2022
PFD Reports
Reports: 385
Areas: 67
78% response rate (above 63% average).
Emma Simkin
All Responded
2022-0313
12 Oct 2022
Lincolnshire
Vine Street Surgery and LPFT Legal Serv…
Concerns summary (AI summary)
Professionals are perceived to accept patients' statements at face value, failing to detect "masking" of mental illness and often ignoring family concerns, requiring policy and training review.
Action Planned
(AI summary)
Lincolnshire County Council intends to review its AMHP policies to incorporate references to 'masking' and will discuss the coroner's concerns at the next AMHP Forum.
Eirwen Hollister
Partially Responded
2022-0314
11 Oct 2022
Stoke-on-Trent and North Staffordshire
Heathview Medical Practice
NHS England
NHS Registrations
Concerns summary (AI summary)
The GP practice lacked a procedure to prevent further prescriptions after a patient overdose without a mandatory full GP review.
Action Taken
(AI summary)
Heathview Medical Practice has updated its local policy on management of hospital letters, held a teaching event on read coding, produced a new policy/procedure on patient registrations and deductions, and introduced a dedicated team to manage patient registrations; EMIS training on registrations is also planned. Heathview Medical Practice reviewed its overdose policy, provided training, and carried out Docman training; it was also reiterated that clinicians should adhere strictly to the practice's overdose policy.
Charles Stringer
All Responded
2022-0317
10 Oct 2022
Surrey
Surrey County Council, Highways Agency …
Concerns summary (AI summary)
The council demonstrated a lack of reflection and action on pothole management, with insufficient information for inspectors, mechanistic risk assessments, poor communication, and slow repairs.
Action Taken
(AI summary)
Surrey County Council has reinforced the process for Surrey Police and the Surrey Contact Centre to notify the Highways Service immediately in the event of serious injuries or deaths related to road defects, and instructed Customer Care Centre operatives to make direct contact with Highways if there are any uncertainties.
Hollie Richardson
Unknown
2022-0311
6 Oct 2022
Bedfordshire and Luton
Concerns summary (AI summary)
Patients with Protein S deficiency are not adequately informed about risk factors or routinely monitored, leaving them unaware of actions to mitigate thromboembolic risks.
Charles Rothwell
All Responded
2022-0312
5 Oct 2022
Cheshire
Department of Health and Social Care, N…
Concerns summary (AI summary)
Ambulance service demand critically outstrips supply, leading to excessively long response times across all categories due to wider resource shortages in healthcare and social care.
Noted
(AI summary)
AACE acknowledges the coroner's concerns about ambulance response times and capacity and highlights that the issue has been flagged nationally, leading to a national demand and capacity modelling exercise led by NHSE.
Reginald Cauthery
All Responded
2022-0326
4 Oct 2022
Inner North London
CECOPS
Care Quality Commission
Department of Health and Social Care
+3 more
Concerns summary (AI summary)
A vulnerable person's telecare service was not reviewed despite increased fire risk, and smoke alarms were not connected to telecare, delaying emergency fire brigade notification.
Noted
(AI summary)
The TEC Services Association (TSA) will issue guidance to certified monitoring organizations by the end of November 2022. They also plan to develop a Fire Call Handling Pathway Decision Support Tool with the support of NFCC and LFB, but anticipate it will not be available until 2024. The CQC acknowledges the concerns but states they relate to services outside their scope of regulation (fire service and telecare service) and therefore they have no powers to prevent future deaths in relation to these services. The Department of Health and Social Care has reminded local authorities to consider technology-enabled care in maintaining independence and linking preventative devices like smoke detectors. It also published an updated Adult Social Care Digital Skills Framework to support the development of digital skills across the adult social care workforce. The Home Office will share information from the case with the National Fire Chiefs Council (NFCC) and encourage them to disseminate findings and highlight the importance of linking telecare systems to smoke alarms during fire safety checks. The London Borough of Hackney will address its procedures and guidance within its 'Mosaic' system to reduce risks to vulnerable individuals, especially regarding fire safety for those with risk factors like being bed-bound and a smoker; a table detailing planned actions and timelines is attached. The organisation recommends monitored smoke detectors and rapid heat detectors for elderly and vulnerable service users, referencing recommendations made with London Fire Brigade in 2003.
George Elliott
All Responded
2022-0309
4 Oct 2022
Avon
North Bristol NHS Trust
Concerns summary (AI summary)
The patient safety investigation overlooked obvious failings in falls risk assessment and management, including inadequate assessment and missed re-assessments, resulting in lost learning opportunities and compromised patient safety.
Action Taken
(AI summary)
The Trust acknowledges shortcomings in the investigation report regarding Mr. Elliot's fall and states that the Falls Policy referenced has been replaced with an updated policy in December 2021. They are conducting a gap analysis using the PSIRF national guidance to improve investigation processes, and findings will be reported through relevant committees.
Katherine Tyrer
All Responded
2022-0307
30 Sep 2022
Liverpool and Wirral
Cheshire and Wirral Partnership NHS Fou…
Concerns summary (AI summary)
The ward's inadequate layout hindered patient observation. Inexperienced staff, lacking clear protocols for senior review, conducted inadequate risk assessments, leaving vulnerable patients unattended after trigger events.
