2022
PFD Reports
Reports: 385
Areas: 67
78% response rate (above 63% average).
Nora Foulkes
Partially Responded
2022-0112
14 Apr 2022
North Wales (East and Central)
Betsi Cadwaladr University Health Board
Ysbyty Gwynedd
Concerns summary (AI summary)
Advance Nurse Practitioners failed to routinely review elderly care home patients' medication regimes during multiple visits, missing critical errors due to time constraints, posing a significant risk to patient safety.
Action Taken
(AI summary)
Following a safeguarding referral and internal review, the Health Board has implemented improved record keeping and medication reviews. Additionally, the Health Board will review the Medicines Policy (MM01) by 30 September 2022, deliver medication administration training to residential and nursing homes, develop an audit of the existing training program, and explore collaborative medication reviews with the Central Community Pharmacy team.
Hannah Beardshaw
All Responded
2022-0111
13 Apr 2022
Manchester West
Greater Manchester Police
Independent Office for Police Conduct
Concerns summary (AI summary)
Police response was critically delayed by nearly four hours due to escalation failures, compounded by a lack of readily available entry equipment and poor document management practices.
Noted
(AI summary)
GMP has revisited its Graded Response Policy (GRP), implementing a new GRP on 1 February 2022 using the THRIVE framework for risk assessment. They are also implementing a new IT system called 'Sherlock' by August 2022 to improve information storage and access in the FCC. The IOPC acknowledges the report and highlights its power to make organisational learning recommendations to relevant bodies. They state that GMP has a legal obligation to respond to the recommendations in writing by 20 July 2022.
Tracy Wood
All Responded
2022-0110
11 Apr 2022
Norfolk
Hellesdon Hospital
Concerns summary (AI summary)
Insufficient staffing, failure of a duty doctor to assess a patient, unapproved medication administration without proper tracking, and significant inaccuracies in clinical records led to compromised care.
Action Taken
(AI summary)
The Trust outlines actions taken following the death of Tracy Wood including: review of staffing levels, changes to observation policy, review of access to patient information, review of the SBAR tool, and updates to the PSII report process. They also mention routine uploading of the SBAR tool onto the electronic record.
Saima Usman
Historic (No Identified Response)
2022-0108
8 Apr 2022
Inner West London
London Borough of Wandsworth
Concerns summary (AI summary)
Privately rented accommodation in Wandsworth is at increased fire and CO risk due to the lack of mandatory smoke/CO detectors, as the borough has no registered landlord scheme or enforcement powers.
Manhareen Kaur
Historic (No Identified Response)
2022-0107
8 Apr 2022
Inner West London
London North West University Healthcare…
Concerns summary (AI summary)
There is no system for monitoring high-risk babies on postnatal wards, leading to insufficient observations and delayed detection of collapse in infants requiring assisted delivery or resuscitation.
Laura Smallwood
All Responded
2022-0109
7 Apr 2022
Cornwall and the Isles of Scilly
Minister for Crime and Policing
Concerns summary (AI summary)
The absence of a single 'Event Organiser' for public events hinders safety planning and risk management, as authorities lack legal powers to mandate an organiser or refuse unsafe events.
Noted
(AI summary)
The Home Office acknowledges the concerns raised, explains the existing legislative framework, and states that it prefers to encourage sensible planning rather than mandating every element of it through legislation, pointing to guidance from the Cabinet Office.
Nicholas Rose
All Responded
2022-0106
7 Apr 2022
Dorset
HMP Guys Marsh Prison
Concerns summary (AI summary)
Accepting a "grunt" as a verbal response during prison welfare checks is insufficient for assessing a prisoner's true welfare, potentially missing signs of distress or incapacitation.
Action Taken
(AI summary)
HMP Guys Marsh has republished notices to staff and prisoners regarding the requirement for verbal responses during welfare checks, with compliance checks by wing Custodial Managers, and has introduced toolbox talks for Prison Officers, including training on welfare checks.
Oliver Lindsay
All Responded
2022-0103
6 Apr 2022
Manchester South
Department of Health and Social Care
Concerns summary (AI summary)
Delays in urgent fetal growth scans due to capacity issues, coupled with a lack of widespread understanding of fetal growth restriction risks, compromise timely intervention and parental awareness.
