2022
PFD Reports
Reports: 385
Areas: 67
78% response rate (above 63% average).
Awaab Ishak
All Responded
2022-0365
16 Nov 2022
Manchester North
Department of Health and Social Care
Ministry of Housing, Communities & Loca…
Concerns summary (AI summary)
The provided text refers to a Housing Ombudsman report but does not detail specific coroner's concerns.
Noted
(AI summary)
The Secretary of State calls on social housing providers to treat damp and mould seriously, meet the Decent Homes Standard, and self-refer to the Regulator of Social Housing if in breach of standards. They also highlight the upcoming Social Housing Regulation Bill to hold landlords accountable. The Secretary of State requests local authorities prioritize improving housing conditions for private and social tenants, focusing on damp and mould. They request information on the number of properties with damp and mould and how enforcement of housing standards is being prioritized. The Secretary of State asks legal representatives to direct social housing tenants with concerns about housing to the Social Housing Ombudsman, highlighting recent changes making it easier to access the Ombudsman. The government outlines actions taken to address damp and mould in social housing, including issuing guidance to landlords, suspending funding to Rochdale Boroughwide Housing, and awarding funding to areas with poor privately rented homes. They also highlight the Social Housing Regulation Bill to hold landlords accountable.
Sally-Ann Few
All Responded
2022-0366
15 Nov 2022
Mid Kent and Medway
Medway NHS Foundation Trust
Concerns summary (AI summary)
Critical medication information was lost between GP and hospital systems, leading to incorrect prescribing and potential pain control issues. Additionally, medical record-keeping was poor, failing to document clinical decisions and discussions.
Action Taken
(AI summary)
The Trust has reminded ENT clinicians to document the reasons for their decisions on daily ward rounds and is sharing a case study on medication reconciliation with pharmacy colleagues at a Controlled Drug Local Intelligence Network meeting. They have also addressed the issue of delayed discharges by requiring conscious decisions to be made regarding recommendations.
Robert Kelly
All Responded
2022-0364
15 Nov 2022
Milton Keynes
Milton Keynes University Hospital and C…
Concerns summary (AI summary)
An elderly, post-operative patient was discharged from hospital without a care package or follow-up, and subsequent GP referrals for home support were mishandled, highlighting a systemic lack of patient aftercare.
Disputed
(AI summary)
The hospital disputes the coroner's concerns, stating that Mr. Kelly's discharge was appropriately handled, he had mental capacity, and a care package was not deemed necessary. They state that hospital procedures functioned well and could not have reasonably foreseen subsequent events. The Trust reviewed its referral process for the District Nursing Single Point of Access service following the incident. The Standard Operating Procedure will be amended to ensure tighter follow-up when additional referral information is requested.
Frederick King
All Responded
2022-0363
15 Nov 2022
Berkshire
Care Quality Commission
Concerns summary (AI summary)
The care home failed to ensure adequate fluid intake for the resident, particularly during hot weather, and maintained poor records. A critical lack of on-site management was also identified.
Action Taken
(AI summary)
CQC conducted follow-up inspections of Birchwood Care Home after concerns were raised and rated the home as 'requires improvement' or 'inadequate' in several domains. They are keeping the service under review and will conduct another comprehensive inspection by August 2023, and will consider enforcement action based on the circumstances leading to the death.
Karen Starling and Anne Martinez
All Responded
2022-0368
14 Nov 2022
Cambridgeshire and Peterborough
Department of Health and Social Care
Concerns summary (AI summary)
Hospital water systems are contaminated with M abscessus, posing a serious risk to immunosuppressed patients. Existing water safety guidance is inadequate, lacking specific protocols for identifying and controlling mycobacteria in hospital settings.
Noted
(AI summary)
NHS England has commissioned a review of HTM 04-01 by Dr Susanne Surman-Lee, specifically related to immunosuppressed patients and NTM, including identifying any specific measures required for new hospital premises, and a gap analysis between British Standard BS 8580-2:2022. They aim to publish a technical bulletin with any amendments by Spring. The Department of Health and Social Care acknowledges the concerns and states that NHS England is the correct organisation to respond, noting that NHSE already sent a response on Feb 6, 2023.
