2022

PFD Reports
Reports: 385 Areas: 67

78% response rate (above 63% average).

385 results
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.
Vincenzo Lippolis
Partially Responded
2022-0339 26 Oct 2022 Lincolnshire
LPFT Legal Services NAViGO Grimsby
Concerns summary (AI summary) Mental health services failed to consider Mental Health Act admission criteria, focusing instead on social stressors after suicide attempts. A recommended face-to-face assessment was replaced by a telephone call, leading to case closure.
Disputed (AI summary) NAViGO disputes the coroner's concerns, stating that the decision not to section Mr. Lippolis followed nationally recognized practice and the professional judgement of experienced practitioners, based on his presentation at the time.
John White
Historic (No Identified Response)
2022-0337 25 Oct 2022 South Wales Central
South Wales Police
Concerns summary (AI summary) The distribution of ligature cutters to frontline police officers remains incomplete, posing a risk in emergency situations. Additionally, bespoke training for officers responding to mental health crisis incidents is not widely available.
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.
Carl Langdell
Partially Responded
2022-0331 21 Oct 2022 West Yorkshire Western
HMP Wakefield Ministry of Justice
Concerns summary (AI summary) A patient with chronic suicide risk was observed deteriorating after refusing medication. There is a systemic concern regarding items prisoners can possess in their cells overnight, and a national proposal is underway to remove identified risks.
Action Planned (AI summary) HM Prison and Probation Services conducted pilots across the prison estate, testing alternatives to the current wet shave provision, to be evaluated in Spring 2023.
Daniel O’Sullivan
Partially Responded
2022-0330 21 Oct 2022 Inner South London
Central and North West London NHS Found… Department of Health and Social Care The Chief Coroner for England and Wales
Concerns summary (AI summary) The decision to rescind Mental Health Act detention was flawed due to a failure to update the suicide/self-harm risk assessment and an absence of a comprehensive care and treatment plan for core needs.
Action Planned (AI summary) Central and North West London NHS Foundation Trust has implemented changes including safety planning for all patients, strengthening processes for recording patient leave, improved training, strengthened scrutiny of serious incident reports and is transitioning to the new national framework, PSIRF. The Department of Health and Social Care notes that the draft Mental Health Bill proposes a statutory duty on clinicians to create a care and treatment plan for relevant patients detained under the Mental Health Act.
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.
Charley Patterson
Historic (No Identified Response)
2022-0328 19 Oct 2022 North and South Northumberland
Department of Health and Social Care
Concerns summary (AI summary) A significant post-pandemic surge in children and young people experiencing mental health difficulties has led to severe, prolonged waiting times (up to 63 weeks) for treatment. Current services and resources are insufficient to meet this drastically increased demand.
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.
Kenneth Perkins
Partially Responded
2022-0325 18 Oct 2022 Derby and Derbyshire
Ilkeston Community Hospital University Hospitals of Derby and Burton
Concerns summary (AI summary) A lack of clear, detailed handover and transfer documents between hospitals meant critical patient information was not exchanged, preventing appropriate enhanced care and falls prevention.
Action Taken (AI summary) UHDB already had a SBAR form for transferring patients within site and out to community sites and a STOP Safe Transfer of the Patient Tool for acute to acute ambulance hospital transfers. The Derbyshire Shared Care Record became operational in December 2021 to improve information sharing between health and social care professionals.
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.
Molly Russell
Partially Responded
2022-0315 13 Oct 2022 North London
Baker & McKenzie LLP Department for Digital, Culture, Media … Meta Platforms +5 more
Concerns summary (AI summary) Internet platforms lack age verification, age-specific content control, and parental monitoring features, exposing children to harmful material through algorithms and unrestricted access.
Action Planned (AI summary) Twitter acknowledges the concerns and highlights existing safety features, including user controls to manage content, block accounts, and a parental controls guide developed with Internet Matters. Meta highlights existing tools and policies, including content moderation, reporting options, and parental supervision features. They also mention partnerships with experts and engagement with the UK Online Safety Bill. Snap highlights existing safety measures and resources, including reporting tools, partnerships with mental health organizations, and extra protections for under 18s. They mention a Global Safety Advisory Board that includes UK members. Pinterest commits to limiting the distribution of depressive content to teens, updating its self-harm policy for stricter enforcement, partnering with a third-party content checking service, improving moderation processes, and expanding resources for parents. These actions are planned for implementation by the end of 2023. The government plans to strengthen online protections for children via the Online Safety Bill, including requiring platforms to publish risk assessments and naming the Children's Commissioner as a statutory consultee for Ofcom.