2022
PFD Reports
Reports: 385
Areas: 67
78% response rate (above 63% average).
Rita Flynn
All Responded
2022-0310
3 Aug 2022
Black Country
Royal Wolverhampton NHS Trust
Concerns summary (AI summary)
A patient was discharged home with clear indicators of infection before blood test results were available, contrary to best practice.
Action Taken
(AI summary)
The Royal Wolverhampton NHS Trust has incorporated a section for documenting investigations and results into the ED clerking document. They have also agreed to include training on reviewing blood results in the postgraduate doctor training portfolio, and allocated consultant time for reviewing blood results in the Clinical Webb Portal - ICE system.
Nigel Saunders
All Responded
2022-0300
3 Aug 2022
Nottinghamshire and Nottingham
HMP Lowdham Grange
Concerns summary (AI summary)
The prison repeatedly failed to retain and preserve crucial evidence following deaths in custody, undermining investigations and preventing lessons from being learned, indicating a serious local systemic issue.
Noted
(AI summary)
HMP Lowdham Grange has updated its DIC checklist to include the Oscar Journal. The use of ACCT tick sheets has been discontinued and all records are contained within the ACCT book. This is a response from a coroner to HMP Lowdham Grange, acknowledging the measures taken and suggesting further alignment with Chief Coroner guidance on disclosure.
Kellum Thomas
Historic (No Identified Response)
2022-0244
3 Aug 2022
Nottinghamshire and Nottingham
Birmingham Women and Childrens Hospital…
the NHS Commissioning team
Concerns summary (AI summary)
The patient lacked a cardiac monitoring device for 18 months due to a poor system for identifying battery end-of-life and excessively long replacement waiting lists. Additionally, crucial outpatient letters were significantly delayed.
Alison Dallow
Historic (No Identified Response)
2022-0238
3 Aug 2022
Herefordshire
Wye Valley NHS Trust
Concerns summary (AI summary)
Clinical advice on weight-bearing status was unclear, and the hospital's VTE risk reduction policy for outpatients lacked clarity. There was also no documented evidence of information provided to the patient.
Stanley Hardy
All Responded
2022-0237
2 Aug 2022
Newcastle and North Tyneside
Department for Transport
Concerns summary (AI summary)
A coach driver avoided emergency braking, despite seeing a pedestrian, due to training prioritising passenger welfare. Emergency braking procedures are not a required part of bus and coach driver training.
Action Planned
(AI summary)
While the Department for Transport believes there is already an adequate framework, the DVSA will review all learning materials where emergency braking skills are covered at the next opportunity and consider whether these sections could benefit from additional or stronger information.
Charles Wheatley
All Responded
2022-0304
29 Jul 2022
County Durham and Darlington
Department for Transport
Concerns summary (AI summary)
The current system illogically allows individuals to purchase and keep a car without possessing a driving license, raising concerns about road safety.
Noted
(AI summary)
The Department for Transport explains that there is no legal requirement to hold a driving licence to register a vehicle, or to become the keeper of an already registered vehicle, and outlines circumstances where this might occur.
Locksley Burton
All Responded
2022-0236
29 Jul 2022
Inner South London
Kings College Hospital
QHS GP Care Home
Tower Bridge Care Home
Concerns summary (AI summary)
Inadequate wound care occurred due to reduced clinic attendance without an alternative plan, and the GP prescribed antibiotics without examination. There was no clear process for managing patients declining care or lacking capacity.
Action Planned
(AI summary)
Tower Bridge Care Home describes arrangements for diabetic foot clinic attendance, communication with GPs and multidisciplinary meetings, and identifies residents with high needs to the consultant geriatrician for face-to-face reviews, since September 2022. They also describe processes for DNAR (Do Not Attempt Resuscitation) orders and managing capacity issues. The RCGP is working to improve communication between secondary and primary care with colleagues across specialities, and with NHS England and NHS Improvement to improve communication links. King's College Hospital has established a working group to improve consent and MCA assessments, reviewing consent and MCA training programmes, and updated the Trust's consent policy. The Trust also initiated a Trust-wide consent audit in September 2022.
Christopher Boughton
All Responded
2022-0235
29 Jul 2022
Surrey
National Police Chiefs’ Council
Concerns summary (AI summary)
A lack of communication and clear ownership between bordering police forces hindered effective tasking and transfer of investigations, resulting in search requests being mismanaged and crucial information not being disclosed.
