2022
PFD Reports
Reports: 385
Areas: 67
78% response rate (above 63% average).
Stephanie Moyce
Historic (No Identified Response)
2022-0059
25 Feb 2022
Essex
Essex Partnership University NHS Founda…
Concerns summary (AI summary)
Conspicuous lack of clarity regarding responsibility for discharge planning, post-discharge oversight, and safety-netting for psychotherapy patients without a Care Coordinator was identified.
Amanda Gibbens
Historic (No Identified Response)
2022-0061
23 Feb 2022
Buckinghamshire
Oxford Health NHS Foundation Trust
Concerns summary (AI summary)
Ineffective "within eyesight" observations due to continued reliance on monitor screens and inadequate bedroom search processes failed to remove self-harm items, despite prior warnings.
Adrian Balog
All Responded
2022-0056
23 Feb 2022
Manchester City
Department for Education
Concerns summary (AI summary)
National safeguarding guidance for children omits "obesity" as a sign of neglect, contrasting with malnourishment, which risks failing to identify and protect obese children at risk.
Noted
(AI summary)
The Secretary of State acknowledges concerns about including 'obesity' as an indicator of abuse and neglect in safeguarding guidance, highlighting existing guidance on safeguarding children's welfare and health. They note existing initiatives to improve access to services for children living with overweight or obesity and refer to the Independent Review of Children’s Social Care, stating that the concerns will be considered in the context of the review's recommendations.
Christopher Osland
All Responded
2022-0060
22 Feb 2022
North East Kent
East Kent Hospitals University NHS Foun…
Concerns summary (AI summary)
The report identifies that nursing staff were unaware that the room monitor volume could be reduced to inaudible levels, circumstances were undocumented, and no steps were taken to respond to a persistent 'OFF COMS' notification.
Action Taken
(AI summary)
The hospital describes changes to alarm volume settings on room monitors, restricting ICU staff from adjusting them and assigning control to the EME department. They also describe updates to the process for reporting issues with the central monitoring system and implementing twice-daily audit checks.
Van Tuyen
All Responded
2022-0058
22 Feb 2022
Inner North London
Barts Health NHS Trust
Department of Health and Social Care
NHS England
Concerns summary (AI summary)
Misplaced nasogastric tubes continue to cause avoidable deaths, despite being a 'never event', with no unified national approach to prevent recurrences across NHS Trusts.
Action Taken
(AI summary)
The Department of Health and Social Care highlights existing guidance and resources related to nasogastric tube misplacement, including a patient safety alert and eLearning materials. They also mention the HSIB investigation and the awarding of funding for research on patient safety, including the reduction of never events.
Dorothy Spiby
All Responded
2022-0055
22 Feb 2022
Birmingham and Solihull
Prime Life Limited
Concerns summary (AI summary)
A resident's fall incident was poorly documented, not investigated, lacked a formal incident report, and showed no evidence of learning to prevent future occurrences.
Action Taken
(AI summary)
Prime Life Ltd has taken several actions, including Defensible Documentation Training for Registered Nurses (completed by 15.4.22), conducting competency checks, and initiating monthly reviews and safeguarding audits with action plans. They will also disseminate a new lessons learned document to each Prime Life location monthly, commencing 1 May 2022.
Jane Shilton
All Responded
2022-0053
22 Feb 2022
Leicester City and South Leicestershire
Hamilton Community Homes Ltd
Concerns summary (AI summary)
The quality of online first aid training and the minimum 3-year training interval are insufficient for staff caring for vulnerable residents with complex mental health and substance misuse needs.
Action Taken
(AI summary)
Hamilton Community Homes has implemented several measures, including having one awake staff member on night shifts, updating alcohol and room search policies, implementing signature sheets for care plan and medication understanding, updating training policy for mental health, mandating annual first aid training, and issuing two-way radios to staff.
Sean Ennis
All Responded
2022-0054
21 Feb 2022
Northern District of Greater London
London Borough of Brent, Network Homes …
Concerns summary (AI summary)
Inadequate fire risk assessments and an unregulated telecare sector fail to ensure vulnerable residents receive essential safety provisions and monitoring, exacerbated by a lack of person-centred risk assessments and accreditation.