Action Taken
(AI summary)
NHSEI published a Core Competency Framework to address variation in maternity and neonatal training and competency assessment, including training on the Saving Babies Lives Care Bundle Version 2, which includes monitoring fetal growth restriction.
Sandra Barnett
All Responded
2024-0019
5 Apr 2022
Lincolnshire
Holme Farm
Concerns summary (AI summary)
The staircase at a holiday rental may not have met safety regulation standards for width, depth, and handrails at the time of a fatal fall, indicating a potential ongoing risk.
Action Taken
(AI summary)
Following the incident, the property owners added a second handrail to the staircase, fitted permanent stairgates, and added further information to the AirBnb web pages and Visitors Information pack giving advance notice that this is an old property with steps and stairs.
Ryan Merna
Historic (No Identified Response)
2022-0102
5 Apr 2022
Dorset
Dorset Healthcare University NHS Founda…
Concerns summary (AI summary)
The forensic team failed to adequately probe and document disclosures regarding a perpetrator's living situation and weapon possession, hindering risk assessment and police notification.
Beatrice Dawkins
All Responded
2022-0099
5 Apr 2022
Hampshire, Portsmouth and Southampton
Portsmouth Hospitals NHS Trust
Concerns summary (AI summary)
Critical patient allergy information was not accessible or flagged to clinicians, despite being recorded in medical notes, resulting in the inappropriate prescription of a contraindicated medication.
Action Taken
(AI summary)
The Trust is implementing electronic prescribing, reviewing processes for highlighting allergies, developing handheld severe allergy cards for patients, and participating in a national Information Standard for medicine and allergy/intolerance data transfer.
Faizan Nazar
All Responded
2022-0101
4 Apr 2022
West Yorkshire Western
Spire Harpenden Hospital
Concerns summary (AI summary)
The coroner highlighted a general concern about the appropriateness of reviewing an unspecified practice, suggesting a need for internal re-evaluation.
Noted
(AI summary)
The consultant psychiatrist will now email his secretary of planned follow-ups for patients and advise her to remind the patient two weeks before the scheduled time to make an appointment. If they do not respond, the GP will be informed that they are no longer attending the clinic. No actions or stance were discernible from the provided text.
Emma Pring
All Responded
2022-0105
3 Apr 2022
Mid Kent and Medway
Interweave
Concerns summary (AI summary)
"Anti-ligature" safety clothing failed, allowing self-harm and potentially providing staff with false reassurance. Older, riskier versions of the product remain in circulation, requiring urgent action.
Action Taken
(AI summary)
Interweave Textiles Ltd. notified customers who had been supplied with similar products, recommending they check their stock for damage and reminding them to check garments before use and dispose of damaged ones, as well as reviewing and updating care instructions.
Mandy Dickerson
All Responded
2022-0100
3 Apr 2022
Bedfordshire and Luton
Atrumed Ltd and Bedfordshire Hospitals …
Concerns summary (AI summary)
System glitches prevented mandatory sepsis template use, hindering timely diagnosis. There was confusion over inter-departmental patient referrals, and critical patient observations were not recorded or conveyed to specialists.
Action Taken
(AI summary)
Following the death, the trust has implemented "Mandy's Rule", where clinicians at the Urgent GP Clinic (UGPC) must record in the medical notes and send the patient to the Emergency Department if they feel that the patient needs to be seen without delay despite the specialty team not agreeing. Atrumed Healthcare has changed its policy so practitioners can refer patients back to the hospital without needing agreement from a specialty doctor, requires practitioners to record the names and times of any specialty clinicians they speak to, and conducts monthly audits to ensure compliance.
Corrie McKeague
All Responded
2022-0097
1 Apr 2022
Suffolk
British Standards Institute, Container …
Concerns summary (AI summary)
In effective bin locks and the absence of an automated weight flagging system failed to detect an individual in a bin, further compounded by poor driver visibility and inadequate search tools.