Action Planned
(AI summary)
The National Police Chiefs' Council (NPCC) highlights existing APP guidance on cross-border cases and states that a Task and Finishing Group has developed draft NPCC advice on ‘Requesting Missing Person Enquiries in Another Force and Transfers of Investigations’ which has been circulated for comment.
Brian Parry
Historic (No Identified Response)
2022-0234
28 Jul 2022
South Yorkshire Western
Brunswick Retirement Village
Concerns summary (AI summary)
Staff lacked training to immediately call emergency services and were not confident in basic first aid; emergency assistance calls were inefficiently routed, and no advanced first aider was on site.
Hemanta Rai
Partially Responded
2022-0232
26 Jul 2022
South Wales Central
Brecon Beacons National Park Authority
Natural Resources Wales
Neath Port Talbot Council
+2 more
Concerns summary (AI summary)
Inadequate and unclear signage at a waterfall location fails to explicitly warn visitors of drowning risks. Furthermore, responsibility for safety in this multi-jurisdictional area is poorly defined.
Action Planned
(AI summary)
Brecon Beacons National Park Authority and Neath Port Talbot Council have jointly commissioned an independent reviewer to conduct a comprehensive signage review in public access areas and advise on creating user-friendly signage, also implementing a uniform signage approach. Brecon Beacons National Park Authority and Neath Port Talbot Council have jointly commissioned an independent reviewer to conduct a comprehensive signage review in public access areas and advise on creating user-friendly signage, also implementing a uniform signage approach.
Archi Johnson
All Responded
2022-0231
26 Jul 2022
Exeter and Greater Devon
Devon Partnership NHS Trust
Concerns summary (AI summary)
Crucial information, especially about previous suicide attempts, was not consistently recorded or shared across different risk assessments. This prevented staff from knowing significant risks, potentially impacting care decisions and safety measures.
Action Taken
(AI summary)
Devon Partnership Trust has shared the coroner's findings with relevant services and completed the action plan developed in response to a Serious Incident Investigation following the death. Actions taken address how risk assessment information is recorded and shared.
Kane Davidson
All Responded
2022-0230
26 Jul 2022
Manchester North
Oldham Council
Concerns summary (AI summary)
The council's landlord licensing process lacks prior premises audits and doesn't explicitly address child safety risks like internal blinds. Enforcement for non-compliance is unclear, and tenant certificates are misleading.
Noted
(AI summary)
Oldham Council has amended the wording on licenses, added blind cord safety as a license condition (checked at every property visit), briefed enforcement officers on blind cord safety, and added related information to the Council's website. A new selective licensing scheme was also reintroduced in July 2022. The Department acknowledges the coroner's concerns but believes awareness campaigns are key. They support RoSPA's 'Make It Safe' campaign and will consider how to strengthen its reach.
Stephen Coombes
Partially Responded
2022-0229
25 Jul 2022
Suffolk
Kier Highways Ltd
Suffolk Highways
Concerns summary (AI summary)
Inadequate signage for a temporary 30 mph speed limit, with higher speed limit signs remaining visible, led to confusion for road users and police. This failure significantly increased the risk of collisions at a known road defect.
Action Taken
(AI summary)
Kier obscures existing speed limit signs and road markings when implementing temporary speed reductions, checks temporary traffic management daily, updated its WMS (Work Management System) to ensure checks are scheduled from the point of installation. They have also implemented an enhanced procedure with an audit program and provided enhanced guidance and toolbox talks to work gangs and completed a site investigation and options study of Burnt Fen Turnpike.
Natalie Mortimer
All Responded
2022-0227
25 Jul 2022
Mid Kent and Medway
Green Porch Medical Centre
Concerns summary (AI summary)
A patient's prior overdose attempt was not updated in their GP record, leading to a GP prescribing a large, potentially unsafe quantity of medication without awareness of the patient's history.
Action Taken
(AI summary)
The practice has employed a full-time read-coder, introduced a correspondence triage policy, implemented a system for important patient alerts, updated its significant event policy, communicated a case study to clinicians via the GP bulletin (planned actions also to remove the 100-tablet pack size of colchicine from formularies and add a warning message to script switch), placed alerts on patient records for colchicine requests, and is auditing Docman for quality compliance.
Ethan Wright
All Responded
2022-0226
25 Jul 2022
Suffolk
Suffolk Highways
Concerns summary (AI summary)
A public bridleway's junction with a main road has severely restricted visibility and lacks measures to slow down cyclists or pedestrians. This design creates a high collision risk, particularly for children.
