2022

PFD Reports
Reports: 385 Areas: 67

78% response rate (above 63% average).

Clear 262 results
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.
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.
Sylvia Gibson
All Responded
2022-0342 27 Oct 2022 County Durham and Darlington
Lambton House LTD
Concerns summary (AI summary) Critical information about a resident's fall was not conveyed by care home staff to a visiting doctor, highlighting a lack of robust systems for sharing important patient details with healthcare professionals.
Action Taken (AI summary) Following a fall incident, Lambton House implemented immediate actions: mandatory full documentation of falls, visual checks by senior staff, recording of observations (O2 sats, pulse, BP, temp, resps), contacting appropriate medical personnel, and following documented advice. Senior staff received supervision on communication and documentation.
Hazel Mayho
All Responded
2022-0340 26 Oct 2022 Hampshire, Portsmouth and Southampton
Westlands Care Home
Concerns summary (AI summary) Frail, dementia patients at high risk of falls have unsupervised access to hazardous gardens due to open doors and distracted staff. The care home lacks effective exit control or alert systems to prevent vulnerable residents from entering alone.
Action Taken (AI summary) Westlands Care Home installed an additional beam to the garden doors to alert staff if a resident enters the garden without observation, addressing concerns about exit control.
Terri Malone
All Responded
2023-0001Deceased 24 Oct 2022 Herefordshire
Herefordshire and Worcestershire Health…
Concerns summary (AI summary) An inexperienced practitioner made treatment decisions without senior oversight. Patients were discharged for a single missed appointment and voicemail, despite long waiting lists, without assessing their current situation or input from other agencies.
Noted (AI summary) Herefordshire and Worcestershire Health and Care NHS Trust, responding for its Healthy Minds service, asserts that the initial assessment was appropriate, was reviewed by a senior colleague, and was rated as excellent by an independent clinician through a structured judgment review, and is in line with the IAPT model.
Matthew Rouch
All Responded
2022-0335 24 Oct 2022 South Wales Central
Vale of Glamorgan Council
Concerns summary (AI summary) The A48 'Forage roundabout junction' is deemed dangerous, requiring urgent changes to enhance road user awareness and implement traffic calming measures to prevent further fatalities.
Disputed (AI summary) The Vale of Glamorgan Council disputes that the 'Forage roundabout junction' is dangerous, asserting it conforms to design guidance and that advanced warning signage is adequate. However, the Council has published a Legal Order (TRO) with the intention of reducing the speed limit on the A48 Cowbridge bypass subject to identifying available budget.
Glendys Roberts
All Responded
2022-0333 24 Oct 2022 North West Wales
Betsi Cadwaladr University Local Health… Welsh Ambulance Service Trust
Concerns summary (AI summary) Ambulance availability is critically low for inter-hospital transfers due to bed blocking and a lack of community care. Implementation of crucial reviews for intra-hospital transfers, vascular emergency pathways, and an ambulance handover plan has been unacceptably slow.
Action Planned (AI summary) Betsi Cadwaladr University Health Board is reviewing intra-hospital transfer processes with support from the National Collaborative Commissioning Unit and modeling service demand. They are also working with WAST on ambulance performance and handover delays, and have an Integrated Commissioning Action Plan. The Trust is working with Betsi Cadwaladr University Health Board and the National Collaborative Commissioning Unit to improve intra-hospital transfer resources, including developing a proposal for dedicated transfer resources, and is considering actions to address issues in the Regulation 28 report, including changes to Standard Operating Procedures.
Bradleigh Barnes
All Responded
2022-0332 24 Oct 2022 Dorset
HMPPS HMP YOI Portland NHS England +1 more
Noted (AI summary) A memorandum of understanding has been put in place between healthcare and the prison regarding attendance of healthcare and all planned use of force interventions and healthcare staff are to be trained alongside prison officers. NHS England will request assurance from regional Directors of Commissioning that actions regarding the use of the PSA (proactive systematic assessment) vital signs tool have been implemented and evidenced by April 2023. They will also work with HMPPS on their review of PSO 1600: Use of Force, providing clinical leadership on section 6. HMPPS implemented a memorandum of understanding with the new healthcare provider at HMP Portland regarding the role of healthcare during use of force incidents. Whitewood furniture beds have replaced metal bedframes at HMP Portland. The Governor of HMP Portland confirms their involvement in the HMPPS response to the Regulation 28 report.
Keith Dimond
All Responded
2022-0338 22 Oct 2022 North East Kent
East Kent Hospitals University NHS Foun…
Concerns summary (AI summary) Significant communication failures led to treating clinicians being unaware of a previous aneurysm diagnosis, resulting in inappropriate treatment. Additionally, patients were discharged on anticoagulants without adequate risk advice, and specialist recommendations were disregarded.
Action Taken (AI summary) East Kent Hospitals University has taken several steps including improving digital record accessibility, emphasizing the importance of clinical history and previous conditions, improving communication regarding patient status and treatment decisions, and providing additional training on Careflow usage.
Ruwaida Adan
All Responded
2022-0336 22 Oct 2022 East London
Capital Karts Trading Ltd
Concerns summary (AI summary) The report raises concerns about the reliance on reception checks for go-kart clothing and hair, noting track marshals frequently miss loose items, and there is a lack of changes to training and monitoring of track marshals.
Action Taken (AI summary) Capital Karts implemented enhanced safety measures following the incident, including providing safety information at booking, reiterating warnings at reception, and ensuring staff check for loose clothing before customers enter the venue.
Clifford Rose
All Responded
2022-0329 20 Oct 2022 Milton Keynes
Central North West London NHS Foundatio… Milton Keynes Adult Social Care