Action Taken
(AI summary)
Cheshire and Wirral Partnership NHS Foundation Trust updated its Supportive Observation & Engagement Policy (CP25) to include a requirement for an automatic review when a non-registered member of staff identifies a trigger event. In addition, face-to-face clinical risk training using a formulation approach will be delivered to all in-patient staff as part of a Quality Improvement approach.
Shahan Aman
All Responded
2022-0306
30 Sep 2022
East London
Department of Health and Social Care
Royal London Hospital
Concerns summary (AI summary)
Miscommunications among nursing and medical staff, coupled with a discharging doctor's failure to check recent observations, led to a patient's concerns being overlooked before an inappropriate discharge.
Action Planned
(AI summary)
Barts Health NHS Trust is working through process pathway redesign to reduce pressure in emergency departments and reduce levels of risk. The trust also plans to work alongside North East London to support paediatric flow from the Emergency Department, exploring ambulatory step down from the paediatric ward and increased use of paediatric clinical decision unit to work into the community to support early discharge. Barts Health Trust has updated guidance on managing gastroenteritis in children and revised the Emergency Department's policy on observations prior to discharge, and is prompting clinicians to consider adding urine output assessment to the online patient documentation system; learning summaries from the incident will be shared trust-wide.
Aleksandra Markowska
Historic (No Identified Response)
2022-0303
29 Sep 2022
East London
NHS England
Concerns summary (AI summary)
Patients receiving services from BPAS lack direct, confidential access to NHS perinatal psychiatry teams for pregnancy-related mental health decline, hindering timely and private support.
Charlotte Warkcup
All Responded
2022-0301
29 Sep 2022
Sunderland
Department of Health and Social Care
Concerns summary (AI summary)
Concerns exist regarding the safety of standalone midwife-led birthing centres, the lack of midwife recruitment for continuity of care, and insufficient detection of small gestational age babies.
Action Planned
(AI summary)
Version 3 of the Saving Babies’ Lives Care Bundle is being developed for publication in 2023, aiming to introduce a more nuanced risk assessment and clarify guidance for staff.
Donna Neill
Historic (No Identified Response)
2022-0299
28 Sep 2022
East London
East London Foundation Trust
Concerns summary (AI summary)
The report identifies a failure to document, assess, or manage the risk of a patient taking medication prescribed to her husband, and the Trust's internal investigation did not identify this failing.
Aaron Edwards
All Responded
2022-0302
27 Sep 2022
South Wales Central
Merthyr Tydfil County Borough Council
Concerns summary (AI summary)
A dangerous road junction with poor visibility, exacerbated by school traffic, requires safety improvements to prevent further deaths from high-speed driving.
Action Planned
(AI summary)
Merthyr Tydfil Council disputes the coroner's concern about visibility at the junction. However, they state that planned road layout changes as part of the Welsh Governments A465 dualling project will remove the bridge/parapet obstruction, and the Gurnos Ring Road will become 20mph in September 2023.
Liam Lyes-Watson
All Responded
2022-0297
27 Sep 2022
Shropshire Telford and Wrekin
Midlands Partnership NHS Foundation tru…
Concerns summary (AI summary)
The report identifies that a call handler was not trained and needed advice from a colleague who did not speak to the caller, and consideration should be given to recording incoming calls to the Access Team.
Action Taken
(AI summary)
The call handler has discussed their working practice in supervision meetings, an aide memoire has been introduced to gather relevant information when patients call to self-refer, and a mandatory question has been added to the RiO electronic patient record to ensure all staff ask about the caller's ethnicity.
Lewis Begley
All Responded
2022-0380
26 Sep 2022
Norfolk
Norfolk and Suffolk NHS Foundation Trust
Concerns summary (AI summary)
The mental health hospital lacked a proper record of stored medication, especially drugs subject to misuse, and had no system to track patient access or provide fixed overdose treatment training for doctors.
Action Planned
(AI summary)
Norfolk and Suffolk NHS Foundation Trust is revising its Medicines Management Policy, led by a new Chief Pharmacist, to address stock oversight. They will not train medics to administer Naloxone due to infrequent use.
Sandra Kirk
All Responded
2022-0298
26 Sep 2022
Surrey
NHS England
NHS Improvement
Concerns summary (AI summary)
Ligature risk policies inadequately address potential ligature items like clothing, focusing instead on anchor points and avoiding 'blanket restrictions' without sufficiently identifying actual risks to vulnerable patients.
Action Planned
(AI summary)
NHS England is reviewing national guidance around risk assessments and working towards a more personalised safety planning approach. They are supporting units in urgent need of support, redesigning the model of care, and driving cultural change through leadership development. NHS England acknowledges the concerns regarding ligature risk reduction policies and guidance. They state that Cygnet is providing ligature training and enhancing their ligature risk reduction policy. They are also reviewing national guidance around risk assessments.