Action Planned
(AI summary)
The council plans to install an illuminated 'STOP' sign, paint a white stop line, paint 'STOP' on the tarmac, and paint the existing concrete bollards with yellow and black paint. Installation is planned within 15 weeks.
Christopher Ryan
All Responded
2023-0053Deceased
22 Jul 2022
West London
South West London and St George’s Menta…
Concerns summary (AI summary)
The trust tolerated a blurring of therapeutic escorted leave with unsecure smoking breaks, where one staff member supervised multiple patients in an unsecure car park. This lack of clear boundaries and a safe smoking area allowed patients to abscond with catastrophic consequences.
Action Planned
(AI summary)
The Trust details the policy regarding smoking, highlighting that it isn't permitted in buildings, carparks, grounds and gardens. The Trust has committed to undertaking a formal and comprehensive review of its 'Smoke Free' policy which has commenced and is due to be concluded in July 2023, which will also include how we ensure that practice reflects policy, particularly around leave.
Michael Shuttleworth
All Responded
2022-0224
22 Jul 2022
West Yorkshire Eastern
Mercedes-Benz
UPS
Concerns summary (AI summary)
A van's design created a large blind spot masking pedestrians, compounded by a lack of audible impact sensors and insufficient driver training and appraisal.
Noted
(AI summary)
Mercedes-Benz clarifies its role as a supplier of a 'cowl' chassis and states that the modifications to the vehicle were the responsibility of Firma Sommer, who converted it into a complete vehicle. The driver was dismissed, and UPS details its driver training and assessment procedures, including a 'Space and Visibility' program. The company refutes that it provides no feedback.
Lewis Powter
Historic (No Identified Response)
2022-0223
21 Jul 2022
Cambridgeshire and Peterborough
Ministry of Justice
NHS England
Concerns summary (AI summary)
There is no clear policy for multi-agency information sharing meetings for complex IPP offenders, particularly when agencies lack access to shared record systems.
Gaia Pope-Sutherland
All Responded
2022-0222
21 Jul 2022
Dorset
Association of British Neurologist
BCP Council
Department of Health and Social Care
+6 more
Concerns summary (AI summary)
Poor communication between neurology and mental health teams, under-resourced epilepsy services, and inadequate police training on epilepsy and complex mental health conditions pose significant risks.
Noted
(AI summary)
NHS Dorset will undertake a review of nursing resources in epilepsy care locally, encompassing primary and secondary care for adults and children, and interaction with other specialities. The Regulation 28 Report will be shared and reviewed with NHS partners at the Pan Dorset Mortality Group. BCP Council's AMHP service uses the Mental Health Act 1983 and Code of Practice, monitored through a Quality Assurance Framework, to inform practice. They are actively engaging with Dorset Healthcare Trust to amend the Pan-Dorset Standard Operating Procedure and discussing with AMHPs how to succinctly share information with GPs. The Integrated Care Board (ICB) are carrying out an 8 week review of the entire Epilepsy and Neurology service which started on 11 August 2022. Dorset Council has completed an internal review of its AMHP pathways and recording systems to ensure adherence to the Mental Health Act Code of Practice, focusing on information sharing. The AMHP service managers will ensure review of records before assessment and there is a new mandatory field to notify the allocated social care practitioner of any Mental Health Act assessment. The trust outlines multiple planned actions, including updating policies to address sexual harassment/assaults on inpatient units, reviewing patient observation practices, improving documentation of rationale for observation levels, reviewing guidance on informal patient status, ensuring comprehensive discharge summaries are sent to GPs after Mental Health Act assessments. The College of Policing believes their current approach to vulnerability training, which focuses on risk management and information gathering, is appropriate. They argue that the complexity and variability of medical conditions make specific training impractical for non-medical personnel. Dorset Police supports sharing learning about life-threatening illnesses with the College of Policing and has offered to support national training. They have implemented changes to the POLSA/LPSM process, directed staff to use Niche for logging decisions, and are including a session on log keeping in Vulnerability 4 training; revised processes are in place to monitor training activity. The Trust has introduced a Standard Operating Procedure in May 2022 which covers the provision of information following Mental Health Act assessments. The Association of British Neurologists will communicate suggested actions to improve communication between psychiatry and neurology teams, such as copying communications to the treating neurologist and informing neurologists of psychiatric admissions. They will also discuss these issues with the President of the Royal College of Psychiatrists. The Royal College of Psychiatrists acknowledges the lack of effective communication between neurology and mental health services. They highlight workforce issues in neuropsychiatry and support the development of integrated services in neuroscience centers in ICSs. The Trust has updated its Safeguarding policy to highlight the response needed when an adult discloses they have experienced sexual abuse, with two appendix documents added to the policy setting out further details.
