2023
PFD Reports
Reports: 552
Areas: 65
85% response rate (above 63% average).
Odichukwumma Igweani
All Responded
2023-0296
16 Aug 2023
Milton Keynes
BLMK Integrated Care Board
North West London NHS Foundation Trust
Red House Surgery
Concerns summary (AI summary)
A critical lack of clear information and guidance prevented an individual from accessing urgent out-of-hours mental health assessment and care, despite their obvious deteriorating condition.
Noted
(AI summary)
The ICB will work with primary care practices to ensure patients declined registration receive details on how to find and register with a GP and ensure practices are aware of the mental health single point of access. They will also work with CNWL to ensure mental health crisis information is available in surgery waiting areas and continue to work with 111 providers on the dedicated process for mental health due in Spring 2024. Red House Surgery states it was unable to register the patient due to their address being outside the practice catchment area, and this is practice policy. They assert they provided the mother with the number for the crisis centre, which is practice policy for anyone raising a mental health concern who cannot access a GP. CNWL will discuss the case in a Care Quality Improvement Forum meeting, cascade a learning leaflet to local GPs via the Primary Care Network (PCN) alliance, and supply posters to GP surgeries with information on how to access mental health services via the ED at MKUH. Nationally, NHS England are working with NHS 111 to create a dedicated process to access MH services due in April 2024.
Absolom Duffy
All Responded
2023-0295
16 Aug 2023
Lincolnshire
Lincolnshire County Council
Concerns summary (AI summary)
The "give way" signage at a junction with restricted visibility may be insufficient, as drivers must stop to ensure safety, raising concerns that a "stop" command would be safer.
Noted
(AI summary)
Lincolnshire Council will assess vegetation at the junction regularly to ensure maximum visibility. However, they are not proposing to change the existing GIVE WAY signage as the visibility at the junction exceeds requirements.
Barry Lall
All Responded
2023-0385
15 Aug 2023
Central and South East Kent
General Dental Council
Concerns summary (AI summary)
The General Dental Council's practice of publishing extensive, detailed allegations on its website for unconcluded cases can cause significant mental health distress to practitioners who are contesting them.
Action Planned
(AI summary)
The GDC is undertaking a review of its policy on publishing Interim Order determinations and holding hearings in public, aiming to balance public interest with the interests of the registrant, with the first stage of the review expected to complete by early next year.
Haik Nikolyan
All Responded
2023-0340
15 Aug 2023
Buckinghamshire
Prison and Probation Service
Concerns summary (AI summary)
HMP Aylesbury's transition to a Category C prison is challenged by recruitment and retention issues among experienced staff, impacting daily operations, training, incident response, and the management of vulnerable prisoners.
Action Taken
(AI summary)
HMP Aylesbury has improved staffing levels, expanded key work provision, appointed a Neurodiversity support manager, reviewed the adjudication tariff for drug-related incidents, and reconfigured the safety team. Nationally, a TV and radio advert has been launched to support recruitment.
Ian Darwin
All Responded
2023-0291
15 Aug 2023
County Durham and Darlington
Tees, Esk and Wear Valleys NHS Foundati…
Concerns summary (AI summary)
Tees Esk and Wear Valleys NHS Foundation Trust routinely fails to conduct timely serious incident investigations, allowing hazards to persist and compromising learning, despite past assurances and national guidelines for 60-day completion.
Action Taken
(AI summary)
The Trust has contracted additional expert capacity for incident reviews, implemented weekly sitrep meetings, modified documentation and report templates, and is introducing more flexibility to Serious Incident Review Panels, and is contracting with an external incident review company. They anticipate being able to allocate an SI review within the month the incident occurs from November 2023. The Trust has contracted additional expert capacity for incident reviews, implemented weekly sitrep meetings, modified documentation and report templates, and is introducing more flexibility to Serious Incident Review Panels, and is contracting with an external incident review company. They anticipate being able to allocate an SI review within the month the incident occurs from November 2023.
Leonard King
Partially Responded
2023-0294
14 Aug 2023
Milton Keynes
Association of Ambulance Chief Executiv…
Royal College of Emergency Medicine
Royal College of General Practitioners
+1 more
Concerns summary (AI summary)
Clinicians often misdiagnose acute epiglottitis in adults as a common sore throat, missing a life-threatening airway obstruction due to a perception it's a childhood disease. Education is needed for timely recognition.
