2023

PFD Reports
Reports: 552 Areas: 65

85% response rate (above 63% average).

552 results
Ross Ballatine, Carl McGrath, Alan Minard
All Responded
2023-0245 17 Jul 2023 North Wales East and Central
Maritime & Coastguard Agency
Concerns summary (AI summary) The agency failed to adequately assess vessel stability after significant modifications, relying on inadequate checks and skipper assurances, leading to a risk of other unassessed modified vessels operating unsafely.
Action Taken (AI summary) The MCA published an Urgent Safety Bulletin (Safety bulletin 32) on 4 September 2023, informing owners of the requirements in the Code and the importance of assessing the impact on stability of any modifications which may not have been notified to the MCA.
Sean Heeney
All Responded
2023-0250Deceased 14 Jul 2023 Northamptonshire
HM Prison and Probation Service
Concerns summary (AI summary) Bridgewood House lacked a clear plan for safely extricating medically unwell or uncooperative residents from its first floor, compounded by the building's layout, leading to dangerous delays.
Action Planned (AI summary) Bridgewood House Approved Premises is consulting with the local emergency services on the preparation of a plan to deal with evacuation from the building in a medical emergency. A clearly recorded understanding between the agencies involved in such a procedure should ensure a successful evacuation should a similar situation arise in the future.
Emily Corfield
All Responded
2023-0247 14 Jul 2023 North Wales East and Central
Adferiad Recovery Betsi Cadwaladr University Health Board
Concerns summary (AI summary) An addiction support service lacked robust communication and record-keeping policies, relying solely on written correspondence, which led to service users being disengaged and facing long waiting times.
Action Planned (AI summary) Adferiad is seeking a range of updated automated communication routes for the service (such as a text reminder service) and as we proceed with this initiative, we will, of course, continue to have regard to your concern. The Health Board has re-issued communication detailing the referral process to liaison services and will share it with clinical teams across the Health Board to ensure there is clarity and consistency across all areas. The MHLD Liaison Psychiatry Services in Acute Hospitals Delivery Framework will also be reviewed.
Phoenix Chapman
All Responded
2023-0246 14 Jul 2023 Inner North London
Homerton Healthcare NHS Foundation Trust
Concerns summary (AI summary) A lack of shared understanding and communication breakdown among hospital clinicians regarding protocols for high-risk unplanned home deliveries, particularly between obstetricians and midwives, hindered effective care.
Action Taken (AI summary) The London Ambulance Service notes that national JRCALC breech birth guidance has been reviewed and updated with input from the LAS maternity team and senior paramedics. They include updated visuals of breech birth scenarios. The Trust has been alerting the London Ambulance Service NHS Trust (LAS) in respect of any birth plans in place where mothers choose to birth outside of guidance so that they are aware of these cases and the plans for emergency management. The Trust has been working collaboratively with the LAS, and the North East London Local Maternity and Neonatal System (LMNS) to formulate a separate standard operating procedure and guidance for cases where the birth is imminent as there is currently no national guidance on this.
Peter Fleming
All Responded
2023-0244 14 Jul 2023 Birmingham and Solihull
Birmingham and Solihull Integrated Care… Birmingham and Solihull Mental Health N… Birmingham City Council +3 more
Concerns summary (AI summary) The coroner states action should be taken to prevent future deaths.
Noted (AI summary) NHS England highlights national initiatives to improve digital systems, workforce, and mental health services, including the Long Term Workforce Plan and the Mental Health, Learning Disability and Autism Inpatient Quality Transformation Programme. All reports received are discussed by the Regulation 28 Working Group. BSMHFT is working jointly with the Integrated Care System and highlights other areas to assist with lack of resources, including 3 Places of Safety available. The Shared Care Platform has been enhanced allowing different organisations to access different clinical information across the system. NHS Birmingham and Solihull ICB clarifies that GPs are not contractually required to monitor the collection status of medicines that they have prescribed. Birmingham City Council is working with NHS partners on a new Memorandum of Understanding to increase AMHP capacity and will fund AMHP training for NHS staff. They also trained 8 AMHPs in 2022 with funding from Skills For Care and aim to train 5 per year. The Department of Health and Social Care acknowledges the concerns, highlights existing investment in mental health services and workforce, and points to integration of services through integrated care systems and the Major Conditions Strategy.
Terence Burns
All Responded
2023-0243 14 Jul 2023 Blackpool & Fylde
Highgrove Rest Home
Concerns summary (AI summary) A patient's care plan failed to accurately document their essential blended diet, and critical nutritional information was not checked or transferred during hospital admission, risking appropriate care.
