2023

PFD Reports
Reports: 552 Areas: 65

85% response rate (above 63% average).

552 results
Meghan Chrismas
All Responded
2024-0118 29 Dec 2023 Surrey
Hampshire and Isle of Wight Constabulary NHS England
Concerns summary (AI summary) Inadequate supervision of police control room operators and the absence of effective information-sharing structures between NHS and private healthcare providers posed significant risks.
Action Taken (AI summary) NHS England highlights existing policies and guidelines, including the Summary Care Record (SCR) and professional guidelines on information sharing, to address concerns about information transfer between NHS and private healthcare providers. It also mentions a working group that reviews PFD reports to identify and address emerging trends. The Constabulary provided CPD training on THRIVE Risk Assessment and Re-assessment of Risk to control room staff in 2023. They adopted the THRIVE risk assessment model in October 2023 and expanded the remit of the QuAD team to audit incidents and supervisory reviews. They also launched a 'Your Call' learning publication in January 2024.
Karmchand Gulzar
All Responded
2023-0550 29 Dec 2023 Black Country
Sandwell and West Birmingham NHS Trust
Concerns summary (AI summary) Failures in following surgical referral pathways, performing necessary CT scans, and recognizing patient deterioration due to communication issues and disregarded family concerns, despite previous warnings.
Action Taken (AI summary) Sandwell and West Birmingham NHS Trust updated and re-issued their 'Management of Acute Abdomen' guideline in June 2023 with a flowchart and emphasis on early CT scanning. They are also trialling a 'Carers Passport' to improve carer involvement in patient care in April 2024 and have identified training and education in patient experience and communication as Trust priorities.
Andrew Guillaume
All Responded
2023-0549 29 Dec 2023 Coventry and Warwickshire
Department of Health and Social Care NHS England South Warwickshire University NHS Found… +1 more
Concerns summary (AI summary) Communication breakdowns from inaccessible switchboards and unknown emergency numbers, combined with an incomplete referral, caused significant delays in patient discussion and transfer.
Noted (AI summary) NHS England acknowledges the concerns raised and notes the Root Cause Analysis Investigation Report by South Warwickshire University NHS Foundation Trust (SWFT). They also note that SWFT is reviewing referral mechanisms and circulating a safety practice alert and that all PFD reports are discussed by a working group. South Warwickshire University NHS Foundation Trust (SWFT) and University Hospitals Coventry and Warwickshire NHS Trust (UHCW) jointly reviewed communication and referral processes and completed several actions including a roundtable discussion, confirming a one-contact referral process, circulating a safety practice alert and sharing learning at governance meetings. University Hospitals Coventry and Warwickshire NHS Trust engaged with South Warwickshire University Hospitals (SWUFT) and have agreed an escalation process that provides a direct line of communication 24/7. They will also explore technological options to improve communication and share this with other providers across the System. The Department of Health and Social Care notes that the South Warwickshire University NHS Foundation Trust and the University Hospitals Coventry and Warwickshire NHS Trust have addressed the coroner's concerns. They also note that NHS England has replied and are sighted on the issues raised.
Adrian Gallagher
All Responded
2024-0010 28 Dec 2023 Cheshire
Department of Health and Social Care
Concerns summary (AI summary) An online book providing explicit, step-by-step suicide instructions, including methods to avoid detection, is readily accessible with inadequate age verification, posing a significant risk to vulnerable individuals.
Action Planned (AI summary) The National Crime Agency (NCA) is engaging with Ofcom to combat illegal suicide content online under the Online Safety Act. It also mentions the HMG Drugs Strategy, the Suicide Prevention Strategy and the Criminal Justice Bill, as well as the Department of Health and Social Care's work with Samaritans on the delivery of their online excellence programme. The Department for Science, Innovation and Technology outlines how the Online Safety Act will require tech companies to take responsibility for user safety and remove illegal content, including suicide and self-harm content. It details the duties of user-to-user services and search services, as well as enforcement powers for Ofcom. The Department of Health and Social Care is reviewing actions to reduce harm from suicide-related publications and collaborating with government departments, charities, and experts. They lead a cross-sector working group and support the Samaritan’s Online Excellence Programme.
