2022
PFD Reports
Reports: 385
Areas: 67
78% response rate (above 63% average).
Mark Jones
All Responded
2022-0040
3 Feb 2022
Manchester South
Department of Health and Social Care
Concerns summary (AI summary)
Significant backlogs are delaying patient appointments, and the absence of a national protocol for dentists to include photographs with referrals hinders triage accuracy, risking urgent cases being missed.
Action Planned
(AI summary)
The Chief Dental Officer will reinforce the importance of good referral practice in future communications on oral cancer to the dental profession and commissioners, and will cascade similar communication and guidance to NHS general medical practitioners.
Stephen Cloudsdale
Partially Responded
2022-0035
3 Feb 2022
Cumbria
Cumbria County Council
National Highways
Concerns summary (AI summary)
Highway safety concerns on the A66 include inadequate lighting and warning signage for crossing vehicles, high traffic speeds, and an insufficient central reservation width.
Action Planned
(AI summary)
National Highways is upgrading traffic signs and road markings, including interactive electronic vehicle-activated signs, in the area of Stainmore Cafe Services. They do not plan to install lighting or widen the central reservation.
Harry Simmons
All Responded
2022-0028
3 Feb 2022
Plymouth, Torbay and South Devon
Plymouth City Council
Concerns summary (AI summary)
A dangerous road junction is prone to collisions due to drivers cutting corners, sun glare impairing visibility, and a lack of effective signage or road design to mitigate risks.
Action Planned
(AI summary)
Plymouth City Council has designed a scheme including a humped zebra crossing, narrowing of a junction, and parking restrictions. They are bidding for funding to construct the scheme later in the current financial year or early in 2022/23, subject to consultation.
Carol Cole
All Responded
2022-0033
2 Feb 2022
Dorset
Dorset Council
Dorset Police
Concerns summary (AI summary)
A flawed process for sharing Public Protection Notices (PPNs) with GPs in the Dorset Council area meant crucial mental health concerns were not received, leading to missed patient assessments.
Action Planned
(AI summary)
Dorset Council will fund a co-located member of staff in the MASH to share PPNs with GPs. A further review with Health partners commenced on 12 April 2022 to review the current process. Dorset Council amended its internal process on 25/02/22 so that the Adult Access Team forward PPNs to relevant agencies or professionals regardless of whether the person is known or not known to Adult Social Care. Dorset Council will provide additional staffing resources to MASH to assist with the sharing of PPNs to GPs pending a wider system review.
Jake Cahill
All Responded
2022-0032
1 Feb 2022
Cornwall & the Isles of Scilly
Youth Justice Board for England and Wal…
Concerns summary (AI summary)
Vulnerable young people complete self-assessment forms without professional discussion about sensitive issues, a gap compounded by inadequate guidance from the Youth Justice Board.
Action Taken
(AI summary)
The Youth Justice Board has updated national guidance to support practitioners in using self-assessment tools appropriately when engaging with children. The updated guidance covers topics such as bail, custody, family and health.
Eirlys Roberts
All Responded
2022-0034
31 Jan 2022
North West Wales
Minister for Health and Social Services…
Concerns summary (AI summary)
A critical shortage of residential and nursing placements in Gwynedd prevents elderly patients from accessing appropriate care as their needs evolve, posing a risk to their well-being.
Noted
(AI summary)
The Welsh Government describes plans for an Expert Group to support a National Care Service for Wales and states that the Minister for Health and Social Services will write to Regional Partnership Boards, Health Boards and Directors of Social Services requesting a review of provision for older peoples residential care and robust exploration of sufficiency of provision. Gwynedd Council explains the challenges it faces in providing care placements, particularly due to COVID-19 and staffing capacity, but states that the link between the incident and placement availability is not entirely clear.
Oskar Nash
All Responded
2022-0031
31 Jan 2022
Surrey
Department for Education
Department of Health and Social Care
National Child Safeguarding Review Panel
+3 more
Concerns summary (AI summary)
Child mental health services lack mandatory Autism training for triage staff, risking inadequate understanding and inappropriate closure of referrals. Routine referrals are automatically deemed low risk, despite potential for significant harm.