Action Taken (AI summary) Hospital passports are checked by two members of senior staff weekly, and Care Plans updated monthly or when any changes to care are required by a senior member of management. A hospital passport checklist has been implemented, and the provider contacted North West Ambulance Service to discuss the checklist.
Mackenzie Cooper
All Responded
2023-0431 13 Jul 2023 Nottingham City and Nottinghamshire
Central England Co-operative Department of Health and Social Care
Concerns summary (AI summary) A community defibrillator was supplied in a non-workable state due to missing parts, highlighting inadequate maintenance systems and poor staff communication. A national system for defibrillator status is also lacking.
Action Planned (AI summary) A review has been conducted and certain improvements have been or are shortly to be made to the system operated by Central England Co-operative Limited, and further discussions with The British Heart Foundation will take place in due course in the interests of a wider positive impact. The Government has provided funding of £1m for a grant scheme to buy life-saving defibrillators for community spaces, which launched in September 2023. All Automatic External Defibrillators (AED’s) granted by the fund must be registered on The Circuit – The British Heart Foundation’s national defibrillator database which is synchronised with the Computer Aided Dispatch systems of the 14 Ambulance Trusts in the UK and holds the location and where required access codes for defibrillators.
Mohammed Hussain
All Responded
2023-0241 12 Jul 2023 Birmingham and Solihull
Birmingham and Solihull Mental Health F… Department of Health and Social Care
Concerns summary (AI summary) The report identifies issues with monitoring clozapine levels, a lack of a safe system to communicate high clozapine levels or effect medication changes, and a lack of understanding of when to measure and how to respond to high clozapine levels; concerns were also raised about pharmacy resourcing and the quality of internal investigations.
Action Planned (AI summary) The Trust is developing a specialist Pharmacy Clozapine Team, plans a recorded webinar to improve knowledge around clozapine, and the pharmacy team have prioritised reviewing assay levels and communication to consultants. The Trust has also established a set of MDT standards and will review the carer engagement tool. The MHRA will continue to keep the issue of monitoring for clozapine toxicity under close review, including reviewing Yellow Card cases and will be writing to the marketing authorisation holders to investigate further thresholds for clozapine toxicity.
Luke Ashton
Partially Responded
2023-0238 12 Jul 2023 Leicester City and South Leicestershire
Betfair Flutter UK & Ireland Department for Culture, Media and Sport +1 more
Concerns summary (AI summary) Inadequate player protection tools and a flawed algorithm failed to identify and intervene with a problem gambler. The operator's reliance on minimal regulatory standards, rather than best practice, exacerbated risks.
Noted (AI summary) The Department for Culture, Media and Sport outlines actions planned following the Gambling Act Review, including enhanced affordability checks, strengthened protections for young adults, and empowering consumers to control their gambling, with the main measures expected to be in force by summer 2024. Flutter provides background information on the company and its brands, particularly Betfair, explaining the difference between the Sportsbook and the Exchange. The Gambling Commission outlines several initiatives and planned actions, including collaboration with stakeholders to improve understanding of gambling-related harm, support for research, and the development of GamProtect, a 'Single Customer View' solution for identifying customers at risk of harm.
June Peel
All Responded
2025-0403 11 Jul 2023 South Yorkshire (West District)
Belle Green Court Care Home
Concerns summary (AI summary) Failures in documenting injuries, inadequate handover of critical information, and staff not following care plans led to a patient with a femur fracture receiving inappropriate care without timely medical attention.
Action Taken (AI summary) Staff at Belle Green Court Care Home have received updated training on care planning and record keeping, and reviewed key policies and procedures. The Manager has commenced a tracker of all accidents and incidents to assist identifying any patterns or concerns.
John James
All Responded
2023-0242 11 Jul 2023 East London
Barts Health NHS Foundation Trust
Concerns summary (AI summary) A critical lack of an electronic system to alert medical staff when essential anti-coagulation medication is refused or unadministered, significantly increasing the risk of life-threatening venous thrombo-embolism.
Action Taken (AI summary) The trust will update Millenium training to ensure teams know how to use the flag system to ensure critical medications are not omitted. A medicines safety dashboard is being developed to track dose omission and support quality improvement. Learning from the serious incident investigation has been shared across the organisation.
Mustafa Nadeem
All Responded
2023-0237 11 Jul 2023 Birmingham and Solihull
Collaborative Mobility UK Department for Transport West Midlands Combined Authority
Concerns summary (AI summary) Children easily bypassed age and licence checks to illegally use hire e-scooters, facilitated by inadequate identity verification and payment system vulnerabilities. Limited regulation and ineffective education exacerbate this risk.