Larry Spriggs
All Responded
2024-0104 22 Dec 2023 Surrey
Surrey and Boarders Partnership NHS Fou…
Concerns summary (AI summary) The coroner notes a lack of evidence of cultural change in patient care and treatment, as well as concerns regarding inpatient risk assessment, information passage between staff, and intermittent observation management at Farnham Road Hospital.
Action Taken (AI summary) The Trust has launched a new five-year strategy focused on high-quality care, an inpatient improvement plan for safety and quality improvements, and introduced the Supportive Observations Audit Tool, with a digital solution being tested for recording supportive observations. They are also leading a national work stream on workforce and training for therapeutic observations.
Barbara Woodman
All Responded
2024-0100 22 Dec 2023 Surrey
NHS England Surrey and Borders Partnership NHS Foun… Surrey County Council +1 more
Concerns summary (AI summary) Missed opportunities for collateral history gathering, inaccessible information systems, inadequate risk assessment handling, and poorly recorded care plans collectively hindered effective mental health support.
Noted (AI summary) Surrey Police acknowledges the PFD report but notes that no specific issues were raised in relation to their force, however they will share the findings amongst relevant teams. NHS England highlights the National Care Records Service (NCRS) and Shared Care Records, aiming for national interoperability between all Shared Care Records in England by March 2025 to improve information sharing. Surrey and Borders Partnership NHS Foundation Trust and Surrey County Council clarify the purpose of the SCARF process and highlight existing crisis support services. A project group will be carrying out a detailed review of their cross-agency SCARF process.
Carrianne Franks
All Responded
2024-0032 21 Dec 2023 Nottingham City and Nottinghamshire
National Institute for Clinical Excelle… NHS England UKHSA
Concerns summary (AI summary) Inadequate TB exposure guidelines for healthcare professionals, overly narrow "close contact" definitions, insufficient staff education, and failures to include all staff in notifications for highly transmissible cases.
Action Planned (AI summary) NHS England developed the TB Action Plan for England, 2021-2026 and commissioned a GIRFT review of TB service provision. They also supported professional awareness resources, a TB eLearning resource, and issued a TB service specification. The UKHSA co-developed and co-owns the National TB Action Plan with NHS England. It has developed and delivered a series of webinars on TB available to healthcare professionals, and contributed to the RCN competency framework for TB nurses. NICE will share the report with their guideline surveillance team to check for new evidence on TB contact tracing. They also plan to discuss the report with the UK Health Security Agency.
Denise Porter
Historic (No Identified Response)
2023-0548 21 Dec 2023 West London
Oxleas NHS Foundation Trust
Concerns summary (AI summary) The Trust's failure to thoroughly interrogate a police referral and reliance on an incomplete incident summary led to a critical misassessment of suicide risk and an inadequate care plan.
Wyndham Thomas
All Responded
2023-0547 21 Dec 2023 Nottingham City and Nottinghamshire
HM Prison and Probation Services
Concerns summary (AI summary) The absence of in-cell ligature point risk assessments, ligature point maps, and mandatory "Safer Cells" in prisons creates critical missed opportunities to prevent self-harm by ligation.
Action Taken (AI summary) HMPPS has implemented a revised ACCT case management approach across the prison estate to improve support for prisoners at risk of self-harm or suicide. They are also developing a safety training package for staff which will improve understanding of suicide and self-harm prevention.
Nicholas Dymond
All Responded
2023-0545 21 Dec 2023 Exeter and Greater Devon
Devon Partnership NHS Trust
Concerns summary (AI summary) Independent mental health assessors lack mandated access to full patient records, while staff misunderstand voluntary admission and the "least restrictive option," potentially hindering appropriate care.