Ghulam Mohammad
Partially Responded
2022-0361
14 Nov 2022
East London
Department of Health and Social Care
Royal London Hospital
Concerns summary (AI summary)
There was a four-day delay in conducting a crucial CT head scan after an elderly patient's fall and suspected head injury. Additionally, the patient was inappropriately prescribed an anticoagulant before the scan.
Action Taken
(AI summary)
The Department of Health and Social Care notes that CQC took regulatory action in May 2021 following whistleblowing concerns at Barts Health NHS Trust. Diagnostic Imaging at Barts Health NHS Trust remains on the risk register of the local team and is a priority for future inspection and the Minister is seeking assurance from the Trust Chief Executive and the Chief Medical Officer that they implement changes to prevent falls and ensure staff have appropriate training for head injuries.
Lee Brown
All Responded
2022-0360
13 Nov 2022
East London
Department for Foreign, Commonwealth an…
Concerns summary (AI summary)
There's a lack of emergency access protocols for consular officers to detained British nationals, especially those in mental health crisis. FCDO travel advice is insufficient regarding the specific consequences of detention in Dubai.
Action Taken
(AI summary)
The FCDO highlights updated training for consular staff, including mental health awareness, and clarifies the protocol for sharing information without consent when an individual's vital interests are at risk. They emphasize that the host state is responsible for the safety and security of individuals.
Derek Shaw
All Responded
2022-0370
11 Nov 2022
Mid Kent and Medway
Department of Health and Social Care
The Secretary of State for Health and S…
Concerns summary (AI summary)
A significant delay in ambulance attendance likely contributed to the deceased's death, stemming from systemic capacity issues within local NHS Trusts, not solely the ambulance service.
Action Taken
(AI summary)
The Department of Health and Social Care highlights that East of England Ambulance Service NHS Trust (EEAST) were under high demand at the time of the incident, and points to improvements in performance this year compared to last year. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and the delivery of new ambulances and specialist mental health vehicles.
Michael Smith
Partially Responded
2022-0417Deceased
10 Nov 2022
County Durham and Darlington
Ministry of Justice
HM Prison and Probation Service
Concerns summary (AI summary)
Insufficient staffing levels in the prison's segregation unit prevented critical medical and mental health assessments for a vulnerable prisoner. A delay in emergency response due to staffing shortages also put his life at risk.
Action Taken
(AI summary)
HMP Durham SACU staffing levels are above national benchmarking, overseen by a dedicated Custodial Manager. A full-time nurse is based within the SACU to provide more flexible healthcare input. HMP Durham will review its contingency plans to incorporate learning from this incident, to allow for appropriate deployment of staff should other incidents occur at the same time.
David Morganti, Winnie Barnes, Robert Conybeare and Anthony Reedman
All Responded
2022-0359
10 Nov 2022
Cornwall and the Isles of Scilly
Department of Health and Social Care
Concerns summary (AI summary)
Systemic delays in discharging medically fit patients from hospital are caused by insufficient intermediate care capacity. Discharging patients to understaffed residential homes results in patient deterioration and re-admissions, exacerbating hospital pressures.
Action Planned
(AI summary)
Cornwall Council has commissioned additional capacity at the Frances Bolitho care home, creating 33 new residential and nursing dementia beds and entered into a partnership with Sanctuary Housing Association. Cornwall Council has relaunched the proud to care Cornwall recruitment campaign to support providers with their recruitment of care staff. The Department of Health and Social Care is addressing concerns raised by the coroner through national initiatives, including the Urgent and Emergency Care Services Recovery Plan, which aims to reduce A&E and ambulance wait times. The Government's Primary Care Recovery Plan, currently being drafted, will respond to the challenges facing general practice.
Samuel Pearson
All Responded
2022-0358
10 Nov 2022
South London
Bromley Council
Clarion Housing Group
Oxleas NHS Foundation Trust
Concerns summary (AI summary)
Multi-agency support failed during an emergency housing move for a vulnerable patient, exacerbating anxiety. A GP referral for mental health support was delayed by a long backlog, with referrers unaware of the service's capacity issues.