Action Planned
(AI summary)
The council made Autism awareness training mandatory for all staff working directly with children and young people, to be completed by 31 March 2022. It noted the Coroner's concern regarding post-death reviews, stating that SCC follows national guidance and took appropriate steps by way of a Thematic Review which was accepted by the National Panel. The Department for Education is conducting reviews of special educational needs and disability and of the children’s social care system, which will lead to significant reform of the support available for the most vulnerable of children and young people. The CCG details actions taken including a Surrey CDR team meeting, incorporating thematic review learning into Surrey Children Services academy training, establishing a multi-agency task and finish group and a children and young person subgroup of the Surrey Suicide Prevention Partnership. Oskar's death will be presented at the next suicide themed CDOP meeting and learning shared nationally via NCMD. The Child Safeguarding Practice Review Panel are developing a framework for undertaking rapid reviews, developing a quality assurance framework and publishing anonymised examples of good quality rapid reviews as exemplars of good practice.
Colm McCabe
Partially Responded
2022-0025
31 Jan 2022
Berkshire
Care Quality Commission
Four Seasons Healthcare
Concerns summary (AI summary)
Care home staff failed to follow policies on recruitment, training, and patient reviews. Ineffective auditing missed significant care omissions, and investigations lacked candour.
Action Taken
(AI summary)
Four Seasons Healthcare details actions taken, including revising the policy for observations, undertaking reviews and audits, launching a revised incident reporting system (RADAR), simplifying the Root Cause Analysis function, and developing a bespoke training module for investigations. The group introduced mandatory training on diabetes awareness and management for all nurses.
Jack Taylor
All Responded
2022-0029
28 Jan 2022
West Sussex
Sussex Partnership NHS Foundation Trust
Sussex Police
Concerns summary (AI summary)
Mill View Hospital critically lacks staff and transport to safely return absconding mental health patients, over-relying on police. Ineffective joint policies and poor communication between hospital and police hinder the swift recovery of high-risk individuals.
Action Planned
(AI summary)
Sussex Police is co-developing a Missing Persons Template with SPFT to improve information sharing and is reviewing existing training for Sergeants on missing person investigations, with potential enhancements. The force also plans to review the structure of the Missing Persons Team to enhance support to colleagues. Sussex Partnership NHS Foundation Trust, working with Sussex Police, established a working group to improve the joint response to patients absent without leave, proposing solutions including a Missing Persons Template and updated risk assessment processes. An improved escalation process has been implemented and added to the AWOL Policy and the AWOL reduction project is being rolled out across the Trust.
Barbara Young
All Responded
2022-0027
28 Jan 2022
Gwent
Wales Ambulance Service NHS Trust
Concerns summary (AI summary)
A significant 3-hour delay in ambulance response for a severely injured elderly patient highlights ongoing issues in timely emergency medical care, potentially risking future deaths.
Action Planned
(AI summary)
The Welsh Ambulance Service NHS Trust details actions planned including improving utilisation of resources, supporting patients waiting for a response, reviewing the advice provided via 999 and a review of the response availability and capacity. The Trust has taken a review of the Medical Priority Dispatch System (MPDS) codes for Falls to determine if there were opportunities to improve the timeliness of response.
Mark Athias
All Responded
2022-0024
28 Jan 2022
West Yorkshire (East)
Copperfields Nursing Home
Department of Health and Social Care
Quality and Exemplar Healthcare
Concerns summary (AI summary)
The nursing home lacked essential sterile catheter supplies, leading to a patient's emergency hospital admission and subsequent deterioration.
Action Taken
(AI summary)
Exemplar Health Care updated its catheter policy to emphasize retaining sufficient stocks and changed ordering processes to be electronic. They are introducing a new audit to ensure the appropriate reviews and quality assurance of records are undertaken and implemented processes to ensure the management team review and quality assure records.
Adam Stone
All Responded
2022-0026
27 Jan 2022
Birmingham and Solihull
College of Paramedics, The Association …
Concerns summary (AI summary)
Acute Behavioural Disturbance, a medical emergency with high mortality risk, is inappropriately categorized as a Category 2 ambulance response, potentially causing dangerous delays in urgent medical care.
Noted
(AI summary)
NHS England and NHS Improvement are writing to ambulance services regarding clinical oversight, including a reminder that Acute Behavioural Disturbance (ABD) calls should have oversight of a senior clinician in the control room and calls should be upgraded to Category 1 if the patient’s condition deteriorates or if the patient is being restrained. The Association of Ambulance Chief Executives (AACE) explains its role and states that it cannot mandate response categories. AACE developed and issued national clinical guidance in 2019, updated in 2020, to UK ambulance clinicians, supported education and presented at conferences and webinars for police and ambulance staff, and continues to develop further guidance around managing patients with extreme agitation. The College of Paramedics clarifies it is not responsible for setting standards for paramedic education, training, or practice, but will ensure its pre-registration curricula review includes the latest evidence on Acute Behavioural Disturbance. The College endorses AACE's response and will share the correspondence with NHS England’s Emergency Call Prioritisation Advisory Group and AACE to propose a review of the current response categorisation of Acute Behavioural Disturbance. NHS Digital provides background information on NHS Pathways, a clinical decision support system used by NHS 111 and some ambulance services, and its governance structure. It states that NHS Pathways is concordant with NICE, the UK Resuscitation Council, and the UK Sepsis Trust guidelines.
