialist care.
Action Planned (AI summary) The Department of Health and Social Care outlines the Shared Care Records programme aiming to ensure health professionals can access patient information across different NHS systems, with most Integrated Care Systems expected to have a basic shared care record in place by September. They also mention the expansion of community mental health services and suicide prevention work funded by the COVID-19 mental health and wellbeing recovery action plan.
Henry Boddy
Partially Responded
2021-0227 2 Jul 2021 Inner London North
Fire and Communities, Ministry of Housi… Home Office
Concerns summary (AI summary) There is a gap in enforcement powers regarding fire risks in residential properties, specifically the risks of a fire load arising from hoarding behaviour.
Noted (AI summary) The Home Office acknowledges concerns about fire risks from hoarding but suggests a multi-agency approach is more appropriate than enforcement under the Fire Safety Order. They highlight the role of Safe and Well visits and safeguarding referrals.
Khairul Rahman
Partially Responded
2021-0226 2 Jul 2021 Inner London North
Head of Healthcare) and HMP Pentonville
Concerns summary (AI summary) The prison healthcare system lacks robust, accurate documentation of clinical interactions and response times. There is also an unclear and inconsistent application of the NEWS2 scoring system for monitoring patient deterioration.
Action Planned (AI summary) Practice Plus Group has begun a service improvement project to encourage the appropriate use of NEWS2 scoring and embedding this into practice, including a ‘Back to Basics’ workshop on ‘Identifying the Deteriorating Patient’ for the healthcare team at HMP Pentonville by 30th November 2021.
Samantha Singh
Historic (No Identified Response)
2021-0225 2 Jul 2021 East London
Hainault Surgery SMA Medical Practice
Concerns summary (AI summary) A patient's RAST test results were wrongly categorised as normal, leading to delayed action. Subsequently, only one EpiPen was prescribed against NICE guidance, and no allergy clinic referral or follow-up was offered.
Joan Prescott
Historic (No Identified Response)
2021-0223 30 Jun 2021 Plymouth Torbay and South Devon
Devon County Council
Concerns summary (AI summary) Safeguarding considerations, particularly regarding a known poor property condition, were not adequately recorded or prioritised during a welfare visit. This represented a missed opportunity to formally address broader safeguarding concerns.
Katie Locke
Historic (No Identified Response)
2021-0222 29 Jun 2021 Hertfordshire
Hertfordshire Constabulary Hertfordshire Partnership University NH… National Probation Service
Concerns summary (AI summary) Knowledge and understanding of the Potentially Dangerous Persons (PDP) process were sporadic among police and partner agencies. This lack of dissemination and training hinders the multi-agency process from effectively protecting the public.
Nicholas Spooner
Partially Responded
2021-0360 28 Jun 2021 Brighton and Hove
Brighton and Hove City Council Change Grow Live (Surrey and Borders NH… Department of Health and Social Care +2 more
Concerns summary (AI summary) There is an urgent need for specialist dual diagnosis services with outreach facilities for individuals experiencing mental health crises intertwined with substance abuse, who are often denied adequate support.
Action Planned (AI summary) BHCC CCG SPFT and CGL acknowledge concerns regarding services for those with co-occurring substance misuse and mental ill-health and outline future plans to review the existing co-existing conditions group, ensure continued information sharing about service provision, and ensure that new commissioned services consider co-existing needs. The Dept. of Health and Social Care details plans for improving mental health services for those with coexisting substance use, including providing support to local authorities via the Public Health Grant, and proposed new standards for community-based mental health crisis services regarding referral times. NHS Social Care provides an update to their October 2021 response, stating that the procurement process for a new crisis house has been completed and the contract awarded to Mental Health Matters, with the service set to start on 01 November 2022. They also mention re-commissioning mental health supported accommodation services, and improving information sharing about services via a network of groups and regular newsletters.
Fiona Humberstone
Historic (No Identified Response)
2021-0221 28 Jun 2021 Essex
Basildon and Brentwood Clinical Commiss… Essex Partnership University NHS Founda…
Concerns summary (AI summary) A consultant psychiatrist was unaware of a patient's powerful painkiller prescription due to relying solely on self-reporting, impacting risk assessments. Incompatible electronic systems prevent routine access to full medication records between primary and secondary care.
Amy Ganner
All Responded
2021-0218 24 Jun 2021 Manchester West
Department of Health and Social Care
Concerns summary (AI summary) Insufficient patient education materials regarding opioid tolerance loss and associated toxicity risks are a concern, particularly after periods of abstinence.
Action Taken (AI summary) The Department of Health details actions taken by the MHRA to update warnings on opioid medicines regarding dependence, addiction, and tolerance, as well as issuing a patient safety leaflet. They also mention a Public Health England review of prescription drug dependence and NHS England's programme to implement the review's recommendations, plus the requirement for Primary Care Networks to prioritize patients on potentially addictive pain medication for structured medication reviews.