Colleen Fletcher
All Responded
2022-0308
20 Jul 2022
Rutland and North Leicestershire
Executive NHS Leicester
Leicestershire and Rutland Integrated C…
Concerns summary (AI summary)
Diabetic patients with stable glucose levels lack pre-issued rapid-acting insulin, causing critical delays in treatment when levels rise and risking hyperglycaemic collapse before emergency services attend.
Action Planned
(AI summary)
The ICB has established a task and finish group to review the clinical pathway for management of Hyperglycaemia in Care Homes. The ICB plans to trial new rapid acting insulin guidance, review the existing insulin authorisation form, and support the development of a business case to expand the use of continuous glucose monitors devices for patients in care homes.
Jade Hart
All Responded
2022-0228
20 Jul 2022
Nottinghamshire
Doncaster and Bassetlaw Teaching Hospit…
Concerns summary (AI summary)
The Trust's serious incident investigation was flawed, hindering learning. Newly appointed obstetric consultants lacked sufficient mentoring and access to senior support for complex emergencies.
Action Taken
(AI summary)
The Trust has taken actions including delivering training and reviewing its serious incident investigation process. They have introduced a 'Memory Capture Document' for staff to record events after an incident.
Muhammad Hassan
Historic (No Identified Response)
2022-0221
19 Jul 2022
Cambridgeshire and Peterborough
National Institute for Health and Care …
Royal College of Midwives
Concerns summary (AI summary)
A lack of national guidance on feeding expectations for low-risk, formula-fed babies in their first 72 hours risks premature discharge and insufficient information for families on signs of concern.
Ezra Tamiem
Historic (No Identified Response)
2022-0220
19 Jul 2022
Bedfordshire and Luton
HMP Bedford
HMPPS
Concerns summary (AI summary)
A ligature point in a healthcare wing cell, not designed as a "safer cell," was used by the deceased and remains an unaddressed risk without plans for remedy.
Beryl Simcock
All Responded
2022-0219
19 Jul 2022
Nottinghamshire and Nottingham
Radcliffe Manor House Care Home
Concerns summary (AI summary)
The care home lacked written policies for care planning and review, with falsified records for risk assessments. Families were also denied timely information regarding significant incidents or deprivation of liberty.
Action Planned
(AI summary)
Radcliffe Manor House plans to introduce a digital care planning system and an online total quality system by the end of the year. They have implemented changes to the falls protocol to ensure relatives are informed and are inviting family members to participate in monthly reviews of the resident’s care plan. Swift Management Services conducted a clinical governance review of Radcliffe Manor House and recommended improvements including investment in an electronic care planning system and training for staff and trustees on clinical governance, risk management, and escalation pathways. The trustees have already made significant improvements in falls management and overall clinical governance.
Graham White
Partially Responded
2022-0218
18 Jul 2022
East London
Royal College of Surgeons
Department of Health and Social Care
Barking, Havering and Redbridge Univers…
+1 more
Concerns summary (AI summary)
The Trust lacked a stent patient registry for monitoring and recall, couldn't assess risks to existing patients, and failed to escalate this death as a serious incident.
Action Planned
(AI summary)
The hospital implemented a new electronic stent register in August 2022 to track stents and warn staff of overdue stents. The Trust also retrospectively reviewed all stents inserted over the preceding 3 years and has started contacting patients who had been missed. The hospital has also introduced a lithotripsy service to reduce the need for stent insertion and has secured financial approval for a third Urology Consultant. The Trust has completed a Serious Incident/Root Cause Analysis and made recommendations, including providing patients with information leaflets and stent cards, establishing an electronic stent register, creating a standard operating procedure for stent management, investigating non-attendance, auditing patients with stents, assessing demand and capacity for treating stone patients, and strengthening incident reporting. BAUS acknowledges the need to log and track ureteric stents and improve patient/GP communication. BAUS will consider carrying out an audit of contemporary stent management practices and liaise with the Royal College of General Practitioners to discuss how information regarding stent symptoms and the importance of timely stent removal can best be disseminated to GPs.