2023

PFD Reports
Reports: 552 Areas: 65

85% response rate (above 63% average).

Response Status
Responded 471 Historic 80
AI Classification
Action Taken 43%
Action Planned 36%
Noted 21%
Disputed 1%
Based on 805 classified responses
Top Categories
Hospital Death (Clinical Procedure… (176) Suicide (from 2015) (117) Other related deaths (91) Alcohol, drug and medication relat… (58) Child Death (from 2015) (57)
552 results
John Coles
All Responded
2023-0271 24 Jul 2023 West London
Heathrow Airport
Concerns summary (AI summary) Visual interference as a potential accident factor was not adequately considered or accepted, and the visibility of vehicles at uncontrolled crossings lacked sufficient safety measures and oversight.
Action Planned (AI summary) HAL will commission an independent assessment of potential mitigation measures relating to visual clutter and airside vehicle conspicuity, develop new training materials for airside drivers, and amend the Operational Safety Instruction relating to temporary vehicle permits; with a target implementation date of April 1, 2024.
Christine Nakafeero
All Responded
2023-0270 24 Jul 2023 East London
Barts Health NHS Foundation Trust Department of Health and Social Care NHS England
Concerns summary (AI summary) A patient fatally slipped out of a care pathway, not receiving critical surgery for three years, and VTE risk assessment criteria inadequately accounted for key risk factors.
Noted (AI summary) The Trust is implementing a fully electronic outpatient outcome system and rolling out LUNA, a digital monitoring tool for patient tracking lists, expected by the end of September 2023. They have sought expert advice regarding limitations of the VTE risk assessment and will continue to monitor information from national bodies. The Department acknowledges the concerns raised, notes the actions taken by the Trust, including implementing a digital monitoring tool and seeking expert advice on VTE risk assessment, and refers to broader government efforts to advance patient safety.
Steven Duquemin
Historic (No Identified Response)
2023-0272 21 Jul 2023 Blackpool & Fylde
Northern Care Limited
Concerns summary (AI summary) Inconsistent care records and a senior manager's under-appreciation of a vulnerable patient's choking risk led to inadequate preventative measures, endangering other service users.
Corinne Haslam
Partially Responded
2023-0266 21 Jul 2023 Manchester South
Department of Health and Social Care Pennine Care NHS Foundation Trust
Concerns summary (AI summary) Barriers to physical health input for mental health patients, incompatible electronic record systems, and unclear VTE risk assessment guidance for ward staff pose significant patient safety risks.
Noted (AI summary) The Department acknowledges concerns over physical healthcare in mental health settings and compatibility of electronic patient records, noting expectations for the Trust's response and describing the use of shared care records in Greater Manchester.
Marion Nickson
All Responded
2023-0265 21 Jul 2023 Manchester South
Care Quality Commission NHS England
Concerns summary (AI summary) Observable bay nursing failed due to staff being pulled away for other tasks, highlighting a lack of prioritisation for patient observation and resourcing issues that hinder effective falls prevention.
Action Planned (AI summary) NHS England commissions the National Audit of Inpatient Falls (NAIF) and has been significantly involved in the FallSafe training module produced by the RCP. The Trust have made recommendations to ensure staff have a refresher on the protocols and assessments available and that there are divisional leadership walk rounds with a focus on bay nursing, adherence to policy and the wearing of tabards. CQC has contacted Stockport NHS Foundation Trust and East Cheshire NHS Trust to request written confirmation and evidence of action taken to date, and any additional action they intend to take in response to the prevention of future death report. CQC is reviewing the facts and evidence to determine whether there are grounds to suspect that a criminal offence may have been committed, and whether a formal criminal investigation will be undertaken by the CQC.
Thomas Barton
All Responded
2023-0264 21 Jul 2023 Manchester South
Department of Health and Social Care Greater Manchester Integrated Care
Concerns summary (AI summary) Delayed hospital discharge for frail elderly patients, caused by insufficient social care provision, leads to deconditioning and increased risk of infection and preventable death.
