2022
PFD Reports
Reports: 385
Areas: 67
78% response rate (above 63% average).
Demet Akcicek
All Responded
2022-0277
5 Sep 2022
Inner North London
Camden and Islington NHS Foundation Tru…
Concerns summary (AI summary)
A mental health duty worker failed to escalate a patient's severe distress, omitted their case from multi-disciplinary team discussion, and made inadequate notes, with no clear trust-level actions to prevent future recurrences.
Action Taken
(AI summary)
The CDAT team has updated its Operational Policy and implemented a daily duty sheet/tracker to ensure appropriate follow-up for all issues logged, which is checked daily by the senior on duty. The team has also been reminded of record-keeping obligations.
James Tice
All Responded
2022-0275
5 Sep 2022
Manchester North
NHS Greater Manchester Integrated Care
Concerns summary (AI summary)
There is a critical lack of beds for informal mental health admissions for older adults and insufficient community psychotherapy services for their needs.
Action Planned
(AI summary)
Learning from the case will be presented to the Greater Manchester System Quality Group and cascaded to professionals through governance forums. The Regulation 28 report will be shared with mental health commissioners to ensure a review of older adult inpatient provision.
Stephen Wells
All Responded
2022-0274
5 Sep 2022
West Sussex
NHS England, Royal Surrey County Hospit…
Concerns summary (AI summary)
Significant communication failures between trusts, an outdated service agreement, and reliance on informal referral "workarounds" led to a cancer patient missing crucial chemotherapy, with GPs lacking clear guidance on escalating concerns.
Action Planned
(AI summary)
The Trusts have jointly developed a proforma letter to be given to patients when their care is transferred, containing key contact details and copied to the patient's GP and the receiving Clinical Nurse Specialist. The firewall issue between the Trusts has been resolved and electronic data connections are visible. The Trusts have jointly developed a proforma letter to be given to patients when their care is transferred, containing key contact details and copied to the patient's GP and the receiving Clinical Nurse Specialist. The firewall issue has been resolved.
Asher Sinclair
All Responded
2022-0272
4 Sep 2022
West London
Clinical Commissioning Group
NHS England
Concerns summary (AI summary)
A highly vulnerable child was not provided prescribed 2:1 care, their complex package lacked proper review or quality checks, and critical parental concerns were ignored, compounded by inadequate staff training.
Noted
(AI summary)
NHS North West London has implemented a single children’s continuing care team with registered nurses and experienced managers providing a consistent service. A parental agreement has been developed which sets out expectations and responsibilities in regard to parental responsibility. NHS England highlights the resources provided by The National Tracheostomy Safety Project (NTSP) and notes the NWL's response addressing training, supervision and care packages. They also mention that all reports received are discussed by the Regulation 28 Working Group to share key learnings.
Jennifer Wong
All Responded
2023-0010Deceased
2 Sep 2022
Oxfordshire
Department for Transport
Oxfordshire County Council
Concerns summary (AI summary)
A poorly designed nearside cycle lane creates confusion and places cyclists in conflict with right-turning vehicles, exacerbated by the lane being narrower than recommended standards.
Action Planned
(AI summary)
Oxfordshire County Council has already undertaken a detailed review of the Plain Roundabout and The Parkway junction with amendments planned to be implemented in November 2022, and has reviewed key junctions deemed a potential risk to vulnerable road users with input from cycle safety groups. The Department for Transport will write to the Construction Plant-hire Association (CPA) to raise the issue of compliance with regulations and encourage its members to consider additional devices or technology to help improve mobile crane driver vision.
Violet Howard
All Responded
2022-0273
2 Sep 2022
Manchester North
NHS Greater Manchester Integrated Care
Concerns summary (AI summary)
There is a critical gap in dermatology commissioning for Royal Oldham Hospital inpatients, excluding those from outside the local area unless their skin condition becomes an emergency.
Noted
(AI summary)
NHS Greater Manchester Integrated Care states that the issue is a gap in acute provision rather than a commissioning gap and is being addressed by the Care Organisation via a SLA. Learning will be shared with the Greater Manchester System Quality Group and cascaded to professionals through relevant governance and learning forums.
Gareth Williams
All Responded
2022-0270
31 Aug 2022
Gwent
Aneurin Bevan University Heath Board
Concerns summary (AI summary)
The deceased fell between two non-communicating care teams (mental health and ENT), leading to insufficient support and an inability to resolve his complex health problems.