Action Planned
(AI summary)
Urgent Health UK has distributed the coroner's report to Medical Directors and Nurse Directors of its 30 members, representing 65% of the UK population, and will review/discuss it at a team meeting on September 18th, 2023. AACE will include adult epiglottitis as one of the conditions in the new guidance for ambulance clinicians, including key assessment and management points and the importance of rapid conveyance to hospital for lifesaving treatment. They plan to share the PFD report with ambulance service medical directors and education leads and suggest that individual ambulance services consider if any education or raising awareness of epiglottitis in adults is required.
Linda Oldland
All Responded
2023-0293
14 Aug 2023
Surrey
Leonard Cheshire
Concerns summary (AI summary)
Hydon Hill Nursing Home failed to share critical patient information with medical staff, delayed antibiotic administration, missed a cardiac arrest, and incorrectly reported a DNAR, indicating policy and training deficiencies.
Action Planned
(AI summary)
Leonard Cheshire has implemented measures including manager's daily walkarounds, Sepsis training, and is reviewing their training program, service manager/staff induction, and implementing a quality audit plan, with plans to implement electronic care plans by March 2025.
Marie Zarins
All Responded
2023-0290
14 Aug 2023
Leicester City and South Leicestershire
Leicestershire Partnership NHS Trust
Concerns summary (AI summary)
Flawed Multi-Disciplinary Team meetings and an inadequate serious incident investigation led to a mental health patient not receiving prescribed anti-depressants or sleeping tablets due to incorrect medication understanding and poor record review.
Action Taken
(AI summary)
The Trust was awarded accreditation from the Royal College of Psychiatrists’ Serious Incident Review Accreditation Network (SIRAN) for their Serious Incident (SI) processes. They confirm that all identified service actions are robust and completed within the agreed timescales.
Doris Urch
All Responded
2023-0302
11 Aug 2023
Inner North London
Globe Court Care Home
Concerns summary (AI summary)
The care home's risk assessment process was inadequate, lacking specific recommendations and not updated after falls. Staff were unfamiliar with care plans, and the system failed to preserve historical records.
Action Taken
(AI summary)
Staff training on PCS handheld devices has been implemented during induction, and a list of residents at high risk of falls is maintained to inform staff, with documentation being regularly checked for accuracy. They state that all staff are up to date with training except new employee's.
Rohan Godhania
Partially Responded
2023-0289
9 Aug 2023
Milton Keynes
NHS England
NHS Improvement
Food Standards Agency
Concerns summary (AI summary)
High protein supplements lack adequate warning labels for individuals with undiagnosed urea cycle disorders, risking severe medical emergencies due to sudden protein intake.
Noted
(AI summary)
NHS England are committed to moving to a ‘0-25 year service model’, offering person-centred and age-appropriate care for mental and physical health needs. A Patient Safety Bulletin was issued highlighting the need for ‘prompt measurement of ammonia and action in the event of hyperammonaemia’. The FSA expresses condolences and explains its responsibilities for food safety, noting that nutritional advice and labelling are the responsibility of the DHSC, to whom they will forward the report.
Reginald Bourn
All Responded
2023-0288
8 Aug 2023
Surrey
Health Education England
National Institute for Health and Care …
Concerns summary (AI summary)
There is a critical lack of national guidance and training for the safe insertion and placement confirmation of nasogastric decompression tubes, unlike feeding tubes, risking fatal misplacement.
Action Planned
(AI summary)
While NHS England does not routinely provide guidance on nasogastric decompression tubes, they have asked regional colleagues to raise awareness of the concerns raised in the report and learnings from the case with their regional Integrated Care Boards, which can then engage with local NHS Trusts. NICE has shared the report with its topic selection and prioritisation team to consider guidance on small bowel obstruction and nasogastric decompression. The report has also been shared with NICE’s guideline surveillance team to see if an update to recommendations on nutrition support for adults is required. The MHRA has reached out to manufacturers of nasogastric tubing to confirm their primary intended use and to review their instructions for use, expecting to complete the initial review by 4 January 2024, after which they will work with manufacturers to update their IFU where applicable.
Harry Stobie
All Responded
2023-0284
4 Aug 2023
Milton Keynes
Milton Keynes University Hospital
Concerns summary (AI summary)
Following PEG tube insertion, a patient's deteriorating condition and abdominal pain were not adequately monitored or escalated to a senior doctor, potentially missing a critical bleed.
Action Planned
(AI summary)
The hospital is updating its post-PEG insertion procedures to incorporate a pain score and/or AMBER trigger on the NEWS-2 system to prompt earlier escalation and consideration of a CT scan. They will also liaise with the British Society of Gastroenterology to seek excellent practice in post-procedural protocols.
