2022

PFD Reports
Reports: 385 Areas: 67

78% response rate (above 63% average).

385 results
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.
Helen Burnell
Historic (No Identified Response)
2022-0252 12 Aug 2022 Somerset
Department of Health and Social Care
Concerns summary (AI summary) Staff lacked adequate training and recognition of choking risks for adults with autism and learning disabilities, leading to insufficient adherence to mealtime recommendations.
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.
Lily Girton
Historic (No Identified Response)
2022-0262 11 Aug 2022 East London
Royal College of Paediatrics & Child He…
Concerns summary (AI summary) Community CAMHS failed to adequately monitor and prescribe medication, expedite psychiatric appointments, or properly assess and communicate risk, hindering timely care access. The care plan was not updated despite escalating hospital concerns, leaving the patient without necessary support.
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.
Gerwyn Rees
All Responded
2022-0248 8 Aug 2022 Avon
University Hospitals Bristol and Weston…
Concerns summary (AI summary) The patient was inappropriately allocated a low falls risk, and crucially, the subsequent Root Cause Analysis and senior staff initially failed to recognise this error. This suggests a significant lack of learning and potential flaws in policy understanding or the policy itself.
Action Taken (AI summary) The Trust has reviewed its Enhanced Care Observation and Meaningful Activities Policy and the dementia, delirium and falls team has updated the falls prevention information leaflet as well as providing simulation based bespoke training to ward teams in the management of falls. A small central team of expert investigators will carry out patient safety incident investigations.
Robyn Skilton
All Responded
2022-0247 7 Aug 2022 West Sussex
Department of Health and Social Care
Concerns summary (AI summary) Significant underfunding and under-resourcing of CAMHS caused extensive waiting times for child psychiatrist assessments, preventing timely diagnosis and treatment. Exploding referral rates without proportionate resource increases have made the service unsustainable, endangering young people.
Noted (AI summary) The response acknowledges concerns about access to child and adolescent mental health services (CAMHS) in West Sussex. It outlines national initiatives to increase funding for and access to mental health services, including potential waiting time standards, and mentions a public call for evidence.
Ernest Bacon
All Responded
2022-0246 6 Aug 2022 Manchester South
Department of Health and Social Care Tameside and Glossop Integrated Care NH…
Concerns summary (AI summary) Insufficient weekend doctor staffing led to delayed face-to-face review for a sepsis-triggering patient, causing the seriousness to be unrecognised and the sepsis policy to be un-followed. The failure to escalate concerns was unclear.
Noted (AI summary) The response acknowledges the concerns raised and references actions taken by Tameside and Glossop Integrated Care NHS Foundation Trust, including a Root Cause Analysis and increased medical rota. It also notes that the CQC received assurance regarding a review of the sepsis pathway and retraining for staff. The Trust is planning to pilot an eNEWS application across its surgical wards to improve the accuracy and speed of data recording and to eliminate errors in early score warning calculation. The Trust's incident trigger lists have been circulated widely throughout the organisation with a reiteration of the importance of incident reporting.
Malcolm Garrett
All Responded
2024-0281 4 Aug 2022 Manchester South
Department of Health and Social Care
Concerns summary (AI summary) There was no specific guidance for managing or expediting discharge for high-risk immunosuppressed patients susceptible to Covid-19 in hospital. Additionally, insufficient monitoring and understanding of kidney function led to opiate toxicity.
Noted (AI summary) The Department acknowledges the concerns, states that NHS England engaged with the Trust, and that the CQC did not identify a need for further investigation of this specific case but continues to monitor the Trust’s performance.
Stanislav Mucha
All Responded
2022-0245 4 Aug 2022 Manchester North
Department of Health and Social Care Royal College of Psychiatrists
Concerns summary (AI summary) There was no documented agreement among professionals regarding the outcome and necessary actions following a mental health act assessment, leading to confusion and a failure to progress critical steps like a warrant, delaying further intervention.
Action Planned (AI summary) The Department of Health and Social Care notes that Pennine Care Foundation Trust has implemented a shared electronic system across services (except IAPT) and recommends uploading Mental Health Act documentation into patient records. They will also consider including specific time periods for producing notes of assessments in the revised Code of Practice. The Royal College of Psychiatrists will use communication opportunities to remind members of the need for consistent and comprehensive recording of all clinical contacts, including those related to the Mental Health Act. A mental health assessment recording act template has been created for Section 12 doctors to complete, requiring rationale for not making a recommendation. All AMHPs now complete a social circumstance report when the decision is made not to detain a patient.
Margaret Warwick
Historic (No Identified Response)
2022-0243 4 Aug 2022 Manchester South
Department of Health and Social Care
Concerns summary (AI summary) Significant delays in a hip fracture patient's care were caused by a shortage of cardiologists, particularly during weekends, and further compounded by theatre capacity and High Dependency Unit bed shortages.
Roy Draper
All Responded
2022-0242 4 Aug 2022 Derby and Derbyshire
Medicines and Healthcare products
Concerns summary (AI summary) There is no clear protocol for initiating and managing unblinding requests for clinical trial patients treated in other hospitals. The absence of a formal referral system also hinders transparent communication about adverse events and unblinding.
Noted (AI summary) The MHRA states that no action is required, explaining existing systems for unblinding clinical trials and the responsibilities of those executing the processes, particularly regarding informing participants and documenting contact with treating physicians.
Malcom Garrett
Historic (No Identified Response)
2022-0241 4 Aug 2022 Manchester South
Department of Health and Social Care
Concerns summary (AI summary) There was no specific guidance for managing or expediting discharge for immunosuppressed patients at high risk of COVID-19. Discharge was also delayed by opiate toxicity, exacerbated by inadequate kidney function monitoring.
John Kay
All Responded
2022-0240 4 Aug 2022 Manchester South
Greater Manchester Health and Social Ca…
Concerns summary (AI summary) Critical information about a patient's complex valve care was not shared with the care home, resulting in missed monitoring and increased health risks. The specialist nurse service's role was also poorly understood by community healthcare providers.
Action Planned (AI summary) A briefing paper is to be shared across the Stockport GP population with information about the management of tracheoesophageal valves and the availability of the specialist nurse. Learning from this case will also be presented to the Greater Manchester System Quality Group and cascaded to professionals through relevant governance and learning forums.
James Curry
All Responded
2022-0239 4 Aug 2022 Manchester South
Greater Manchester Health and Social Ca… Tameside and Glossop Integrated Care NH…
Concerns summary (AI summary) Persistent bed shortages caused elderly hip fracture patients to endure lengthy Emergency Department waits, hindering timely orthogeriatric care and preventing surgery within NICE guideline timescales. This impacts patient outcomes and mortality.
Noted (AI summary) Learning from this case will be presented/shared with the Greater Manchester System Quality Group and cascaded to professionals through relevant governance and learning forums to improve outcomes for the population of Greater Manchester. Response contains no content.