Action Planned
(AI summary)
The London Borough of Bromley Council will be notified as soon as possible in the event of future emergency decants, when a vulnerable person subject to social care involvement is moved and London Borough of Bromley’s largest provider Clarion has been asked to review their Emergency Decant Policy around notification of emergency decants to LBB where there is a vulnerable household member. Oxleas NHS Foundation Trust has completed a new ADAPT Operational Policy that clearly sets out expectations of information to service users and referrers regarding waiting times. An automated email will be generated and sent to the referrer informing them of expected screening times and contact information for urgent escalations. Clarion Housing Group is reviewing its alternative accommodation and related assessment process, considering how interagency working can be further embedded into its processes. The review is expected to be completed by 31st January 2023.
Maria Whale
All Responded
2022-0362
9 Nov 2022
South Wales Central
Cardiff and Vale University Health Board
Welsh Ambulance Service NHS Trust
Concerns summary (AI summary)
The report identifies that the emergency services repeatedly advised a gravely ill, disabled woman to take a taxi to A&E, and a call responder concluded that if she could scream then she was not a priority.
Noted
(AI summary)
Cardiff and Vale University Health Board reviewed the patient's triage and management by the Out of Hours GP Service, sharing their initial findings. The board acknowledges that there was poor communication at the inquest hearing which may have led to some of the recommendations. The Welsh Ambulance Services NHS Trust acknowledges the concerns raised regarding triage and response times and the impact of system pressures. The Trust says it will continue to press for real systemic change at every opportunity.
Roy Travers
All Responded
2022-0357
8 Nov 2022
Inner North London
Whittington Health NHS Trust
Concerns summary (AI summary)
There was a critical 12-hour delay in reviewing a patient with melaena, and anti-coagulation therapy was not withheld. The hospital's late disclosure of its internal review hampered the inquest and learning process.
Action Taken
(AI summary)
Whittington Health NHS Trust has provided feedback to the nurse who did not escalate the melaena and booked them on a course covering the deteriorating patient, with further training being put in place. The reviewing doctor was given direct feedback and learning regarding anti-coagulation therapy. The 72-hour report was sent to Dr on 4 December 2022 by email – in the week prior to the inquest.
Liridon Saliuka
All Responded
2022-0355
8 Nov 2022
Inner South London
HMP Belmarsh
Oxleas NHS Trust
Concerns summary (AI summary)
There was a lack of clear, accessible documentation detailing a prisoner's disability adjustments and a general lack of disability awareness among prison staff, leading to inappropriate assumptions about his capabilities.
Action Planned
(AI summary)
Oxleas NHS Foundation Trust will now document adjustments required for a patient's disability on the Prison Nomis (P-Nomis) system, accessible by prison staff, healthcare, and social services. A fortnightly meeting involving all providers has now convened allowing discussion of patients presenting with disability that may be of concern, to facilitate improved care planning and communication. HMP Belmarsh will be holding monthly training sessions throughout 2023, alongside Oxleas NHS Trust and RGB, for all operational staff. These sessions will focus on encouraging staff to think differently about disability and to improve how they engage with disabled prisoners.
Peter Ross
All Responded
2022-0354
4 Nov 2022
East London
Barking, Havering and Redbridge NHS Tru…
Department of Health and Social Care
Concerns summary (AI summary)
A CT scan was misreported, and a reviewing surgeon failed to escalate a noticed abnormality. Repeated communication failures among clinical staff and poor record-keeping led to serious patient harm.
Action Taken
(AI summary)
Barking, Havering and Redbridge University Hospitals NHS Trust has taken multiple actions, including completing SI recommendations within Radiology, providing formal radiology training, sending reminders to staff regarding C-spine injury, developing better communication methods, and undertaking documentation audits. The Trust is currently in the process of implementing electronic patient record system. Barking, Havering & Redbridge NHS Trust presented the specific incident relating to Mr Ross at the Trust-wide Patient Safety Summit, delivered proposed teaching sessions for staff, made improvements to documentation, and audited the implementation of these improvements. The CQC will continue to engage with the Trust and part of the focus of this engagement will be the review of the improvements the Trust has made.