Noted (AI summary) TfWM's new e-scooter operator Beryl will use the same 'selfie' security process for registering an account as the previous operator, Voi. They will work with local police and schools to identify and act on underage riding reports, and will monitor bank account registrations. Beryl will also implement outreach work with institutions and academies. The Department for Transport will encourage operators to continue additional measures to deter under-age riding, and will work with trial operators to gather and disseminate examples of additional measures. They will also work with operators to understand if anything more could be done to alert them to attempts by under-age riders to gain access to e-scooters. CoMoUK acknowledges the concerns but states they don't have the power to make operational changes to shared transport schemes. They have held meetings with Transport for West Midlands and the Department for Transport and will track the changes being implemented.
Christian Tuvi
All Responded
2023-0239 10 Jul 2023 Inner South London
Department for Transport
Concerns summary (AI summary) A prolonged impasse among organizations regarding safe conveyor operation, coupled with inadequate training and competence assessment for cleaners, resulted in an unsafe system relying on temporary measures.
Noted (AI summary) The Department for Transport acknowledges the coroner's concerns but states it has limited power to intervene and that the Office of Rail and Road and London Underground Limited are responsible. It notes that London Underground Limited has reached an agreement with its contractors and will provide details to the coroner. Transport for London states that KONE engineers will undertake all inching activities on LU's moving walks and escalators. TfL is working with KONE to update Safe Systems of Work by 29 September 2023 to reflect these new arrangements.
Mary Jones
All Responded
2023-0236 10 Jul 2023 North West Wales
Betsi Cadwaladr University Health Board…
Concerns summary (AI summary) Persistent and unacceptable ambulance delays, compounded by patient offload issues at emergency departments, are linked to a lack of local authority involvement in addressing social care deficiencies affecting patient flow.
Noted (AI summary) The Welsh Ambulance Service NHS Trust acknowledges concerns about ambulance delays and inability to offload patients. They state they have robust plans in place and liaise with Health Boards but do not believe they are the authority with the power to take such actions.
Harold Wilberforce
All Responded
2023-0235 10 Jul 2023 East Riding and Hull
General Pharmaceutical Council Orchard 2000 Pharmacy
Concerns summary (AI summary) A pharmacy delivery agent, lacking training and dementia awareness, moved an elderly patient who had fallen and resisted help. There's a critical lack of clarity regarding staff responsibilities in such situations.
Noted (AI summary) The GPhC acknowledges receipt of the concern regarding Orchard 2000 Pharmacy and provides context about its role as a regulator of pharmacy professionals and premises, but does not describe any specific actions taken or planned in response to the concern. The GPhC notes concerns about the roles and responsibilities of delivery agents and states that the Superintendent Pharmacist has updated SOPs to clarify how delivery drivers should respond to emergencies, including contacting emergency services and informing the pharmacist. Delivery drivers are also enrolled on a specific training course. Orchard 2000 Pharmacy has made delivery agents aware of their duty to contact emergency services and inform the pharmacist on duty in emergencies. They have also enrolled delivery agents in a training program titled 'Delivering Medicines Safely and Effectively'.
Christopher Smith
All Responded
2023-0420 7 Jul 2023 Nottingham City and Nottinghamshire
Nottinghamshire Healthcare NHS Foundati…
Concerns summary (AI summary) Serious neglect in prison healthcare included unsafe cell door observations, failure to use the NEWS2 system, inadequate GP visits, and poor leadership resulting in a lack of a safe care plan.
Action Taken (AI summary) Nottinghamshire Healthcare NHS Foundation Trust has implemented several improvements, including drill-based NEWS2 training, clear escalation pathways, and additional resources to support the rollout of NEWS2 training. They have also improved processes for supporting staff through the inquest process, including additional training and support from the Medico Legal Team.
David Lyth
All Responded
2023-0233 7 Jul 2023 Cheshire
3D Trans, Health and Safety Executive
Concerns summary (AI summary) Repeated "rollaway" incidents with vehicles indicate a serious ongoing safety risk, suggesting that regular and periodic training for drivers on coupling and uncoupling procedures is inadequate.
Action Taken (AI summary) HSE states that they will engage with key stakeholders to remind them of the need to manage risk when coupling and uncoupling articulated vehicles. HSE has conducted a further inspection of 3D Trans Ltd and is satisfied with the measures the company has put in place regarding training, monitoring, and supervision. 3D Trans has strengthened its training program to ensure that all drivers receive quarterly refresher training against the company's coupling and uncoupling procedure. This includes reviewing written procedures, watching a video, and completing a test.