Hazel Binks
Historic (No Identified Response)
2021-0220 23 Jun 2021 Derby and Derbyshire
Linden Medical Group – Stapleford Care … NHS Nottingham Nottinghamshire Clinical Commissioning …
Concerns summary (AI summary) GP practice administrative staff failed to relay suicidal ideation to the GP, who then did not perform an adequate mental health risk assessment; internal reviews also failed to identify these critical errors.
Netlyn Robinson
All Responded
2021-0219 23 Jun 2021 West Yorkshire Eastern
Leeds City Council
Concerns summary (AI summary) Upon the deceased's return home, there was no falls pendant or alarm, the telephone line was not connected, there was no risk assessment, and the heating was not working; the social worker had not been shown a checklist for issues to check prior to a vulnerable person returning home and there were no processes in place to outline what social services would or would not do to ensure the premises were suitable.
Action Taken (AI summary) Leeds City Council confirms immediate action has been taken on a number of issues raised and a clear plan is in place to address those for which there is a longer timescale, as outlined in the attached action plan which refers to providing suitable equipment and suitable care packages.
Wayne Boughen
Partially Responded
2021-0217 23 Jun 2021 West Yorkshire Eastern
Government Legal Department HMP Leeds
Concerns summary (AI summary) HMP Leeds lacks certified anti-ligature cells, failing national standards, which allowed an inmate to use a jumper for self-harm in an ordinary cell.
Action Taken (AI summary) HMPPS acknowledges the lack of certified safer cells at HMP Leeds but highlights the improvements made to the ACCT (Assessment, Care in Custody and Teamwork) system. All staff at the prison have received awareness training specific to their roles and responsibilities and to highlight the key changes to the procedures.
Heather Page
All Responded
2021-0213 23 Jun 2021 Nottinghamshire
Broxtowe Borough Council Derbyshire County Council Erewash Borough Council +1 more
Concerns summary (AI summary) Numerous pedestrian crossings require walking on tracks, contributing to a high fatality rate on a specific section, exacerbated by local authority opposition to track rationalisation efforts.
Noted (AI summary) Nottinghamshire County Council asserts its duty to protect public highway rights regarding level crossings, clarifies the roles of Network Rail and the public in crossing closures, and states it has been supportive of safety improvements. Derbyshire County Council provides an explanation of their previous involvement in a 2003 proposal to divert Public Footpath No.7, and clarifies that they will work with other agencies to improve safety across the County. Network Rail acknowledged past unsuccessful attempts to change level crossings in the area and expressed willingness to work with local authorities to find potential solutions. Broxtowe Borough Council has scheduled a meeting with Network Rail to seek potential solutions to concerns raised, and will provide further information after the meeting. Erewash Borough Council stated that they previously supported Network Rail's Level Crossing Closures Programme, and would still not oppose the closure of the Barton Road crossing if Network Rail recommends it, though they prefer an accessible footbridge.
Serena Nicolle
Historic (No Identified Response)
2021-0212 22 Jun 2021 Surrey
Ministry of Justice
Concerns summary (AI summary) The standard prison procedure of assessing breathing through a cell hatch by observing chest movement is unreliable, leading to erroneous assessments and a risk of future deaths.
Elsie Woodfield
Historic (No Identified Response)
2021-0211 21 Jun 2021 Plymouth Torbay and South Devon
University Hospitals Plymouth NHS Trust
Concerns summary (AI summary) Concerns include inconsistent consenting for endoscopy, failure to perform a 'sip test', a doctor not acting on a dangerous complication indicated in a report, and poor record-keeping by senior staff.
Judith Varley
All Responded
2021-0210 21 Jun 2021 West Yorkshire Western Division
Wilsden Medical Practice
Concerns summary (AI summary) Inaccurate computer coding for medical procedures and a lack of auditing or quality control for data input raises concerns about the reliability of patient information.
Action Taken (AI summary) Wilsden Medical Practice updated their coding process, provided staff training, implemented system changes to improve accuracy, and undertook an audit of coding accuracy with plans to repeat it.
Rodney Dixon
All Responded
2021-0209 21 Jun 2021 East Sussex
East Sussex County Council Sussex Partnership NHS Foundation Trust
Concerns summary (AI summary) Sub-optimal training for Mental Health Act assessments and assessors, along with inadequate access to patient data for independent clinicians, poses risks to patient risk management.
Action Planned (AI summary) Sussex Partnership NHS Foundation Trust will discuss changes made by East Sussex County Council with their Deputy Chief Nurse to ensure the Trust's doctors working as independent s.12 doctors are informed of ESCC's changes in practice and to identify any difficulties with information access processes. East Sussex County Council updated their Mental Health Act referral and Risk Assessment Forms to include a section on dynamic risk assessment, arranged yearly risk management training with Brighton University for AMHPs, and updated the AMHP warranting and re-warranting process.