Noted
(AI summary)
Barnet Homes will cooperate with fire risk assessments, engage with telecare reviews, and explore telecare funding. They will pursue a recommendation with the London Borough of Barnet for sheltered housing tenants to have a home fire safety visit and will carry out PCRAs on all its Sheltered Housing tenants with target date for completion of any missing PCRAs in Sheltered Housing is Monday 16th May 2022. Network Homes asserts that its fire safety management and systems exceed legal requirements and reflect best practice. They state the fire safety systems at Knightleas Court behaved as expected and the fire was contained. CQC acknowledges the concerns but states Knightleas Court is not a registered service. They are working with the National Fire Chief’s Council on promoting Person-Centred Fire Risk Assessments.
Sasha-Raven Marie Brown
Historic (No Identified Response)
2022-0057
18 Feb 2022
North Yorkshire and York including North Yorkshire Western District
North Yorkshire County Council
Concerns summary (AI summary)
The report identifies that a stretch of the A6068 frequently fails to clear surface water, that this water flow is not adequately regulated by drains, and that there are no signs indicating the risk of flooding.
Irene Fitches
Historic (No Identified Response)
2022-0051
18 Feb 2022
Norfolk
Norfolk and Norwich University Hospital
Concerns summary (AI summary)
The existing falls policy is non-compliant with NICE guidelines, lacks a designated lead, and critical staff training and assisted technology for patient falls prevention are significantly delayed.
Chloe Lumb
Historic (No Identified Response)
2022-0050
17 Feb 2022
Teesside and Hartlepool
Department of Health and Social Care
Concerns summary (AI summary)
The Emergency Department lacked a clinical pathway for suspected aortic dissection and a system to flag patients with genetic predispositions, leading to missed critical diagnostic steps.
Daniel France
Historic (No Identified Response)
2022-0047
16 Feb 2022
Cambridgeshire and Peterborough
Cambridgeshire and Peterborough NHS Fou…
Concerns summary (AI summary)
A vulnerable young person known to the County Council and Mental Health Trust did not receive timely support, facing a long wait for psychological therapy, potentially dangerous given the risk of impulsive acts; there were also considerable delays in obtaining appointments for the Gender Identity Clinic and a shortage of psychological therapies.
Theo Brennan-Hulme
All Responded
2022-0049
15 Feb 2022
Norfolk
Hellesdon Hospital
Concerns summary (AI summary)
A persistent culture of bullying and lack of compassion within the Crisis Resolution Home Treatment Team led to a dangerous belief that some suicides are "inevitable," compounded by unchecked patient discharge decisions.
Action Taken
(AI summary)
Hellesdon Hospital has updated its discharge policy to include a documented discussion and MDT review prior to discharge, particularly for young people. They are also working with service users to improve communication and engaging in suicide prevention initiatives.
Jason Lennon
Historic (No Identified Response)
2022-0048
15 Feb 2022
East London
Department of Health and Social Care, E…
The National Quality Board
Concerns summary (AI summary)
Failures in mental health care involved not using an appropriate care pathway, a flawed clinical review with poor record-keeping and communication, an incomplete incident action plan, and no regulatory referral for staff failings.
David Clark
Historic (No Identified Response)
2022-0046
15 Feb 2022
Hertfordshire
East & North Hertfordshire NHS Trust
Concerns summary (AI summary)
Care in ICU was not escalated appropriately despite adequate staffing, with inaccurate NEWS score calculation and generally poor clinical documentation compromising patient safety.
Norman Barnes
Historic (No Identified Response)
2022-0045
14 Feb 2022
Mid Kent & Medway
Ashley Gardens Care Centre
Care Quality Commission
Concerns summary (AI summary)
Care home staff were unaware of crucial dietary requirements and other key information in resident care plans and risk assessments, leading to inadequate and potentially unsafe care delivery.
Matthew McManus
All Responded
2022-0044
11 Feb 2022
Greater Manchester South
Department of Health and Social Care
Greater Manchester Health and Social Ca…
Concerns summary (AI summary)
An adult with complex mental health and social care needs lacked coordinated care and a single point of contact, resulting in inadequate assessment, information sharing, and risk management.
Action Planned
(AI summary)
Greater Manchester Health & Social Care Partnership acknowledges the potential gap in support for patients with complex needs and describes initiatives to improve data sharing, training, and oversight. They plan to present learning to the Greater Manchester Quality Board and cascade learning through governance and learning forums. The Department of Health and Social Care is implementing the Community Mental Health Framework (CMHF) to improve joined-up support across health and social care, aiming for all areas to have these models in place by the end of 2023/24. It also highlights increased collaboration through the Health and Care Act 2022 and the government's integration white paper.
