2022

PFD Reports
Reports: 385 Areas: 67

78% response rate (above 63% average).

385 results
Alfie Stone
All Responded
2022-0013 14 Jan 2022 Northamptonshire
East Midlands Ambulance Service
Concerns summary (AI summary) Paramedics lacked training in administering buccal midazolam and failed to effectively oxygenate or suction a fitting child, despite clear recommendations from a serious incident report.
Action Planned (AI summary) EMAS will be sharing updated guidance, national PGD and learning from this PFD across the Ambulance Pharmacists Network. Updated guidance and training package is being developed and will be rolled out during 2022/23 which will include the option for clinicians to administer buccal midazolam to adults (18 years and over) who present with convulsive status epilepticus when it is not available within the home as a prescribed medication.
Brian Wareham
All Responded
2022-0010 14 Jan 2022 Gwent
Aneurin Bevan University Health Board a…
Concerns summary (AI summary) A significant breakdown in communication and trust between primary and secondary care led to vulnerable patients being discharged without adequate information or support regarding complex medical conditions.
Action Taken (AI summary) The Richmond Clinic investigated the matter, met with the Health Board, explored communication options between primary and secondary care, and ensured all clinical staff are aware of them. They have explored obstacles to communication in this case and addressed them. The Health Board has established a single point of access Flow Centre for urgent referrals for admission, launched direct access telephone advice lines, and created a directory of "bypass numbers". The Medical Examiner Service is now operating in Gwent and GPs receive a weekly message from the Deputy Medical Director, highlighting key information and any changes to Secondary Care Services.
Jan Goodliffe
Historic (No Identified Response)
2022-0009 14 Jan 2022 Essex
NHS England and Essex Partnership Unive…
Concerns summary (AI summary) Unqualified social workers conducted home mental health assessments, missing critical opportunities to seek medical expertise regarding medication interactions, which may have contributed to the deceased's death.
Darran Busby
All Responded
2022-0011 13 Jan 2022 Cumbria
North Cumbria Integrated Care NHS Found…
Concerns summary (AI summary) A critical flaw in the electronic patient record system allows radiology results requiring urgent follow-up to be inadvertently filed without clinician review, risking missed diagnoses and treatment delays.
Action Planned (AI summary) EMIS is reviewing and will update the EMIS Web Hazard Log and Safety Case to reflect identified concerns; highlighting established system and training mitigations. EMIS is reviewing training material relating to the filing of results, to include reference to those results that may require a more detailed review, such as radiology results. The Neurology team has stopped using the “file no Comment” button in favour of the “File and Comment” button. The Trust has notified colleagues in Primary Care and anticipate implementing a RAD system in April 2022. The neurology team has stopped using the 'file no comment' function and increased vigilance when reviewing results. A new standard operating procedure was developed and reports containing the text "significant radiological finding" have been flagged in the ICE system. A RAD alert system is being piloted to email consultants/GPs about significant radiology findings.
Reginald Weston
All Responded
2022-0008 11 Jan 2022 Avon
Blenheim House Care Home
Concerns summary (AI summary) The care home lacked documented reviews of residents' falls risk assessments following incidents and needed a more timely process for completing these critical safety evaluations.
Action Taken (AI summary) The care home now requires that falls are recorded, and risk assessments are completed within 24 hours of any fall. Falls equipment audits have been taking place and more detailed accident and incident analysis has been included into the monthly accident audit. Pre-admission assessments are taking place in person when possible and The Berkley Care Group Training Manager is supporting Blenheim House with additional Falls Prevention Champion Training in Q2.
Brendan Eccles
All Responded
2022-0007 10 Jan 2022 City of Sunderland
EKO-INVEST, POM-EKO and EURO-EKO
Concerns summary (AI summary) Volatile organic compounds within a pontoon created an easily flammable environment when exposed to external heat, posing a significant explosion risk.
Noted (AI summary) POM EKO explains the safety measures and procedures already in place for their modular steel pontoons, emphasizing the importance of using factory-made binding elements and avoiding unauthorized modifications, and that they have extended the interval between anti-corrosion coating and closure to remove volatile compounds. They also note the legal obligations of employers to ensure workplace safety.
Surekha Shivalkar
Historic (No Identified Response)
2022-0006 7 Jan 2022 East London
Department of Health and Social Care Royal College of Anaesthetists Royal College of Surgeons +1 more
Concerns summary (AI summary) A lack of formal preoperative risk assessment, poor communication between surgical teams, and inadequate monitoring of a surgeon's early departure contributed to a failure to identify a critically ill patient.
Richard Sanders
All Responded
2022-0003 5 Jan 2022 Gloucestershire
British Diving Safety Group National Diving and Activity Centre University Hospitals Sussex NHS Foundat…
Concerns summary (AI summary) There is insufficient awareness of immersion pulmonary oedema risks in diving, a lack of mandatory "fitness to dive" medical certificates, and inefficient diver removal procedures at diving centres.
Noted (AI summary) The British Diving Safety Group (BDSG) highlights its existing efforts to promote awareness of Immersion Pulmonary Oedema (IPO) through training materials, safety documentation, and collaboration with various organizations. They do not believe a 'fitness to dive' medical certificate is required. The UKDMC continues research into IPO and publish findings, educate medical referees via Google-group and conferences, provide information directly to diving organisations and articles are published on the UKDMC website and in magazines for divers, provide lectures at conferences for amateur divers, work with the British Diving Safety Group, spoken to the Royal College of Pathologists and provide guidance on fitness to dive. The new operators of the Diving Centre, Deep Training Services Limited (DTSL), are implementing a requirement for safety boat capability to be available during all diving activities to assist with diver removal from the water.
James Emmerson
Historic (No Identified Response)
2022-0002 5 Jan 2022 Bedfordshire and Luton
Association of Directors of Adult Socia… Department of Health and Social Care East London NHS Foundation Trust +2 more
Concerns summary (AI summary) Ambiguous Mental Health Act guidance resulted in a flawed practice where individuals detained under Section 136 were discharged without assessment by an Approved Mental Health Professional, increasing risk of self-harm or suicide.
Ian Miller
Partially Responded
2022-0001 5 Jan 2022 Gwent
HM Prison Usk Ministry of Justice
Concerns summary (AI summary) A lack of secure medication management in prison, where prisoners controlled their own drugs, led to widespread trading of prescribed medication, posing a significant risk to prisoner safety.
Action Taken (AI summary) The prison updated its prisoner induction process in January 2022 to include information on in-possession medication, the dangers of misusing prescription drugs, and instructions to report concerns. Guidance was issued to staff in January 2022 on identifying risks, amnesty bins have been added to wings, and random medication checks have increased to 10% of the prison population.