Finnian Kitson
All Responded
2022-0023
27 Jan 2022
Manchester City
Universities and Colleges Admissions Se…
Concerns summary (AI summary)
Application forms fail to explicitly separate mental health from "disability" or "special needs," deterring disclosure and preventing essential support for students with mental health conditions.
Noted
(AI summary)
UCAS provides context on how students can share information about support needs within their application and how universities then arrange support. They highlight that the information is optional and handled confidentially, and doesn't impact academic judgement.
Maria Howell
Historic (No Identified Response)
2022-0022
27 Jan 2022
Essex
Holmes Care Group Limited
Concerns summary (AI summary)
The care home lacked qualified nursing staff for critical procedures like reinserting a RIG tube and employed staff with inadequate clinical judgment for critically ill residents.
Manon Jones
Historic (No Identified Response)
2022-0174
26 Jan 2022
South Wales Central
Cwm Taf Morgannwg University Health Boa…
Concerns summary (AI summary)
Clinicians lacked access to comprehensive patient records from community care and the unit's internal records were fragmented, impairing assessment, observation setting, and safeguarding measures.
Ketheeswaren Kunarathnam
All Responded
2022-0030
26 Jan 2022
West London
Home Office
Concerns summary (AI summary)
Detained prisoners awaiting deportation lack adequate access to legal information and support. Ineffective communication and incompatible systems between prison, Home Office, and immigration staff lead to lost information and delayed actions.
Action Taken
(AI summary)
The Home Office outlines actions taken to address concerns, including mandatory training for officials engaged in detention, focusing on best practice and vulnerability, and Self Harm Awareness Sessions run by HMPPS for front-line immigration officers in prisons. They also highlight improvements to the Adults at Risk in Immigration Detention policy and the introduction of Detention Case Progress Panels.
Anthony Rode
All Responded
2022-0021
25 Jan 2022
Norfolk
Great Yarmouth Borough Council and Cais…
Concerns summary (AI summary)
A dispute over land responsibility left a coastal area unmaintained, obscuring Coastwatch views and leading a volunteer to undertake dangerous grass strimming, hindering life-saving operations.
Action Planned
(AI summary)
Great Yarmouth Borough Council and Caister-on-Sea Parish Council will discuss the shoreline management plan with parish councils, write to organizations and businesses near the shoreline, launch a social media campaign, and work with Coastal Protection East partners to increase public awareness of coastal management issues.
Idris Habib
All Responded
2022-0020
24 Jan 2022
Mid Kent and Medway
HMP Swaleside
Concerns summary (AI summary)
Medication from a previous occupant was found in the deceased's cell, indicating poor cell management. A significant disconnect also existed between prison policy and officers' actions.
Action Taken
(AI summary)
HMP Swaleside issued a notice in November 2021 reminding staff of cell clearance procedures and reinforced the process during staff briefings. Since the inquest, the prison has introduced a welfare check at approximately 8am requiring staff to gain a verbal response from the occupant, with completion of the check recorded in the wing assurance book, with staff re-issued a notice to remind them to satisfy themselves of the prisoner's wellbeing.
Thomas Moffett
Partially Responded
2022-0018
22 Jan 2022
Lancashire and Blackburn with Darwen
HMP Preston
HMPPS
Concerns summary (AI summary)
Persistent communication failures between prison healthcare staff and emergency control rooms during medical emergencies, a recurring issue across multiple prisons, indicate a potential national systemic problem.
Action Taken
(AI summary)
Spectrum CIC has held a meeting between the healthcare team, the Safer Custody Governor, and the Governing Governor at HMP Preston to develop a new system that ensures that healthcare staff are able to communicate efficiently with the prison control room and ambulance control. HMP Preston staff are to receive training in ambulance categorisation and the Governing Governor sent a Governor's Order clarifying the process in line with PSI 03/2013.
Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor
All Responded
2022-0017
21 Jan 2022
East London
Metropolitan Police Service, National P…
Concerns summary (AI summary)
Police investigations were marred by a significant number of "very serious and very basic investigative failings," including a profound lack of curiosity and errors, with terrible consequences.
Action Planned
(AI summary)
The NPCC and College of Policing outline actions taken, including updating the Death Investigation Manual and associated training to emphasize treating deaths as suspicious until proven otherwise. They have also highlighted existing guidance on handling personal effects and assessing handwritten notes, and initiated a review of the Forensic Submissions Good Practice Guide. DCMS states that the Online Safety Bill will place new requirements on companies in relation to illegal content and anonymity online and services will have to identify, mitigate and effectively manage the risk of anonymous profiles. Ofcom will set out the types of verification methods a company could use in guidance. The Metropolitan Police Service has updated its Death Investigation Policy to emphasize treating deaths as suspicious until proven otherwise and is providing refresher training to detectives. The CONNECT Investigation platform, which is replacing CRIS, will have improved functionality to track the completion of investigative actions.
Neil Parkes
All Responded
2022-0019
20 Jan 2022
Warwickshire
Warwickshire Police
Concerns summary (AI summary)
Police failures to identify an unconscious patient despite hospital requests and a missing person report meant critical medical history was inaccessible, hindering treatment.
Action Taken
(AI summary)
Warwickshire Police reviewed their response to the incident and provided words of advice to control room staff, organizational learning was circulated, and changes were implemented to improve responses in similar situations; this included reviewing the necessity to take fingerprints and ensuring incidents are resulted with actions taken and rational for closing.
Michelle Whitehead
All Responded
2022-0016
19 Jan 2022
Nottinghamshire
Nottinghamshire Healthcare NHS Foundati…
Concerns summary (AI summary)
The report identifies concerns relating to sedation medication (unclear dose/type, possible excess, poor documentation), delayed recognition of patient's declining condition, lack of medical clerking and consultant involvement, delays in contacting the duty doctor and paramedics, and delays in paramedics accessing the ward; the coroner notes these issues have been raised in previous inquests.
Action Planned
(AI summary)
Following a medication error, staff received supervision and completed self-reflection. The Trust is conducting an audit, creating a Quality Improvement Plan, and plans to share learnings with the family and the coroner by the end of May 2022.
Terance Radford
All Responded
2022-0014
18 Jan 2022
Nottingham City and Nottinghamshire
Minister of State for Prisons and Proba…
Concerns summary (AI summary)
The Home Detention Curfew policy allows early release of high-risk prisoners without adequate assessment of their harm to others or multi-agency information sharing for risk management.
Action Planned
(AI summary)
The Ministry of Justice will issue an instruction to prison governors that no prisoner held in a segregation unit should be released on HDC and will prioritise necessary amendments to the Framework so that changes not being made immediately will be in place by the summer. An investigation has been instigated under Prison Disciplinary powers into the circumstances of the release including the decision made at HMP Ranby to withdraw the referral made to the independent adjudicator.
Coco Bradford
All Responded
2022-0012
18 Jan 2022
Cornwall and the Isles of Scilly
National Institute for Health & Care Ex…
Concerns summary (AI summary)
Outdated IV fluid guidelines for children in shock posed a risk of fluid overload, and there was no clear guidance on balancing antibiotic use for sepsis against the risk of HUS in bacterial gastroenteritis.
Action Planned
(AI summary)
NICE acknowledges the guideline on gastroenteritis in under 5s [CG84] does not align with the UK Resuscitation Council’s 2021 guideline on paediatric advanced life support, and has forwarded the report to their guideline surveillance team who will review the UK Resuscitation Council’s 2021 guideline and consider if CG84 and other related NICE guidance need to be updated.
Luke Wilden
All Responded
2022-0015
16 Jan 2022
Bedfordshire and Luton
East London NHS Foundation Trust
NHS England
Concerns summary (AI summary)
Inadequate transition arrangements within mental health services for young adults with high-functioning autism resulted in a lack of continued treatment and appropriate social care. This service gap may exist nationally.
Action Planned
(AI summary)
NHS England is working with ELFT to strengthen knowledge and understanding of transitions issues in each other’s areas and a shared transition protocol or protocols that link together. They are committed to improving the availability of inpatient mental health support and alternatives to admission for Children and Young People. The Trust has reinforced transition protocols, reviewed the serious incident report into Mr Wilden’s death and the Trust’s transition policy and protocols with relevant staff members. An administrator pulls a list of all existing service users on a monthly basis to address the transitions policy.