Zachariah Richardson
All Responded
2022-0296
26 Sep 2022
Norfolk
Lincs Firwood Co Ltd and DD Dodds and S…
Concerns summary (AI summary)
An inexperienced worker was left unsupervised with poorly maintained Fork Lift Trucks lacking critical safety devices. The company demonstrated a profound lack of health and safety understanding and failed to implement changes years after the death.
Action Taken
(AI summary)
DAC Beachcroft, on behalf of Lincs Firewood Company, states that the procedures were either already in place at the time of the incident, or have been enhanced since. Training includes task-specific chainsaw maintenance, emergency first aid, and health and safety modules.
Robert Howell
All Responded
2022-0294
26 Sep 2022
East Riding and Hull
Elm Tree Court Care Home and HICA Group
Concerns summary (AI summary)
Critical care information and risk needs were not effectively communicated from team leaders to direct care staff, and care plans were inaccessible, leading to a lack of understanding of resident needs and falls policies.
Action Taken
(AI summary)
HICA has introduced a standard handover template and attendance sheet into all services and implemented electronic care planning. They are rolling out the iSTUMBLE platform to support staff on falls procedures and introducing weekly service falls meetings.
Gary McDonald
Partially Responded
2022-0291
20 Sep 2022
Worcestshire
HMP Hewell
Practice Plus Group
Concerns summary (AI summary)
The report identifies that, despite a prisoner's GP records showing a history of depression and overdoses, no appointment was made to follow up or discuss his mental health.
Action Taken
(AI summary)
Practice Plus Group has implemented changes to the Early Days in Custody (EDiC) pathway. This includes ensuring patients are provided with another opportunity to discuss their current position with a member of the healthcare team if there are discrepancies in their records.
Robert Brown
Historic (No Identified Response)
2022-0278
20 Sep 2022
North East Kent
Kent and Medway NHS Social Care Partner…
Concerns summary (AI summary)
“Carer breakdown” was inadequately defined and not addressed during hospital admission or discharge. Without a clear process to involve carers, patients could be discharged without essential support.
Nargis Begum
All Responded
2025-0287
16 Sep 2022
South Yorkshire East
Highways England
Concerns summary (AI summary)
The public lacks crucial understanding and awareness regarding their responsibility to report motorway incidents, despite existing SMART motorway campaigns, leaving stationary vehicles a significant hazard.
Noted
(AI summary)
National Highways expresses sympathy and highlights existing measures to improve safety, including public awareness campaigns and the Smart Motorway Safety Evidence Stocktake and Action Plan. They urge road users to inform themselves about emergency procedures and who to contact.
Colin Smith
Historic (No Identified Response)
2022-0293
16 Sep 2022
Newcastle and North Tyneside
Tyne Housing Association
Concerns summary (AI summary)
Hostel workers lacked structured training to identify risks of alcohol intoxication and recognize the need for urgent medical intervention, creating significant safety gaps.
Harper Denton
All Responded
2022-0288
15 Sep 2022
Bedfordshire and Luton
Metropolitan Police, College of Policin…
Concerns summary (AI summary)
Police forces failed to adopt guidance for managing violent offenders and lacked proactive information sharing to protect children. Additionally, a national register for child cruelty offenders is missing, and health visitor safeguarding assessments are not mandatory.
Action Planned
(AI summary)
The College of Policing will update APP (Authorised Professional Practice) within three months to clarify that disclosure of information about a person who poses a risk of harm can be made to parents and/or carers of children. The MPS is reviewing its MAPPA processes, including scoping the feasibility of introducing a Potentially Dangerous Person (PDP) process as outlined by the College of Policing’s APP Guidance; the outcome of this review is anticipated within six months. The Home Office is considering options for better management of domestic abuse offenders, including a domestic abuse 'register', and is working to improve information and data sharing between agencies for safeguarding children, with a report due before Parliament in Summer 2023. The Department is updating resources for health visitors and school nurses, emphasizing assessments of family relationships and chronology of events for children with additional needs, due to be published shortly. They have also agreed to a cross-government programme of work focusing on strengthening whole family approaches and improving evidence.
Adam Gallagher
Historic (No Identified Response)
2022-0292
14 Sep 2022
Newcastle and North Tyneside
North East Ambulance Service
Concerns summary (AI summary)
The ambulance service failed to conduct a detailed assessment for a mental health incident, resulting in inadequate clinical input and limited learning from a serious event. Trust-wide policy review and comprehensive retraining are urgently required.
Diane Austin-Martin
All Responded
2022-0286
14 Sep 2022
Manchester South
Department of Health and Social Care
Concerns summary (AI summary)
The report identifies a lack of mechanisms to ensure Social Services were aware of a vulnerable person's move, to ensure private care arrangements are of sufficient quality, and to maintain contact with agencies after initial claims and visits.
Noted
(AI summary)
The Department outlines duties and policies in Northern Ireland regarding support for vulnerable individuals moving locations and clarifies that NHS England has processes in place for managing newly registered patients, including initial assessments and referrals, noting that a consultation with Ms. Austin-Martin occurred shortly after registration.