Action Taken (AI summary) Devon Partnership NHS Trust now offers training for independent s.12 doctors to access CareNotes, and makes its best endeavours to ensure that at least one of the assessing doctors is a psychiatrist who works within the Trust; MHA assessments are subject to a robust audit process.
Kimberley Liu
All Responded
2023-0544 21 Dec 2023 Inner North London
Department for Culture, Media and Sport
Concerns summary (AI summary) Unregulated websites facilitate dangerous, unchecked sales of prescription-only sedative medications, actively instructing customers to evade detection, which exploits vulnerable individuals and poses a suicide risk.
Action Taken (AI summary) The MHRA addresses illegal sale of prescription medications, working with partners across government; the Online Safety Act will give powers to Ofcom to ensure platforms remove illegal content; a national near real time suspected suicide surveillance system was launched in November 2023.
Amal Ahmed
Partially Responded
2023-0543 21 Dec 2023 Milton Keynes
Apple Google Milton Keynes City Council +2 more
Concerns summary (AI summary) Inadequate and poorly visible "No Entry" signage at a slip road junction, particularly at night, frequently leads to drivers mistakenly entering the road in the wrong direction.
Noted (AI summary) Milton Keynes City Council states they have received no formal complaints about the junction, confirm that the slip road and signage are the responsibility of National Highways, and note that they will cooperate with any actions arising from the inquest that are in their power. TomTom has implemented additional safeguards to limit driver confusion at the A5 Little Brickhill junction by timing verbal commands closer to the actual exit and after passing the off-slip road; these changes require users to update their maps. Google is working on improvements to the timing of audio guidance in Google Maps, including an amended audio prompt for junctions where drivers cross an overpass and anticipate launching these changes in the near future. Apple found no data or routing error on Maps, but will add special voice guidance for drivers heading past the A5 offramp toward the A5 onramp instructing them to "Continue straight at the overpass" and then "Turn right onto A5 toward Milton Keynes, Bletchley," which will be live by the start of next week.
Ryan Evans
All Responded
2024-0005 20 Dec 2023 Hampshire, Portsmouth and Southampton
Frimley Health NHS Foundation Trust Surrey and Borders Partnership NHS Foun…
Concerns summary (AI summary) Hospital staff failed to conduct a mental health assessment for a patient with obvious self-harm and suicidal ideation, contradicting NICE guidelines. Critical suicidal ideation was also not adequately recorded.
Action Planned (AI summary) The Trust is working with other acute NHS Trusts within Surrey as part of the Surrey Heartlands Mind & Body Programme. A mental health skills module for nurses working at Frimley began last year, and there is space for 30 students for the next cohort starting in March 2024. Frimley Health has updated Emergency Department Triage processes, introduced a Mental Health Assessment form, and developed a Mental Health Strategy Group. They also hold monthly meetings with Psychiatric Liaison services and Surrey Police to discuss practical points and evolving issues.
James Campion
Partially Responded
2023-0539 20 Dec 2023 Liverpool and Wirral
Department of Health and Social Care NHS England NHS Improvement
Concerns summary (AI summary) Significant delays in 999 call triage and ambulance dispatch, stemming from high demand, critically impacted the timely provision of medical and psychiatric assistance for an overdose.
Action Planned (AI summary) The Department of Health and Social Care mentioned plans to improve A&E waiting times, reduce ambulance response times, expand mental health services through NHS111, and invest in mental health infrastructure. They are also deploying mental health professionals in 999 call centers and clinical assessment services.
Shaun Parks
Historic (No Identified Response)
2023-0538 20 Dec 2023 South Yorkshire (Western)
Department of Health and Social Care West Yorkshire Integrated Care System
Concerns summary (AI summary) An excessive ambulance response time was caused by insufficient emergency medical dispatchers and significant hospital patient offloading delays, tying up resources and impacting emergency call response.
Gregor Lynn
All Responded
2023-0537 20 Dec 2023 Cambridgeshire and Peterborough
Cambridgeshire Peterborough Integrated … Department of Health and Social Care NHS England
Concerns summary (AI summary) A cost barrier in private healthcare discourages patients from crucial histological analysis of lesions, unlike NHS treatment where it's included, risking delayed cancer detection for those not meeting NHS referral criteria.