Leah Barber
All Responded
2023-0283
3 Aug 2023
West Yorkshire (Western)
City of Bradford Metropolitan District …
Concerns summary (AI summary)
Bradford Council lacked a unified system for overseeing its involvement with vulnerable children, preventing learning from deaths and maintaining departmental disconnect, which risks future fatalities.
Action Taken
(AI summary)
Following the death, the Council has strengthened processes to ensure organizational oversight where multiple teams are involved and a child dies, with the Director of Children’s Services as the single point of oversight.
Lee Dryden
All Responded
2025-0402
2 Aug 2023
South Yorkshire (West District)
Department of Health and Social Care
NHS England
Concerns summary (AI summary)
NHS Trusts lack understanding of guidance for external image reporting, and the ambulance service experienced significant delays in responding to a category 2 call due to high escalation and hospital handover issues.
Action Taken
(AI summary)
NHS England highlights actions taken including publishing recommendations regarding alerts and notification of imaging reports, hosting a national webinar, and noting that the RCR will review guidance. They are also focusing on improving ambulance performance as part of a delivery plan. DHSC notes actions taken by NHS England to clarify guidance around imaging reports, and additional funding to expand ambulance capacity and improve response times. They also highlight measures to improve patient flow and bed capacity within hospitals.
John Shenton
All Responded
2023-0282
2 Aug 2023
Shropshire, Telford and Wrekin
Range
Concerns summary (AI summary)
Outstanding recommendations for escalator safety, particularly for vulnerable individuals when lifts are unavailable, were not acted upon, indicating insufficient measures to protect users.
Action Taken
(AI summary)
The Range has reviewed and updated the escalator and lift risk assessment, and will locate appropriate customer information signage at the lift and escalator in the event of breakdown. They have removed obstructions blocking CCTV coverage of the top of the escalator, and will trial the effectiveness and longevity of high visibility paint to the nosings of the escalator treads during October 2023.
Dumile Thompson
Historic (No Identified Response)
2023-0281
2 Aug 2023
West Yorkshire (Eastern)
NHS England
NHS National Patient Safety Alerting Co…
Concerns summary (AI summary)
Insufficient national guidance and training on angioedema types, risk factors (including ethnicity), and diverging treatments, alongside poor medical record sharing between Trusts, hindered appropriate emergency care.
David Andrews
All Responded
2023-0329
1 Aug 2023
Hertfordshire
Hertfordshire County Council
Concerns summary (AI summary)
Heavy goods vehicles are permitted to stop and unload on a specific road stretch, effectively blocking the southbound carriageway and creating a hazard.
Action Planned
(AI summary)
Hertfordshire County Council will promote a Traffic Regulation Order to prohibit loading/unloading on the A4251 Tring Road and will engage with NuYard regarding their safety protocols by the end of November 2023; the Active and Safer Travel team will engage with cycling groups to raise awareness of risks.
Edward Rhodes
All Responded
2023-0280
1 Aug 2023
Dorset
Beaufort Road Surgery
Concerns summary (AI summary)
There was a breakdown in communication between GP and an addict regarding mental health referral steps, relying solely on verbal discussions without an automatic referral system or written confirmation, leading to unmet care.
Action Planned
(AI summary)
The Practice refers to the current ICB plan to improve mental health, addiction and wellbeing concerns. They also note that a summary of referral criteria will be prepared by CMHT.
Eileen Walsh
All Responded
2023-0278
31 Jul 2023
Norfolk
Broadlane View Care Home
Concerns summary (AI summary)
The care home failed to complete critical policies and implement a monitoring system for years. Issues include unaddressed faulty alarms, conflicting record-editing policies, and an internal investigation that missed key facts, mirroring CQC concerns.
Action Taken
(AI summary)
The Night Work policy, incorporating a successful daily notes audit to prevent pre-recording of observations, was uploaded to the QCS system and added to the staff reading list on 01/08/2023. They have also engaged an external compliance company for more thorough inspections and monthly visits to assist with continuous improvement.
Kirsty Taylor
All Responded
2023-0507
28 Jul 2023
Hampshire, Portsmouth and Southampton
Hampshire and Isle of Wight Integrated …
NHS England
Southern Health Foundation Trust
Concerns summary (AI summary)
Fragmented mental and physical health services lack seamless connectivity for neurodivergent patients, particularly those with ADHD. Additionally, communication with families of mental health patients remains ineffective, and the Personality Disorder Pathway development is too slow.