Harry Evans
All Responded
2022-0353
4 Nov 2022
Cornwall and the Isles of Scilly
Exeter University
Concerns summary (AI summary)
The university lacked mandatory mental health and suicide prevention training for staff, employed an overly reactive, email-based approach to welfare concerns, and had staff unaware of information-sharing policies. Pastoral support was also limited by a lack of direct contact protocols.
Action Planned
(AI summary)
The University of Exeter has reviewed mental health awareness training, consolidating courses and clarifying attendance. They are also progressing replacement of the CMS, through the procurement of a new case management product, with implementation aimed for the 2023/24 academic year, and have introduced a welfare tracker to track case progress.
Philip Day
All Responded
2022-0351
4 Nov 2022
Manchester South
Department of Health and Social Care
Concerns summary (AI summary)
Severe Emergency Department waiting times and poor communication between community and hospital services hindered prompt assessment. A lack of awareness for neutropenic sepsis guidance also led to missed red flags and delayed critical treatment.
Action Taken
(AI summary)
NHS England (NHSE) is committed to finding ways to make awareness of the potential for sepsis, and the response to it, ever more consistent. The department has seen improvement in A&E waiting times this year following the Delivery Plan’s publication.
Ellen MacFarlane
All Responded
2022-0350
4 Nov 2022
Manchester South
Department of Health and Social Care
Concerns summary (AI summary)
Critical ambulance delays are common due to high demand and staffing shortages. Additionally, weekend availability of cardiac tests at district general hospitals delays urgent surgery, contradicting best practice.
Noted
(AI summary)
The Department of Health and Social Care notes the concerns regarding ambulance response times and access to hospital services and says that ambulance performance is reviewed regularly. More broadly the Trust has governance in place to reduce delays outside the 36-hour timeframe to support compliance with NICE guidance
Graham Flindle
All Responded
2022-0349
4 Nov 2022
Manchester South
Greater Manchester Health and Social Ca…
Concerns summary (AI summary)
Community health professionals lacked widespread understanding of FIT test effectiveness for early bowel cancer detection. GPs also struggled to identify critical haemoglobin test results amidst high volumes, highlighting a need for better prompts and education.
Action Planned
(AI summary)
Greater Manchester Integrated Care's Cancer Alliance recirculated a webinar and resources on cancer and anemia to primary care clinicians and is developing clinical decision support tools for GPs to "think cancer" when certain codes are entered. Learning will be presented/shared with the Greater Manchester System Quality Group and cascaded to professionals through relevant governance and learning forums.
John Fallon
All Responded
2022-0348
4 Nov 2022
Manchester South
Greater Manchester Health and Social Ca…
Concerns summary (AI summary)
Care homes lack routine speech and language therapy assessments for denture changes, leading to unsuitable diets and increased choking risk due to delayed dental services. Furthermore, care homes do not routinely have suction machines for choking emergencies.
Action Planned
(AI summary)
NHS Greater Manchester Integrated Care will share learning from this case with the Greater Manchester System Quality Group and cascade it to professionals through relevant governance and learning forums. The Team are currently looking into any additional training in relation to obstructed airways that can be undertaken by care home staff.
Lynn Moss
Historic (No Identified Response)
2022-0347
4 Nov 2022
Manchester South
Department of Health and Social Care
Concerns summary (AI summary)
The patient experienced extreme delays in emergency department assessment and bed allocation, with multiple missed opportunities to recognize deterioration. This was attributed to systemic high demand on EDs, fueled by broader health and social care failures.
Levi Alleyne
Partially Responded
2022-0346
4 Nov 2022
Berkshire
Association of Ambulance Chief Executiv…
Energy Networks Association
Health and Safety Executive
+2 more
Concerns summary (AI summary)
Ambulance operators lacked clear procedures and accessible contact information for electricity distributors during electrical hazards, leading to significant delays in cutting power. This confusion risked both bystander and emergency service safety and delayed life-saving treatment.