Anne Bradley
Partially Responded
2021-0214 20 Jun 2021 West Sussex
Association of Coloproctology of Great … British Society of Gastroenterology Joint Advisory Group on GI Endoscopy +2 more
Concerns summary (AI summary) Lack of scope guides during colonoscopies reduced tumour localisation accuracy, and the absence of a formal feedback system prevented endoscopists from learning about tattooing issues or incorrect tumour identification.
Disputed (AI summary) The British Society of Gastroenterology does not support a generalised recommendation on the use of MEIs based on this particular case and states the surgeon is ultimately responsible for identifying the correct section of bowel. The Royal College of Physicians, following consultation with JAG, disputes that the lack of a magnetic imaging device was the primary factor in the patient's death, citing multiple contributing factors and questioning the appropriateness of mandating such equipment. NICE states that it has guidelines covering cancer recognition/referral and colorectal cancer management, but not colonoscopy or specific equipment; they consider that no action is required by NICE. St Richard's Hospital reports that scope guides are already in place on the site and confirms that a system to ensure information in relation to tattooing is documented, monitored, and fed back to endoscopists has been instigated.
Andrew Cook
All Responded
2021-0258 18 Jun 2021 Northamptonshire
Medicines and Healthcare products Regul…
Concerns summary (AI summary) Concerns involve potential under-reporting of PEG allergy, insufficient research into its effects, and the lack of clear labelling on medical products regarding PEG's presence, dose, and various synonyms.
Action Planned (AI summary) The MHRA will discuss labelling requirements with other regulators internationally, collect and review information from a range of data sources on PEG exposure, and raise the profile of PEG/macrogol working with relevant stakeholders where appropriate.
Leslie Horsfield
All Responded
2021-0215 18 Jun 2021 Manchester North
Northern Care Alliance NHS Trust
Concerns summary (AI summary) The admissions assessment tool lacks prompts to inquire about previous choking incidents, creating a risk that crucial patient information will be overlooked.
Action Planned (AI summary) The Trust will update the nursing admission proforma as part of the Electronic Patient Record (EPR) Programme roll-out to ask whether the patient has previously experienced any choking episodes, with implementation planned for Spring 2023.
Lesley Mawby
All Responded
2021-0208 18 Jun 2021 Manchester South
Stockport NHS Foundation Trust
Concerns summary (AI summary) Persistent staffing shortages in the dietetic team lead to delayed patient assessments on weekdays and a complete lack of weekend service.
Action Planned (AI summary) The Trust has implemented twice-daily triage by a senior dietitian, prioritising patients, and is updating its enteral feeding policy with specific guidelines for administration. The CCG is satisfied with the Trust's response, and has requested a commissioning led review to ensure service levels can be consistently delivered.
Leonard Pritchard
All Responded
2021-0207 17 Jun 2021 Birmingham and Solihull
NHS England University Hospitals Birmingham NHS Tru…
Concerns summary (AI summary) The emergency department has an inadequate supply of mobility aids for patient assessments, posing a significant risk, and the procurement process for these essential aids is unmanaged and delayed.
Noted (AI summary) NHS England notes that the Trust has responded adequately at a local level and that the matters of concern have been dealt with, and has shared the Regulation 28 Report and both responses with the Regional NHSE/I teams. Immediately following the inquest, the hospital sourced 10 zimmer frames and made them available in the ED; a process for procurement, storage, labeling and auditing of walking frames was fully implemented in early July.
Daniel Rennoldson
All Responded
2021-0206 17 Jun 2021 City of Sunderland
Cumbria, Northumberland, Tyne and Wear …
Concerns summary (AI summary) The Trust lacked contingency for multiple urgent responses, leaving callers at risk, and had a 12-hour delay in following up a high-risk call with no tracking mechanism for unprogressed cases.
Action Taken (AI summary) The Trust had already undertaken a Serious Incident investigation and formed an action plan, and since June 2021 has sent a reminder and flow chart outlining the long standing cross boundary agreement to the team and discussed in individual supervision.
William Rutherford
Partially Responded
2022-0118 16 Jun 2021 North Northumberland and South Northumberland
Alcyone Healthcare Baedling Manor Care Home
Concerns summary (AI summary) Staffing levels at the care home were below minimum requirements for one-to-one care, and record-keeping standards remained inadequate and inaccurate, despite prior concerns.
Action Planned (AI summary) Due to significant failures, the provider is selling the business to an established provider and the home is currently going through transition, with a new management team. Efforts are being made to significantly develop the safe operation of the home during the transition, including reviews, training, audits and revised processes.
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.