Noted
(AI summary)
CHEM notes the concerns raised regarding public entry into containers and will welcome suggestions for additional warnings for operators. Biffa is reviewing operating instructions to ensure clarity on the use of viewing windows, reminding customers about using locks effectively, and continuing to develop relationships with charities supporting rough sleepers. Dennis Eagle explains the design intent of the side window on their refuse vehicles, stating it's for viewing the discharge of container contents and not for viewing the floor of the tailgate. BSI consulted experts and will raise the issue of bin locks when the committee next meets to discuss if changes to existing standards are appropriate.
Yvonne Eaves
Historic (No Identified Response)
2022-0096
1 Apr 2022
Manchester City
GMMH NHS Trust
Concerns summary (AI summary)
Deficient safeguarding reviews and clinical oversight, combined with a lack of staff awareness, training, and audit of the VTE policy, created significant patient risks.
Fadzai Chitakunye
All Responded
2022-0261
31 Mar 2022
Leicester City and South Leicestershire
Department of Health and Social Care
Concerns summary (AI summary)
Significant delays in transferring patient notes between GPs risk important medical history being missed, especially for patients unable to effectively communicate their past health information.
Noted
(AI summary)
The Department of Health and Social Care outlines existing NHS services and policies related to electronic health record transfer and access.
REDACTED
Historic (No Identified Response)
2022-0095
28 Mar 2022
Warwickshire
Coventry and Warwickshire Partnership N…
Concerns summary (AI summary)
Concerns include the failure to appoint a Care Co-ordinator and significant, ongoing staffing shortages within mental health services in the North Warwickshire area.
Natalie Turner
All Responded
2022-0094
25 Mar 2022
Blackpool & Fylde
British Association for Counselling and…
Department of Health and Social Care
Concerns summary (AI summary)
GPs lack specific guidance for managing complex eating disorders, especially when patients are unwilling to engage, leading to uncertainty in treatment. There is also a concern regarding counselling guidance when patients are unwilling to engage.
Action Planned
(AI summary)
BACP conducted a thorough review of member resources relating to confidentiality, competence, and eating disorders, detailed in an attached spreadsheet. The Department of Health and Social Care is working with NHS England and other bodies to improve eating disorder services, expand mental health services, and implement funding for transformed adult community mental health services by 2023/24.
Robert Murray
All Responded
2022-0093
23 Mar 2022
East Sussex
Association of Ambulance Chief Executiv…
Concerns summary (AI summary)
There is a lack of understanding among care home staff and emergency call operators about circumstances where a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order should not be applied.
Noted
(AI summary)
The Nursing and Midwifery Council outlines existing standards and processes related to DNACPR understanding and fitness to practise, without describing new actions taken or planned. Avalon Nursing Home updated DNACPR and RESPECT forms in care plans, discussed clinical judgements with a local surgery and paramedics, provided refresher training in basic life support and first aid, and amended its policy on calling an ambulance and DNACPR.
Emily Caldicott
Historic (No Identified Response)
2022-0092
23 Mar 2022
Worcestershire
Herefordshire and Worcestershire Health…
Concerns summary (AI summary)
Staff failed to adequately assess a patient's capacity to refuse medication, misapplying the Mental Capacity Act 2005. This led to a delay in administering necessary treatment for extreme anxiety.
Zoltan Torok
All Responded
2022-0088
21 Mar 2022
Berkshire
Highways England
Concerns summary (AI summary)
Smart motorways with no hard shoulder create risks for broken-down vehicles, compounded by occupant proximity to running lanes and confusion from mixing smart and traditional motorways.
Action Taken
(AI summary)
National Highways states that the section of motorway was under temporary traffic management and not operating as a smart motorway at the time of the incident, so they do not believe any additional actions are needed, but they have completed the roll-out of stopped vehicle detection on over 200 miles of ALR motorway, installed extra signs, and upgraded enforcement cameras. They also committed to deliver a £390 million programme to install additional emergency areas across operational sections.
Donald Compton
Historic (No Identified Response)
2022-0090
20 Mar 2022
South Wales Central
Cwm Taf University Morgannwg Health Boa…
Concerns summary (AI summary)
Multiple prescribing and dispensing errors occurred due to an electronic prescribing tool that allowed bypassing allergy checks and a lack of specific knowledge about constituent drugs among prescribers and pharmacists.