Noted (AI summary) NHS Cambridgeshire and Peterborough Integrated Care Board have signposted all GPs working for the NHS within to guidance on detection of skin cancers, reminded them to refer any skin lesions where there is diagnostic uncertainty, and reminded all services that they commission in primary care that excised skin lesions should be sent routinely for histology. NHS England stated that the ICS have reminded all GPs within Cambridgeshire and Peterborough Integrated Care System of the guidance on skin cancers, shared the benign skin lesion policy, and reminded their NHS primary care commissioned dermatology services of the guidance on techniques and facilities for conducting minor surgery. The Department of Health and Social Care acknowledged the concerns and stated that NHS England has responded to the coroner in detail. They reiterated the importance of patient safety and the role of the Care Quality Commission and General Medical Council.
Joanne Constable
All Responded
2023-0536 20 Dec 2023 Cambridgeshire and Peterborough
Cambridgeshire County Council
Concerns summary (AI summary) The local authority lacks systems to record, track, and confirm action on highway complaints and defects, meaning reported hazards may not be remedied and posing a clear risk of future fatal road incidents.
Action Planned (AI summary) Cambridgeshire County Council will implement a new highways management system for single source records. The Green Infrastructure Team will proactively manage areas of known risk and identify similar locations across the county’s road network.
Martin Willis
All Responded
2024-0171 19 Dec 2023 Shropshire, Telford and Wrekin
HM Prison and Probation Service Midlands Partnership NHS Foundation Tru… North Staffordshire Combined Healthcare…
Concerns summary (AI summary) The ACCT procedure was not properly implemented or supervised, including false entries and omissions. Concerns remain regarding correct observation levels and the need for an inter-agency review of mental health care provided in prison.
Action Planned (AI summary) Following an inter-agency review, the trust is implementing actions including refresher training, improving the ACCT procedure, updating risk assessment documentation, and reviewing procedures for transferring prisoners to establishments with hospital wings. Various completion timescales are provided, ranging to September 2024. The trust states that the coroner's concerns have informed the development of a Health in Justice Suicide Prevention Plan, including a multi-agency Suicide Prevention Forum, and will share the results of an inter-agency review with staff and partners. Completion is expected by September 2024. HMPPS will present an operational briefing to staff on responsibility for ACCT checks. They have updated Case Co-ordinator processes, and are sharing QA with managers, and meeting with partner agencies to relay responsibilities.
Richard Hedges
All Responded
2023-0546 19 Dec 2023 North West Kent
Gravesham Borough Council
Concerns summary (AI summary) An external concrete staircase presented worn, un-highlighted steps lacking non-slip surfaces, an inadequately short handrail, and poor lighting, increasing the risk of falls.
Action Taken (AI summary) The council removed steps and a platform at a bin store to improve safety and accessibility, installed lighting, and removed a similar structure at another location. They believe these actions address all concerns raised.
Morgan-Rose Hart
All Responded
2023-0540 19 Dec 2023 Essex
Essex County Council Essex Partnership University Trust
Concerns summary (AI summary) The Trust's investigation was incomplete and delayed, failing to address critical issues like inadequate staff observations and security breaches on a locked mental health ward. A dispute over permitted items and failure to escalate risk were also concerns.
Disputed (AI summary) The council is working with Integrated Commissioning Boards to address the shortfall of appropriate placements for people with Autism who have mental health and self-harm risks in Essex and has submitted capital bids to NHS England to develop additional services for complex autistic young people with significant mental health issues. The Trust has taken several actions, including reviewing and reinforcing the Therapeutic Engagement and Supportive Observation policy, commencing a further training programme for all clinical staff on Oxevision and E-obs, and ensuring all inpatient nursing staff complete Food and Fluid Refresher training. Writing on behalf of a client, disputes that the deceased was an informal patient, asserting she was detained under the Mental Health Act and requests a correction to the PFD response.