Action Planned
(AI summary)
Aneurin Bevan University Health Board is expanding a service called 'Adferiad' to include people with other medical and long-term conditions, which will be delivered by a multi-disciplinary team including medical, nursing, and Allied Health Professionals to improve interdisciplinary working between physical and mental health specialties.
Beryl Holt
All Responded
2022-0268
31 Aug 2022
Manchester City
North Manchester General Hospital
Concerns summary (AI summary)
Sepsis protocols are outdated or unknown to staff, including new and agency clinicians, leading to concerns about inadequate training and lack of audits for timely recognition and treatment.
Action Taken
(AI summary)
Manchester University NHS Foundation Trust has implemented actions and recommendations arising from a Root Cause Analysis investigation, including training on the Trust’s new electronic patient record system (HIVE) which issues automated alerts for potential sepsis cases, and periodic audits to ensure appropriate recognition and timely treatment of sepsis.
Jennifer Davies
All Responded
2023-0098Deceased
30 Aug 2022
West Sussex
Department for Transport
Concerns summary (AI summary)
Delivery van drivers, exempt from Working Time Regulations, can work excessively long hours without mandatory breaks, posing a significant risk to public safety, particularly pedestrians in populated areas.
Action Planned
(AI summary)
The Department for Transport will coordinate with the DVSA and ask them to investigate the case if provided with details of the driver's employer, to assess whether the delivery company adhered to working time and health and safety legislation regarding adequate rest.
Christopher Lloyd
All Responded
2022-0266
26 Aug 2022
Manchester South
Department of Health and Social Care
Concerns summary (AI summary)
The deceased lacked ready access to a unified dual-diagnosis service that could holistically assess and treat co-existing mental health conditions and substance misuse issues.
Action Taken
(AI summary)
The Department of Health and Social Care reports that the Greater Manchester ICP developed a Co-Occurring Conditions team for system-wide training, and Tameside launched a Living Well Plus service for high-intensity A&E users; OHID has published guidance for commissioners; and national strategies include additional funding to improve treatment services for mental health and substance misuse.
Christina Ruse
All Responded
2022-0265
26 Aug 2022
Norfolk
East of England Ambulance Service
Concerns summary (AI summary)
Significant delays in emergency ambulance response for a Category 2 call due to high demand led to a patient's deterioration, raising concerns about future deaths despite recent service improvements.
Action Taken
(AI summary)
East of England Ambulance Service has implemented 'Category 1 drop and go' and 'Category 2 rapid release' projects at hospitals in Norfolk to improve response times for critical patients, and shared a briefing for HM Coroners in relation to hospital handover delays. Spire Norwich Hospital has added wording to patient admission letters to ensure all patients are aware that the hospital does not have an on-site critical care unit, and has agreed a process with East of England Ambulance Service for clinician to clinician discussions regarding inter-provider transfers.
Barbara Hollis
All Responded
2022-0264
26 Aug 2022
Norfolk
East of England Ambulance Service
Concerns summary (AI summary)
Emergency ambulance delays due to high demand and an incorrect call pathway led to an extended response time for a Category 2 call, raising concerns about future deaths despite service changes.
Action Taken
(AI summary)
East of England Ambulance Service is working with system partners and the Healthcare Safety Investigation Branch (HSIB) to manage call demand, has implemented daily system calls with stakeholders, and has implemented 'Category 1 drop and go' and 'Category 2 rapid release' projects at a local level in Norfolk. The hospital added wording to admission letters informing patients it does not have an on-site critical care unit. They agreed a process with EEAST for clinician-to-clinician discussions during delayed ambulance responses to share detailed patient information.
Yuksel Ismail
All Responded
2022-0263
25 Aug 2022
Bedfordshire and Luton
Bedford Hospitals NHS Foundation Trust
Concerns summary (AI summary)
Bedford Hospitals NHS Trust failed to implement recommendations for mental health patient transfers, with an inadequate new policy and staff confusion regarding powers to detain 'at-risk' patients lacking mental capacity.
Action Taken
(AI summary)
The Trust updated its Transfer Policy in collaboration with ELFT, adding a section on patient transfers for those at risk of absconding. The Emergency Department and Safeguarding Team reviewed MCA and restraint training, updating it for junior doctors, and implemented monthly shared learning forums.
