2022

PFD Reports
Reports: 385 Areas: 67

78% response rate (above 63% average).

Response Status
Responded 302 Historic 81
AI Classification
Action Taken 48%
Action Planned 32%
Noted 19%
Disputed 1%
Based on 527 classified responses
Top Categories
Hospital Death (Clinical Procedure… (127) Suicide (from 2015) (83) Other related deaths (83) Mental Health related deaths (72) Alcohol, drug and medication relat… (61)
Clear 81 results
Benjamin Stroud
Historic (No Identified Response)
2022-0039 8 Feb 2022 Essex
Essex Partnership University Trust and …
Concerns summary (AI summary) A patient's case was not referred to the Multi-Disciplinary Team, denying essential psychiatric input, as the Care Coordinator made un-documented clinical decisions regarding referrals, posing a significant risk.
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.
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.
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.
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.