Amanda Hitch
Historic (No Identified Response)
2023-0535 19 Dec 2023 Essex
British Transport Police Essex Partnership NHS Foundation Trust
Concerns summary (AI summary) Critical suicidal intent information was missed due to thematic clinical record display and a failure to use structured risk management tools. British Transport Police's multi-agency support plan also failed to communicate railway station attendances, especially from unstaffed stations.
Chloe Macdermott
Partially Responded
2023-0534 19 Dec 2023 Inner West London
Amazon Border Force British Transport Police +6 more
Concerns summary (AI summary) Online forums encourage suicide by providing methods without age restrictions or help signposting, and harmful content is not effectively removed. Lethal products are also easily purchased via international online retailers and delivered to the UK without effective border controls.
Action Planned (AI summary) Amazon has globally restricted the sale of high concentration sodium nitrite to Amazon Business customers since October 2022 and prohibits the sale of poisons as defined under Schedule 1A of the UK Poisons Act 1972. The NPCC Suicide Prevention Steering Group has disseminated briefing materials to all NPCC force and regional suicide prevention leads regarding the emerging trend of Sodium Nitrate and Nitrite use in suicides. They have also supported the National Crime Agency's criminal investigation into the supply of Sodium Nitrite. Ofcom is implementing the Online Safety Act 2023, developing codes of practice to address illegal content and protect children, and will take enforcement action against non-compliant services, including financial penalties and business disruption measures. Google Search prevents predictions for queries relating to methods of suicide and provides prominent signposting to authoritative information and support when users search for suicide-related terms, and delists content that directly facilitates activities that could cause immediate harm. DSIT outlines how the Online Safety Act will force companies to take more accountability for the safety of their users, including those who use VPNs to bypass protections, and details Ofcom's enforcement powers for non-compliant services. DHSC leads a cross-government group to tackle emerging methods of suicide, including sodium nitrite, reducing public access, and working with retailers to ensure labeling compliance for products like curing salt.
Linda Banks
All Responded
2023-0533 19 Dec 2023 County Durham and Darlington
Tees, Esk and Wear Valleys NHS Foundati…
Concerns summary (AI summary) Despite a thematic review identifying issues in mental health services, actions taken were ineffective in implementing change; serious incident investigations were also significantly delayed, compromising investigation quality and timely implementation of safety improvements.
Action Taken (AI summary) Tees, Esk and Wear Valleys NHS Foundation Trust has reviewed and incorporated the thematic review action plan into a larger improvement plan for the Durham and Darlington Crisis Team, restructured operational management, and is progressing patient safety incident reviews under both the old and new frameworks.
Margaret Waylett
All Responded
2023-0532 19 Dec 2023 East London
Barts Health NHS Foundation Trust
Concerns summary (AI summary) Dangerous junior orthopaedic staffing and inaccessible NEWS charts during ward rounds meant consultants were unaware of deteriorating patient conditions. There was also confusion among doctors regarding patient responsibility.
Action Taken (AI summary) Barts Health NHS Trust has displayed on-call doctor contact information in clinical areas, reviewed and updated the interaction between orthopaedic and orthogeriatric teams, and implemented a new escalation process for patients requiring medical assessment, with key actions completed and evidence to be presented to committees.
Carl Owston
All Responded
2023-0542 18 Dec 2023 West Sussex, Brighton and Hove
Department of Health and Social Care
Concerns summary (AI summary) A nationwide shortage of care providers and carers prevents commissioned care packages from being fulfilled, risking individuals not receiving necessary care with potentially fatal results.
Action Planned (AI summary) The Department of Health and Social Care highlights existing funding and initiatives to support local authorities in shaping care markets, including the Care and Support Specialised Housing Fund (CASSH) and the Affordable Homes Programme. They are consulting on a new duty for local authorities to complete strategic plans for supported housing and will set national standards for commissioners, as well as investing in a pilot training programme for senior local authority commissioners.