Eliot Harris
All Responded
2022-0260
22 Aug 2022
Norfolk
Norfolk and Suffolk NHS Foundation Trust
Concerns summary (AI summary)
Critical patient observations were not carried out or recorded correctly, staff lacked training and competency, and there were issues with task allocation, record keeping, and ensuring staff safely enter rooms for patient welfare checks.
Action Taken
(AI summary)
Norfolk and Suffolk Foundation Trust has implemented a Safety Day training program, created a policy folder with policy summaries, and revised the physical health audit process, along with improved training for staff to complete ECGs and phlebotomy; staff now have bleeps for rapid response.
Chelsea Mooney
All Responded
2022-0259
18 Aug 2022
South Yorkshire Western
Cygnet Health Care
NHS England
Concerns summary (AI summary)
The diagnostic process lacked professional curiosity and critical review of patient disclosures, leading to unverified information influencing care. Crucial information sharing with family was inadequate, and self-harm incidents lacked debriefs to inform future risk assessments.
Action Taken
(AI summary)
NHS England's Case Manager attended weekly meetings at Cygnet Hospital Sheffield, and this included discussions about Chelsea’s care. The revised NHSE Case Management Standard Operating Procedure and the in-patient quality programme will strengthen the importance of engagement with families and carers. Cygnet has taken several actions, including reviewing and improving policies and training related to risk assessment, observations, and communication. They have also implemented enhanced governance and oversight processes, including safety huddles and regular audits, to identify and address risks.
John Heffron
All Responded
2022-0258
18 Aug 2022
West Yorkshire Eastern
Leeds Teaching Hospitals NHS Trust
Concerns summary (AI summary)
Significant delays occurred in making a crash call and initiating CPR for a patient who suffered cardiac arrest in A&E, due to initial misidentification of death and confusion regarding DNAR status.
Action Taken
(AI summary)
The Trust has considered and addressed the issues raised, including revising procedures and providing additional training to staff. They have also implemented audit arrangements to check bank and agency staff's familiarity with essential procedures.
Lee Winslow
All Responded
2022-0257
17 Aug 2022
Manchester South
Manchester University NHS Foundation Tr…
Concerns summary (AI summary)
The Trust failed to formally refer a doctor who misappropriated medicines for self-harm to external authorities (police, GMC), and did not reconsider its position when he continued private practice. A critical lack of multi-disciplinary review, relying on the medical hierarchy, was noted given the gravity and prior similar cases.
Disputed
(AI summary)
The Trust believes the coroner's concerns were already addressed during the inquest and in prior correspondence. While noting collaborative work among Greater Manchester Medical Directors, it suggests a national-level review would be more appropriate.
Susan Regan
All Responded
2022-0256
17 Aug 2022
Manchester South
Pennine Care NHS Foundation Trust
Concerns summary (AI summary)
The Home Treatment Team failed to follow clinical guidance to consult the patient's sons about inpatient admission and medication non-compliance. There was also a breakdown in properly recording and communicating the care plan with the family.
Action Taken
(AI summary)
Pennine Care NHS Foundation Trust has re-established supportive forums, established a Patient and Carer Involvement team, and developed a pathway for Lived Experience members to participate in paid roles, and implemented an updated information pack for carers. Also, HTT now has a substantive Consultant Psychiatrist in place and the MDM's have been adjusted to ensure regular attendance of the consultant.
Philip Jones
All Responded
2022-0255
17 Aug 2022
Manchester South
Department of Health and Social Care
Concerns summary (AI summary)
Significant backlogs for neurology appointments and delays in consultant communications were exacerbated by national clinician shortages. Incompatible IT systems between hospitals also hindered crucial information sharing and holistic patient views.
Noted
(AI summary)
NHS Greater Manchester will present learning from the case to the Greater Manchester System Quality Group and cascade shared learning to professionals through relevant governance and learning forums. No content in response.
Gerald Tuck
All Responded
2022-0254
12 Aug 2022
Dorset
Tricuro
Concerns summary (AI summary)
The care home lacked a formal policy or guidance for reviewing care plans and risk assessments following incidents like falls. This systemic gap led to a crucial falls risk assessment not being updated after multiple falls, increasing future risk.