Noted
(AI summary)
ENA has asked each DNO and TNO member company to check that emergency services have contact details and know how to respond to incidents; ENA will open dialogue with the HSE to see whether it can support them to further enhance awareness and will review and update its safety leaflet - Safety advice for the Emergency Services. NHS Digital explains the function and governance of NHS Pathways, noting that standard operating procedures and contact numbers are the remit of local service providers and do not fall under NHS Pathways' responsibility. AACE shared South Central Ambulance Service NHS Trust's updated SOPs, including a map and contact details for electricity Distribution Network Operators, across all NHS ambulance services. They are also discussing the matter with all Heads of Emergency Operations Centres. HSE shared concerns with the Care Quality Commission (CQC) and Healthcare Inspectorate Wales (HIW), the Association of Police Health and Safety Advisors (APHSA), the National Police Chiefs Council (NPCC) and the National Fire Chiefs Council Health and Safety Committee, and the Energy Networks Association (ENA), who have requested that DNOs and TNOs check their arrangements with the emergency services on an annual basis; the ENA is currently reviewing their information leaflet on Safety Advice for the Emergency Services.
Raneem Oudeh and Khaola Saleem
All Responded
2022-0352
3 Nov 2022
Birmingham and Solihull
Home Office
West Midlands Police
Concerns summary (AI summary)
Severe understaffing in the domestic abuse unit meant cases were not investigated, leaving high-risk victims vulnerable to ongoing violence and threats due to a lack of effective police action.
Noted
(AI summary)
West Midlands Police restructured the Public Protection Department in 2019, increasing staff allocated to DA investigation and replacing Domestic Abuse Teams with Adult Investigation and Adult Complex Investigation Teams; they have also established a scrutiny panel with the CPS to review decisions where no further action is taken. West Midlands Police restructured the Public Protection Department in 2019, increasing staff allocated to DA investigation and replacing Domestic Abuse Teams with Adult Investigation and Adult Complex Investigation Teams; they have also established a scrutiny panel with the CPS to review decisions where no further action is taken. The Home Office highlights the Domestic Abuse Act 2021 and the Tackling Domestic Abuse Plan, committing to assist in funding the rollout of Domestic Abuse Matters training and funding the College of Policing to develop a new module aimed at investigators of domestic abuse; they also mention the Police Uplift Programme and additional funding for West Midlands Police. The College of Policing has created a 'DA Matters' training package for police responders focusing on coercive control, delivered by DA charities, and has rolled out the Domestic Abuse Risk Assessment tool (DARA) to every force in England and Wales. West Midlands Police is publishing a revised Domestic Abuse policy with an initial response action checklist and will launch it with a tailored communication and briefing package; they have also created an improvement plan to increase the number of Domestic Violence Protection Notices and Orders. The Police and Crime Commissioner acknowledges the coroner's report and highlights ongoing efforts by West Midlands Police to address domestic abuse, while also noting resource constraints and the impact of cuts to public services.
Rowan Thompson
All Responded
2023-0365
1 Nov 2022
Manchester North
Greater Manchester Mental Health NHS Fo…
NHS England
Action Planned
(AI summary)
Greater Manchester Mental Health NHS Trust is implementing a new electronic patient record system, undertaking a thematic review of observation audits, and reinforcing the availability of additional staffing resources to ward-based staff via the Duty Manager and on-call systems. NHS England has commissioned an external Independent Review of services and culture at Greater Manchester Mental Health NHS Foundation Trust, and will publish the findings; they also discuss all Regulation 28 reports at a national level to identify learning and emerging trends.
Jade Hutchings
All Responded
2022-0398
28 Oct 2022
West Sussex
Sussex Police
Sussex Police and Crime Commissioner
Concerns summary (AI summary)
Police officers received inadequate mental health training and lacked understanding of support services. Additionally, an early intervention scheme had an age-based prioritisation that excluded vulnerable older adolescents, missing crucial support opportunities.
Action Taken
(AI summary)
The Police and Crime Commissioner launched the REBOOT initiative in 2019 as an early intervention youth programme, secured additional funding for it, and funded it for an additional year in 2020/21. In April 2021, coordination of the REBOOT scheme was migrated to Sussex Police and funded from the force’s core budget. Sussex Police has completed a roll out of a more modern BWV platform, allowing officers to swap out cameras with low battery life, and run a weekly “bad battery” report to determine cameras that may have battery issues. Sussex Police has significantly developed mental health training for officers since 2020, enhancing both entry-level and continued professional development; a retrospective review found the deceased's needs likely surpassed the criteria for the REBOOT programme at the time of referral.