Emiliano Sala
All Responded
2022-0089
18 Mar 2022
Dorset
British Chambers of Commerce
British Horseracing Authority
Confederation of British Industry
+17 more
Concerns summary (AI summary)
The market for illegal commercial flights, especially in sports, operates without required safety standards, risking future deaths. The Civil Aviation Authority has limited powers to investigate and prosecute these breaches.
Noted
(AI summary)
The RFU cascaded the findings in the Regulation 28 Report to all clubs involved in the Premiership. The RFU also raised this subject at the June meeting of the Professional Game Board. The ECB intends to circulate communications to appropriate representatives, including a list of steps from the CAA, within one month and emphasize the need to share the information directly with players. All corporate travel for ECB employees and representatives must be booked through the ECB's travel management company Ventur. The EFL reissued guidance to all Clubs, which was received in March 2021. The EFL will reissue a link to the guidance in advance of each transfer window. The British Horseracing Authority briefed its Board and prepared a draft guidance note to send to its member bodies and engaged with the Civil Aviation Authority (CAA). The Department for Transport and the CAA are reviewing the powers available to them in investigating breaches of aviation regulations and what powers they would find of assistance in their investigative and enforcement role. The FA states they were not aware of the coroner's report until it was provided by the English Football League. The FA relayed CAA guidance on illegal flights to clubs and Registered Intermediaries in March 2021. The Jockey Club requires aircraft operating at its racecourses to obtain prior permission, demonstrate pilot licensing, provide aircraft registration and insurance, and confirm whether flights are private or commercial. The Jockey Club and Helicopter & Aviation Services Ltd provide records of aircraft activities to authorities when requested. The organisation circulated a note to its members recommending that they do not pay for or use unlicensed commercial flights, sharing the concerns of the Dorset Coroner. The Professional Footballers Association has written to its current members and put information on its website to raise awareness on the issue of unlicensed aircraft, and attached the guidance issued by the CAA. UK Athletics has distributed information regarding private flights to World Class Programme athletes, coaches, support staff, and known agents, emphasizing the need to check the legality of flights. The LTA sent a communication to relevant players on 9 August 2022 regarding commercial flights from unlicensed operators, including a link to CAA guidance. The Institute of Directors included a statement in its 'Influence' email to 20,000 members and posted a notice on its website warning of the dangers of unauthorised flights, following a request from the Civil Aviation Authority. The Premier League will send correspondence to the Legal, Club Secretarial, and Football departments at each of the Clubs. The Premier League met with Clubs at the Annual General Meeting on 9 June 2022 and raised the issue to the Chairs/Chief Executives/Owners attending. The Confederation of British Industry plans to publish an article on employee wellbeing and safety linking to the Sala case, use social media to amplify the importance of employee well-being and safety, and flag the case to its account managers who manage the CBI's aerospace members. The Rugby Football League wrote to all member clubs advising them of the situation regarding private flights and asking them to ensure they do not use such flights. The Department for Digital, Culture, Media and Sport shared CAA guidance with sports organisations, Live music Industry Venues & Entertainment (LIVE), the Music Venues Trust (MVT), and the Musicians' Union. The EFL circulated a CAA notice to club secretaries raising awareness of the risks of illegal public transport using unlicensed aircraft. The Executive Association of Great Britain stated that the report and concerns are not applicable to their particular circumstances as they do not arrange travel for members, and members do not travel by air to attend meetings. UK Sport asserts that the use of illegal private plane journeys is not permitted with their funding and that the risk of government funded sports using them is minimal. Motorsport UK will publish advice to its license holders on its website and in its monthly ezine regarding air-worthiness of chartered aircraft and pilot qualifications. The RFU requested Premiership clubs review the PFD report on commercial flight chartering and ensure flights are legal and have required authorisations, certifications and permissions, and pass the information to relevant employees. The British Chambers of Commerce circulated briefing materials to its Chamber of Commerce members, raised the issue in a call with Chamber of Commerce CEOs, and highlighted the importance of taking action at the BCC Board.
Gary Ottway
Historic (No Identified Response)
2022-0087
18 Mar 2022
Inner North London
East London NHS Foundation Trust
Concerns summary (AI summary)
Inadequate nursing observation, delayed emergency response due to perceived safety risks, and unfamiliarity with resuscitation equipment by the sole junior doctor contributed to a critical delay.