Action Taken
(AI summary)
Tricuro has reinforced policy training, introduced a live accident and incident reporting system, created a policy and procedure for any deaths in service, and implemented a monthly safeguarding and accident/incident report for senior leadership review, and implemented falls focus group to keep staff updated and reiterate the falls policy process and importantly how to reduce the risk of falls.
Brandon Pryde and David Faulkner
All Responded
2022-0250
12 Aug 2022
Manchester South
Greater Manchester Police and Roads and…
Concerns summary (AI summary)
A police pursuit protocol failed to provide effective Command and Control when pursuits crossed force boundaries, due to confusion, unclear communication, and misperceptions of authority. This created a significant safety risk, despite not directly contributing to these deaths.
Noted
(AI summary)
GMP is creating a training schedule to deliver an Initial Pursuit course (IPP) to traffic officers over the next 6-9 months, a 4-day tactical phase commanders' course in the final stages of design, and training for Team 3 dispatch operators, which is planned to take place within the next 6-9 months. Cheshire Constabulary, as lead force of the NWMPG, will deliver a training package regarding command protocols for cross-border pursuits and will monitor GMP's training package to disseminate best practices. Cheshire Police (on behalf of the NWMPG) and GMP have revised the managing pursuits protocol and produced a clearer document which removes the previous ambiguity on the issue of Command and Control. No content in response. Cheshire Constabulary, as lead force of the NWMPG, will deliver a training package regarding command protocols for cross-border pursuits and will monitor GMP's training package to disseminate best practices. Cheshire Police (on behalf of the NWMPG) and GMP have revised the managing pursuits protocol and produced a clearer document which removes the previous ambiguity on the issue of Command and Control.
Katie Horne
All Responded
2022-0253
11 Aug 2022
Inner South London
Princess Royal Hospital
Concerns summary (AI summary)
Significant delays in doctors reviewing crucial blood test results and consulting a gastroenterologist led to late commencement of steroid therapy and delayed liver transplant referral, hindering timely and effective care.
Action Taken
(AI summary)
The Acute Medicine service at the Princess Royal Hospital now has a substantive acute physician and geriatrician on weekdays. Ambulatory care is now in a larger area, and a Gastroenterology 'hot clinic' has been established with specialist staff and a dedicated phone line.
Allan Waddup
All Responded
2022-0343
10 Aug 2022
North Northumberland and South Northumberland
Tees, Esk and Wear Valley NHS
Concerns summary (AI summary)
Mental health services at HMP Northumberland failed to ensure inmates received appointment notifications, leading to discharge without assessment. The "Did Not Attend" policy lacked in-person follow-up before discharge, and urgent weekend referrals were not triaged.
Action Taken
(AI summary)
Appointment letter templates have been reviewed and updated and have now been introduced across all prison establishments, including HMP Northumberland, to notify inmates of planned appointments. Also, the prison service provider at HMP Northumberland has granted the request to remove the ability to refer to mental health services via kiosk and posters have been produced and displayed on the wings providing information about how to refer to the mental health team.
Neil McDougall
All Responded
2022-0251
10 Aug 2022
Somerset
Military of Defence
Concerns summary (AI summary)
Military debriefs lack individual trauma support and promote alcohol use over discussion. The resettlement process for leavers fails to provide mandatory comprehensive mental health assessments, leaving ex-personnel reliant on external services.
Action Taken
(AI summary)
The Army has current policies and procedures to minimise the risk of suicide within the ranks of serving military personnel and the veteran community including education to tackle stigma, providing rapid and flexible access to trauma risk management, and through comprehensive support to personnel transitioning to civilian life. The response includes enclosures detailing specific policies, briefings, and healthcare arrangements.
Mathew Moore
All Responded
2022-0249
9 Aug 2022
Dorset
Swanage Medical Practice
Concerns summary (AI summary)
An unsafe amount of benzodiazepine was remotely prescribed to a patient consuming excess alcohol, without a clear policy for such circumstances or documented communication of concerns. There was also a lack of follow-up for this remote prescribing.
Action Taken
(AI summary)
A protocol alert that triggers on the patient electronic record when any drugs in the prescribing group are issued has been created to warn the prescriber to consider the amount and dosage being prescribed, highlighting the risk of use of the drug combined with excess alcohol use and to consider arranging a face to face medication review with the patient.