Noted (AI summary) NHS Greater Manchester Integrated Care acknowledges concerns about the demand and availability of social care and has connected with Trafford Local Authority. Supported by NHS GM funding, localities have commissioned home from hospital support; NHS GM has undertaken capacity and demand modelling of home care and care home markets and will share learning across Greater Manchester. The Department of Health and Social Care acknowledges concerns over delayed hospital discharge due to social care package challenges. It notes that Trafford Council has redesigned the homecare offer, and Greater Manchester ICB has undertaken capacity and demand modelling of home care. The response also mentions national initiatives like the Hospital Discharge and Community Support Guidance.
Andrew Vizard
Historic (No Identified Response)
2023-0273 20 Jul 2023 Nottinghamshire
Nottingham Healthcare Trust
Concerns summary (AI summary) Emergency response systems and staff training are inadequate, causing significant delays in obtaining monitoring, doctor attendance, and ambulance calls for patients with critical breathing concerns.
Stephen Weatherley
All Responded
2023-0269 20 Jul 2023 Inner South London
HM Inspectorate of Prisons HM Prison and Probation Service HMP Thameside +1 more
Concerns summary (AI summary) Significant issues with data recording and retention in HMP Thameside led to lost critical documents and incomplete records, alongside the absence of a written drug swallow policy.
Noted (AI summary) HM Inspectorate of Prisons acknowledges receipt of the report but states its remit is limited to the inspection process, referring to published inspection reports and stating the information will inform future risk assessments at HMP Thameside. HM Inspectorate of Prisons acknowledges receipt of the report but states its remit is limited to the inspection process, referring to published inspection reports and stating the information will inform future risk assessments at HMP Thameside. Serco (HMP Thameside) details actions taken, including the introduction of MS Teams folders for data retention, enhanced security strategies with trained analysts, and the implementation of a bodyscanner, with learnings from the inquest shared with senior management. They will also share learnings of the inquest with the senior management team, with advice that where there is a suspected 'swallow' and absence of a positive bodyscanner result, they should re-locate to healthcare. HM Prison and Probation Service acknowledges the concerns regarding record keeping and data retention at HMP Thameside, confirms receipt of the prison director's response, and outlines the contract delivery indicators and monitoring processes in place.
Albert Dovey
All Responded
2023-0263 20 Jul 2023 Manchester South
NHS England
Concerns summary (AI summary) Sustained pressure on emergency services caused significant delays in ambulance response and hospital processing for an elderly frail patient, increasing their risk of death after a fall.
Action Taken (AI summary) NHS England acknowledges concerns about ambulance delays at Tameside General Hospital, highlighting the Delivery plan for recovering urgent and emergency care services and the work of the North West Every Minute Matters Hospital Handover Collaborative, which has led to improved response times in Greater Manchester.
Marianne Erika
All Responded
2023-0262 20 Jul 2023 Manchester South
NHS England
Concerns summary (AI summary) Severe, common delays in emergency department clinician assessments, exacerbated by radiography shortages, led to significant patient deterioration and missed opportunities for timely treatment.
Action Planned (AI summary) NHS England highlights actions being taken to improve ambulance performance, hospital flow, and discharge processes under the UEC recovery plan. The GM Imaging Network is supporting upskilling of the imaging workforce and coordinating international recruitment to address radiologist vacancies.
Elliott Harratt
All Responded
2023-0261 20 Jul 2023 Manchester South
Greater Manchester Integrated Care
Concerns summary (AI summary) Inadequate and inconsistent information provided to expectant mothers regarding sensitising events and when to call maternity triage increases the risk of Rhesus disease in newborn babies.
Action Planned (AI summary) NHS Greater Manchester Integrated Care will share learning from the case with the Greater Manchester System Quality Group and at the Local Maternity and Neonatal Network Safety Assurance Panel to ensure learning is incorporated into commissioned services.
Peter Harris
All Responded
2023-0260 20 Jul 2023 City of London
Barking, Havering and Redbridge Univers…
Concerns summary (AI summary) Critical scan results indicating malignancy were not promptly seen or acted upon by clinicians due to system failures in alerting and reporting delays caused by an incorrect hospital number.
Action Planned (AI summary) Barking, Havering and Redbridge University Hospitals NHS Trust will alert referrers to all imaging with expected, unexpected, or newly detected cancer, and critical non-cancer findings, with actions tracked in a version-controlled action plan. They will develop and implement a Standard Operating Procedure (SOP) for radiological findings of cancer, as well as a SOP for lung nodules identified as an incidental finding.