Daphne Holloway and Ivy Spriggs
Historic (No Identified Response)
2022-0043
10 Feb 2022
Hertfordshire
Ministry of Housing, Communities & Loca…
Concerns summary (AI summary)
Sprinkler systems are not mandatory for care homes with residents of limited mobility, and these buildings aren't classified as 'Higher Risk Buildings' based on occupant vulnerability, leaving them at elevated fire risk.
Sheila Steggles
All Responded
2022-0042
10 Feb 2022
Norfolk
Hellesdon Hospital
Concerns summary (AI summary)
Patient care failures included neglected VTE risk assessments for reduced mobility, poor clinical documentation, inadequate care planning, and junior staff failing to consult on critical medication interactions.
Action Taken
(AI summary)
Hellesdon Hospital is updating the Trust induction for junior doctors to include physical health training, supported by senior consultants and underpinned by the SBAR framework. They will offer "3 Ps" training to all staff, rolling out "bite-size" training on VTE, and set up a working group for flexible working colleagues to support an education passport for health workers.
John Skinner
Historic (No Identified Response)
2022-0041
10 Feb 2022
Hertfordshire
NHS England
Concerns summary (AI summary)
A significant medication overdose resulted from a junior doctor mishearing a verbal dosage instruction, highlighting a foreseeable communication risk when numbers are expressed orally in clinical settings.
Michelle Jennings
Partially Responded
2023-0220
9 Feb 2022
Manchester South
Department of Health and Social Care
Ministry of Justice
Concerns summary (AI summary)
Critically long national waiting lists for mental health therapy, inconsistent application of referral/discharge policies, and a lack of proper consideration for mental health vulnerabilities during prosecutions, with no clear mechanism for sharing lessons.
Action Planned
(AI summary)
The Department of Health and Social Care is increasing investment in mental health services by £2.3 billion by 2023/24. They are also working to improve joined-up working across the NHS, expanding community mental health services, and growing the mental health workforce through training and recruitment.
Benjamin Stroud
Historic (No Identified Response)
2022-0039
8 Feb 2022
Essex
Essex Partnership University Trust and …
Concerns summary (AI summary)
A patient's case was not referred to the Multi-Disciplinary Team, denying essential psychiatric input, as the Care Coordinator made un-documented clinical decisions regarding referrals, posing a significant risk.
John Moore
All Responded
2026-0210
8 Feb 2022
Essex
Department of Health and Social Care
Essex Partnership NHS Trust
Health Education England
+1 more
Concerns summary (AI summary)
EPUT Care Coordinators receive inadequate formal training for their role, leading to failures in record keeping, care plan updates, communication with other providers, and recognising the clinical significance of patient disengagement.
Noted
(AI summary)
• The EPUT response has been shared with NHS England and Improvement, and NHS England is assured that the actions will address concerns about the training of current Care Coordinators.
• The NHS Long Term Plan sets out investment in community mental health services for adults with severe mental illness.
• From April, all areas are receiving additional funding to develop integrated primary and community mental health services. • Since April 2021, all areas are receiving additional funding to develop fully integrated primary and community mental health services.
• This investment includes improved access to psychological therapies, improved physical health care, employment support, personalised and trauma informed care, medicines management and support for self-harm and coexisting substance use.
• By 2023/24, this investment will amount to almost £1billion extra per year for adults and older adults with severe mental illness.
Joy Burgess
All Responded
2022-0038
4 Feb 2022
Greater Manchester South
Department of Health and Social Care
Concerns summary (AI summary)
Mental health patients face 'chaotic' ward environments unsuitable for recovery due to resource limitations, alongside lengthy waiting times (around one year) for psychological therapies.
Action Planned
(AI summary)
The Department of Health and Social Care references NHS England's consultation on new waiting time standards for mental health services and states they are working on the next steps following the consultation.
Sarah Gilbert-Jones
All Responded
2022-0037
4 Feb 2022
South Wales Central
Welsh Ambulance NHS Trust
Concerns summary (AI summary)
Emergency call handling failed to appropriately categorise a time-critical overdose due to protocol shortcomings and clinical misjudgment, leading to significant delays and inconsistent response vehicle deployment.
Action Planned
(AI summary)
The Welsh Ambulance Services NHS Trust is considering a specific question set within the Medical Priority Dispatch System (MPDS) to identify propranolol overdoses, and has an existing Standard Operating Procedure for flagging overdose cases to dispatchers. The trust is also proposing further actions outlined in an attached plan.