Concerns summary (AI summary) Remote telephone assessments for vulnerable, elderly patients yield inaccurate information, as individuals may misrepresent their abilities. All assessments should be conducted face-to-face, ideally involving family members, for accurate needs identification.
Action Planned (AI summary) Milton Keynes City Council has agreed to a reciprocal arrangement with CNWL to access healthcare (System One) and social care (Liquid Logic) systems, with technical issues to be addressed in early 2023. Central and North West London NHS Foundation Trust is updating assessment templates to include mandatory questions about family involvement and other service providers, and sharing lessons learned with staff.
Max Turbutt
All Responded
2022-0327 18 Oct 2022 Inner North London
Kent County Council
Concerns summary (AI summary) A vulnerable person struggled to contact their social worker for weeks due to unavailable contact channels, including an unattended crisis line. This highlights inadequate support arrangements for those in need.
Action Taken (AI summary) KCC has advised staff to immediately inform young adults if their Personal Advisor is on long-term sick leave and provide contact details for the Team Manager and Duty service. The Team Manager will ensure staff add a voice message and out-of-office reply with alternate contacts when on longer-term leave.
Robert Evans
All Responded
2022-0322 18 Oct 2022 Swansea and Neath Port Talbot
HMP Swansea
Concerns summary (AI summary) HMP Swansea has a repeated history of self-inflicted deaths soon after arrival. Critical witness accounts were not immediately captured after a death, hindering investigations and preventing lessons from being learned.
Action Planned (AI summary) HM Prison and Probation Services is drafting a new HMPPS Policy Framework, updating the policy for prisons to follow in the event of a death in custody, including guidance to ensure that staff who have relevant information are identified and prompted to make a record of this at an early stage.
Carl Wright
All Responded
2022-0324 17 Oct 2022 Nottinghamshire and Nottingham
Nottingham University Hospital NHS Trust
Concerns summary (AI summary) Inexperienced junior doctors handled patient care and deterioration assessments without senior input, and blood test results were not reviewed promptly, risking patient safety.
Action Taken (AI summary) Nottingham University Hospital has taken immediate actions, including a Consultant from Linden Lodge physically assessing patients transferred there, and developing a specialty referral guidance and a Standard Operating Procedure (SOP) to review all requested tests for patients daily with documentation.
Seth Thind
All Responded
2022-0323 17 Oct 2022 Hampshire, Portsmouth and Southampton
Hampshire Highways Highways England
Concerns summary (AI summary) A bridge lacked safety barriers, emergency help points, mental health signage, and CCTV, despite a high number of crisis incidents and fatalities, indicating insufficient preventative measures.
Noted (AI summary) Hampshire County Council acknowledges the concerns but states that National Highways is responsible for the bridge in question. They offer to work collaboratively with National Highways to review solutions. National Highways will install Samaritans signs by September 2022, add the location to the South East "Network Needs" list by December 2022, add it to the agenda of Hampshire Safer Roads Partnership quarterly meeting in December 2022 and apply for funding for a study into suicide prevention at this location by September 2023.
Adam Simms
All Responded
2022-0320 17 Oct 2022 North Lincolnshire and Grimsby
North Lincolnshire Council
Concerns summary (AI summary) Blocked drainage gullies were missed during inspections, causing significant standing water on the carriageway. The unexplained accumulation of water indicates an ongoing highway safety risk.
Disputed (AI summary) North Lincolnshire Council concludes that the event was unforeseeable due to extreme rainfall and that no further action is needed, as subsequent inspections found no standing water.
Neha Raju
All Responded
2022-0319 14 Oct 2022 Surrey
Department of Health and Social Care
Concerns summary (AI summary) Lethal substances are readily available for purchase online and delivered within the UK without safeguards to protect vulnerable individuals from making such purchases.
Action Planned (AI summary) The Department of Health and Social Care is working to set up a national near-Real Time Suspected Suicide Surveillance System (nRTSSS), likely to be operational by the end of Spring 2023 and is investing an additional £57 million in suicide prevention by 2023/24 through the NHS Long Term Plan.
Kenneth Goodwin
All Responded
2022-0318 14 Oct 2022 Manchester South
Stockport NHS Foundation trust
Concerns summary (AI summary) Inadequate handover for falls risk patients, slow completion of falls risk assessments on new wards, and inconsistent use of visual fall-risk signs on beds posed a safety concern.
Action Taken (AI summary) Stockport NHS Foundation Trust relaunched its formal patient handover document and the use of maple leaf signs for patients at risk of falls across the Trust on 15 November 2022, adding the latter to agency staff induction checklists.
Rebecca Hayward
All Responded
2022-0321 13 Oct 2022 Nottinghamshire and Nottingham
Nottingham City Council
Concerns summary (AI summary) Inexperienced staff conducting assessments for vulnerable individuals with homelessness and substance misuse issues lead to inaccurate plans, and Care Act re-referrals for changing accommodation are resisted.
Action Planned (AI summary) Nottingham City Council has developed an overarching action plan, governed by the Senior Leadership Team and Principal Social Workers, to address the concerns raised; the plan will be reviewed monthly.
Oli Hoque
All Responded
2022-0316 13 Oct 2022 East London
Department of Health and Social Care
Concerns summary (AI summary) The MHRA's inability to compel timely clinical data hinders robust safety investigations into potential vaccine adverse events, impacting public interest in drug safety.
Action Taken (AI summary) The MHRA has worked with the NHS to enable interoperability and connectivity of reporting systems, such as the new Learning from Patient Safety Events System (LPSE) to allow automatic electronic upload into MHRA databases. The MHRA also continues to educate and promote the Yellow Card scheme with healthcare professionals.