Kenneth Rippon
All Responded
2023-0268 19 Jul 2023 County Durham and Darlington
Care Quality Commission Tees, Esk and Wear Valley NHS Foundatio…
Concerns summary (AI summary) Extensive delays in serious incident investigations (10 months instead of 60 days) prevented timely learning and improvements, compromising investigation quality and evidence preservation.
Action Taken (AI summary) Tees, Esk and Wear Valleys NHS Foundation Trust has contracted additional expert capacity in incident reviews to actively address delays, allocating 41 reviews. They have increased capacity in the mortality team, provided additional training, and are externally reviewing a specific case. Tees, Esk and Wear Valleys NHS FT has contracted in additional expert capacity in incident reviews, increased internal capacity, and reviewed all incidents to ensure they have met Duty of Candour. They have also modified documentation, reviewed report templates, and are utilising standard operating procedures. The CQC has monitored the trust’s progress with reducing the backlog of serious incidents and preventing reoccurrence. They state the trust provided information showing the backlog had reduced, with a target date of December 2023 for completion of all historical investigation reports, and a revised process is in place to prevent reoccurrence of this backlog.
Shane West
All Responded
2023-0267 19 Jul 2023 Swansea Neath Port Talbot
Swansea Bay University Health Board
Concerns summary (AI summary) Inconsistent medication records, challenges in assessing a learning-disabled patient's condition, and an unclear appreciation of respiratory risks associated with laxative administration for abdominal distension.
Action Planned (AI summary) Swansea Bay University Health Board will develop an explicit clinical management plan to address clinical issues throughout a patient's treatment, to be changed on a multi-professional basis. They will remind staff prescribing medications to select the correct drug and report adverse reactions and have reported the death nationally via the "Yellow Card" scheme.
Michael Amesbury
All Responded
2023-0259 19 Jul 2023 Manchester South
Greater Manchester Integrated Care
Concerns summary (AI summary) Incompatible information systems and reliance on postal services delayed critical patient referrals and image transfers between trusts, compounded by a shortage of cardiology clinicians, hindering timely treatment.
Action Planned (AI summary) NHS Greater Manchester plans to scale and spread the Patient Pass model of care within the GM ICS, leveraging the installed user base and existing clinical pathways. Deployment at an ICS level would enable complex case transfers and out-patient planning to be managed at a higher and more efficient level.
Sylvia Pollitt
All Responded
2023-0258 19 Jul 2023 Manchester South
L&Q Group Housing
Concerns summary (AI summary) The Housing Association lacked an audit system to ensure subcontractors escalated non-contact referrals for welfare checks and failed to monitor referral outcomes, missing crucial safety oversight for vulnerable adults.
Action Taken (AI summary) L&Q took immediate action following the inquest, including self-referring to the Regulator for Social Housing. They have implemented additional processes and checks, including aligning call recording processes, instituting weekly meetings with Liberty to review all jobs raised, and automatically following up on incomplete jobs with welfare checks.
Bernhard Marek
All Responded
2023-0257 19 Jul 2023 Manchester South
Department of Health and Social Care Greater Manchester Integrated Care
Concerns summary (AI summary) The report cites concerns about ambulance service delays due to high demand and resource issues, which are exacerbated by long waits to offload patients at Emergency Departments, impacting frail elderly patients with hip fractures.
Action Taken (AI summary) NHS Greater Manchester Integrated Care shared learning from the case with the Greater Manchester System Quality Group and cascaded it to professionals through relevant governance and learning forums. Ambulance performance is reviewed regularly, and they are committed to achieving ARP standards. The DHSC describes national actions to improve urgent and emergency care, including ambulance resources, increasing hospital bed capacity, scaling up virtual wards, and funding for timely discharge. They report improvements in ambulance response times.
Thelma Radmore
All Responded
2023-0256 19 Jul 2023 Manchester South
Department of Health and Social Care
Concerns summary (AI summary) Systemic demand and patient flow issues led to prolonged ambulance waits and emergency department delays, preventing timely pressure ulcer prevention and increasing risks for frail patients.
Action Taken (AI summary) The DHSC outlines actions taken nationally to improve urgent and emergency care, including dedicated funding, scaling up virtual ward capacity, and providing funding for timely discharge from hospitals. They report improvements in ambulance response times and A&E waiting times.