Action Planned
(AI summary)
NHS England is working to develop new models of integrated primary and community mental health care, including a dedicated community mental health offer for those with diagnoses of ‘personality disorder’ or complex emotional needs. By 2024/25 all parts of the country will have introduced crisis text lines to enable easier access to crisis care for people who are neurodiverse. The ICB has endorsed the creation of a new all-age Trust to oversee community and mental health services across Hampshire and Isle of Wight, expected to go live on 1 April 2024. The HIOW All Age ASC and ADHD Improvement Group will be developing a greater range of resources for families to access post diagnosis. Southern Health NHS Foundation Trust, along with other trusts, is working towards establishing a new, single community and mental health provider by 1 April 2024 (Project Fusion). They are continuing to develop the Family Connections programme to be accessible to a broader range of people with complex emotional needs, including those with neurodiversity.
Benjamin McQueen
All Responded
2023-0285
28 Jul 2023
London City
Ministry of Defence
Concerns summary (AI summary)
Military diving training had critical safety shortcomings, including no spare breathing gas for standby divers, inappropriate acceleration of training, lack of readily available defibrillators, and inconsistent safety pressure guidelines.
Action Taken
(AI summary)
The Ministry of Defence has reviewed and aligned figures in the Divers Policy (JSP286) and the maintenance Policy (BR2807), stipulating the minimum abort pressure as 50 Bar, and updated the figures prescribed for tolerances to the minimum pressure to start a dive.
Johanne Blackwood
All Responded
2023-0275
27 Jul 2023
Essex
Essex Partnership NHS Trust
Concerns summary (AI summary)
A severe lack of clarity in Care Coordinator handovers and absence of formal policy left a vulnerable patient without an allocated CC, and her risk assessment/care plan unupdated, following hospital discharge.
Action Taken
(AI summary)
The Trust has implemented a formal structured handover template for care coordinators, approved for Trust-wide implementation, to capture vital information about patients' care and risk. All staff who administer medication are now required to complete annual medication competency assessments.
Finley May
All Responded
2023-0277
26 Jul 2023
East Riding and Hull
NHS England
Royal College of Obstetricians and Gyna…
Concerns summary (AI summary)
There is a need for increased awareness of complications associated with Keilland's forceps and guidance on maintaining skill levels or providing clear alternative methods if abandoned, to manage obstetric problems.
Noted
(AI summary)
NHS England refers to the RCOG guidance on assisted vaginal birth and highlights the need for clinicians to be aware of the guidance and assess the advantages and disadvantages of available delivery techniques; the results of the ROTATE trial will be carefully reviewed. Following inaccurate assessments of fetal head position by clinicians prior to starting procedures, RCOG advises that ultrasound assessment of the fetal head position prior to application of forceps is more reliable than clinical examination. Updated RCOG Green-top Guideline No. 26 provides recommendations to support practitioners around the use of instruments for assisted vaginal births.
Paul Keating
All Responded
2023-0279
25 Jul 2023
West Yorkshire (Eastern)
Home Office
Leeds City Council
Concerns summary (AI summary)
The local authority lacked statutory power to install sprinkler systems in private flats without consent, leading to one resident's flat remaining unconnected, which likely contributed to his fire-related death.
Noted
(AI summary)
Leeds City Council acknowledges the coroner's concerns regarding a lack of legal powers to access properties for safety works without tenant consent. The council states that granting additional legal powers to landlords is a matter for central government. The Home Office acknowledges the coroner's concerns about fire risks in social housing but explains the existing regulatory framework, including the Regulatory Reform (Fire Safety) Order 2005 and the Housing Health and Safety Rating System. It highlights the role of Fire and Rescue Authorities and the Home Office's Fire Kills campaign.
Alan Nippard
All Responded
2023-0276
24 Jul 2023
Avon
Royal United Hospitals
Concerns summary (AI summary)
Grossly inadequate basic nursing care led to preventable pressure sores, marked by incorrect risk assessments, delayed preventative equipment, poor adherence to care bundles, and insufficient patient repositioning.
Action Taken
(AI summary)
The Tissue Viability Nursing Team has conducted face-to-face training for all substantive nursing staff, physiotherapists, and occupational therapists on Pierce Ward. Other actions include increasing staffing levels, introducing bedside patient care handovers, and piloting a bespoke Tissue Viability monitoring tool.