Elizabeth Agbejimi
All Responded
2023-0232 6 Jul 2023 Lincolnshire
Concerns summary (AI summary) A significant abnormal respiratory acidosis reading was not further investigated, potentially indicating a training or communication failure that contributed to the patient's death from a respiratory condition.
Action Taken (AI summary) The Trust is implementing mandatory documentation requirements for ED clinicians acknowledging blood gas results, including noting abnormalities and planned management. They will communicate the potential altered response to infection in those with Trisomy 21 to relevant teams and remind them to fully review ED notes. Clinical audits will be undertaken to assess embedding of the learning.
Oleg Khala
All Responded
2023-0231 6 Jul 2023 Inner West London
West London NHS Trust
Concerns summary (AI summary) A vulnerable patient with complex mental health needs was repeatedly discharged for community care despite suicidality and non-engagement, likely due to a shortage of care-coordinator provision and lack of consultant advice.
Action Planned (AI summary) West London NHS Trust is implementing NICE guidance (NG225), undertaking an audit of CATT processes by December 2023, and providing additional training for staff regarding ASD. They are also in discussion with North West London ICB to develop a local commissioned pathway for ADHD assessment and intervention.
Gordon Renfrew
All Responded
2023-0230 6 Jul 2023 Nottinghamshire
Nottinghamshire Healthcare NHS Foundati…
Concerns summary (AI summary) Inadequate communication and collaboration between stroke and neurosurgical teams, coupled with the stroke team's limited understanding of crucial NICE guidance, led to serious issues in patient care.
Action Planned (AI summary) The Trust will develop joint learning strategies between Stroke, Neurosurgical, and Neuro-Radiology teams, present decompressive surgery cases at quarterly regional stroke meetings, share minutes of speciality meetings, coordinate responses to SJCRs across specialties, and continue discussing complex Mechanical Thrombectomy cases at the Mechanical Thrombectomy steering group.
Emlyn Roberts
Historic (No Identified Response)
2023-0229 6 Jul 2023 North Wales East and Central
Betsi Cadwaladr University Health Board…
Concerns summary (AI summary) Unacceptable and persistent ambulance delays, a problem worsening over ten years despite previous reports, demonstrate inadequate cohesive planning for both short-term pressures and long-term solutions.
[REDACTED]
All Responded
2023-0234 5 Jul 2023 Inner North London
Metropolitan Police Service
Concerns summary (AI summary) Officers struggled to recognise the point for immediate CPR, delaying its commencement, and there was a lack of proactive, focused support from secondary safety officers during a critical incident.
Action Planned (AI summary) The MPS will introduce a "first aid safety officer" role in annual first aid training from April 2024. From April 2024, the MPS will deliver additional ELS Module 2 training (increased from 9-12 hours) which will introduce techniques such as the ‘jaw thrust’ and also provide more practical scenario-based drills.
Andre Moura
All Responded
2023-0348 3 Jul 2023 Manchester South
College of Policing National Police Chiefs Council
Concerns summary (AI summary) Police training on Acute Behaviour Disturbance (ABD) was ineffective in real-life recognition, lacked formal testing, failed to embed the safety officer role, and relied on subjective assessments instead of objective AVPU checks.
Action Planned (AI summary) The College of Policing has revised its First Aid Learning Programme (FALP) and the new Public and Personal Safety Training (PPST) training implementation went live in 2023, and the revised ABD training package will be published mid-September 2023. The NPCC is revising the Body Worn Video (BWV) guidance to include that BWV should be left running during periods of prisoner transport. This guidance will be published in October.
Liam Bentley
All Responded
2023-0227 3 Jul 2023 Mid Kent and Medway
HM Prison and Probation Services
Concerns summary (AI summary) Critically low and predicted further reductions in prison staff complements compromised the safety of the deceased and pose an ongoing risk due to staff shortages.
Action Taken (AI summary) HMPPS is improving staffing at HMP Swaleside through interventions across pay, recruitment and retention, including a colleague mentor scheme, Advance into Justice, Prison Officer ‘Futures’, the National First Time Officer scheme, locally targeted PR activity, a market supplement and a pay increase.
Arezou Tirgari
All Responded
2023-0226 3 Jul 2023 City of London
Landsec
Concerns summary (AI summary) Insufficient action has been taken to prevent individuals from jumping from a specific roof terrace, leading to two deaths in eight weeks and an ongoing risk of further fatalities.
Action Taken (AI summary) Landsec has implemented measures including a two-metre exclusion zone, warning signs, planters, and security officers to prevent access to the perimeter wall at One New Change's roof terrace.