Evelyn Dutton
All Responded
2023-0254 19 Jul 2023 Manchester South
NHS England
Concerns summary (AI summary) Elderly, frail patients with hip fractures faced prolonged ambulance waits and significant delays in Emergency Department and ward transfers, posing a high risk to their health.
Action Taken (AI summary) NHS England acknowledges the pressures on ambulance services and highlights the Delivery plan for recovering urgent and emergency care services. The North West Every Minute Matters Hospital Handover Collaborative has seen improvements in Greater Manchester, and ambulance performance is reviewed regularly.
Carole McQuinn
All Responded
2023-0253 19 Jul 2023 North Yorkshire and York
Leeds Teaching hospitals and York Hospi…
Concerns summary (AI summary) Poor discharge procedures, unrecorded post-discharge infection concerns by nursing staff, and critical inter-hospital communication failures led to missed opportunities for timely patient assessment and treatment.
Action Planned (AI summary) The Trust will update its out-of-date clinical record-keeping guidance and share it with all clinical staff. A patient safety briefing will be drafted and sent to all staff and the case will be presented at a Surgical Clinical Governance meeting. The Trust has implemented an electronic discharge summary, and staff have been reminded of the importance of detailed record-keeping. Referral pathways have been reviewed, and discussions have taken place with surgical teams in York to improve communication and collaboration.
Christine Dickinson
All Responded
2023-0255 18 Jul 2023 Manchester South
Stockport NHS Foundation Trust
Concerns summary (AI summary) Inconsistent and fragmented chemotherapy administration record-keeping systems led to errors, including misattributing patient details, and there was a lack of recent audits on recording practices.
Action Taken (AI summary) The Trust is piloting a new paper-based 'Sepsis Six' assessment, with plans to digitize it, and has purchased additional computers on wheels for nurses to document at the patient's side. They are also participating in an electronic patient record (EPR) programme with the aim to procure and implement a single electronic patient solution to replace the majority of the Trust’s clinical systems.
Colin Greenway
All Responded
2023-0252 18 Jul 2023 Norfolk
Queen Elizabeth Hospital
Concerns summary (AI summary) Incorrect prescribing by junior doctors, inadequate VTE assessments, and consultants' failure to properly supervise prescribing and ensure continuity of patient care were identified.
Action Taken (AI summary) The Trust updated VTE guidelines with NICE guidance, introduced mandatory e-learning on VTE, rolled out NEWS2, mandated patient monitoring documentation in Tendable© audits, and implemented a Patient Safety Incident Response Plan, identifying VTE as a focus area. They are also working with other trusts on a joint Electronic Patient Record System implementation by 2025.
Ronald Ashdown
All Responded
2023-0249 18 Jul 2023 Essex
Mid and South Essex NHS Foundation Trust
Concerns summary (AI summary) A hospital's internal investigation into poor patient care was critically flawed and unprofessional, as key photographic evidence was withheld, preventing proper identification of systemic failings.
Action Taken (AI summary) The Trust has updated its action plan and completed several actions to improve personal care, record keeping, and investigation processes including improved management oversight, audits, training, and an updated safeguarding policy with improved governance. They have shared information about the actions taken with the Local Authority.
Philip Hawkins
Historic (No Identified Response)
2023-0248 18 Jul 2023 North Wales East and Central
Betsi Cadwaladr University Health Board Welsh Ambulance Service Trust
Concerns summary (AI summary) Significant delays in hospital admission and bed allocation, coupled with inadequate staffing, resulted in poor personal care, missed observations, and incomplete documentation for a vulnerable patient.
Jane Wadsworth
All Responded
2023-0251Deceased 17 Jul 2023 Manchester South
NHS England Tameside and Glossop Integrated Care NH…
Concerns summary (AI summary) Missed critical medication doses, lack of senior medical input during holiday periods, and ineffective communication for ICU referrals and specialist discussions contributed to a patient's deteriorating condition.
Noted (AI summary) NHS England acknowledges the concerns and states that the Tameside and Glossop Integrated Care NHS Foundation Trust is the appropriate organisation to respond. They note the Trust's response addresses the concerns and that they have been implementing improvement work. The Critical Care Unit has amended their daily review chart to provide additional clarity and comprehensive documentation regarding referrals to the Liver Unit. Also clinical induction training includes intravenous (IV) cannulation for all registered staff.