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
Sinon Masha
All Responded
2023-0228 30 Jun 2023 Birmingham and Solihull
University Hospitals of Birmingham NHS …
Concerns summary (AI summary) The hospital's multiprofessional appointment system for high-risk home births is not functioning as per guidance, resulting in fragmented communication and depriving patients of crucial collective professional perspectives, risking lives.
Action Taken (AI summary) The Trust has appointed two consultant midwives, implemented a bi-weekly MDT meeting, established an audit process for high-risk home births, and plans to review the Birth Choices Guidelines and home birth guidance by 31 October 2023.
Sam Taylor
All Responded
2023-0224 30 Jun 2023 Herefordshire
Herefordshire Council
Concerns summary (AI summary) Herefordshire Council's communication failure prevented contact with the deceased, failing to establish his vulnerability for housing support, and highlighted a lack of effective systems for identifying process failures.
Action Taken (AI summary) Herefordshire Council has made changes to the structure, processes, and practice within the service, including robust processes and proactive work with partners. A system for identifying process failure is now in place, covering supervision of officers, management oversight of the CRM system, and weekly reviews of each case. A programme of case auditing is also being developed.
Victoria Storey
Partially Responded
2023-0222 30 Jun 2023 Surrey
Department of Health and Social Care Ministry of Justice
Concerns summary (AI summary) A highly potent, illicitly traded synthetic opiate with high fatal overdose risk is not yet controlled as a Class A, Schedule 1 drug, despite official advice for its urgent inclusion.
Action Planned (AI summary) The government accepted ACMD recommendations to control synthetic opioids, including , under the Misuse of Drugs Act 1971 and intends to bring forward this legislation by the end of the year to come into force in early 2024.
Kaye McCoy
All Responded
2023-0221 30 Jun 2023 Gwent
Aneurin Bevan University Health Board
Concerns summary (AI summary) The health board failed to provide a strategy for family engagement and 24-hour crisis support, despite national recommendations, suggesting these crucial guidelines are not fully integrated into practice.
Action Planned (AI summary) The Health Board is considering the findings and recommendations of a 6-month pilot extending the hours of the Community Mental Health Team, exploring other alternatives for crisis support, and will continue to audit the use of the current pathway by the older adult population.
Clinton Fear
Historic (No Identified Response)
2023-0286 29 Jun 2023 Avon
UK Health Security Agency
Concerns summary (AI summary) Current guidelines inconsistently notify patients of Mycobacterium Chimaera infection risk only for post-January 2013 surgeries, despite earlier evidence, potentially delaying diagnosis and harming patients from prior procedures.
Matthew Phipps
Historic (No Identified Response)
2023-0219 29 Jun 2023 East London
Barking, Havering and Redbridge Univers…
Concerns summary (AI summary) The hospital lacked a contingency plan for providing intensive care when the unit was full, resulting in a patient requiring critical care not being admitted.
Peter Walker
Partially Responded
2023-0217 29 Jun 2023 Suffolk
Department for Transport UK Civil Aviation Authority
Concerns summary (AI summary) The CAA's self-declaration system for older pilots lacks comprehensive medical guidance and a central licence revocation system, allowing revalidation without independent assessment of fitness to fly.
Action Planned (AI summary) The CAA has accepted the AAIB recommendations and is planning to update its Pilot Medical Declaration (PMD) system, including updating the PMD webpage and form, providing guidance to medical professionals, reviewing administrative approaches with the DVLA, and introducing PMD 'spot checks'. They will also review revalidation processes for certain pilots.
George Griffiths
All Responded
2023-0223 28 Jun 2023 Herefordshire
Wye Valley NHS Trust
Concerns summary (AI summary) A significant pressure sore developed during the patient's lengthy and complicated hospital admission, contributing to death and raising concerns about care quality in the elderly care ward.
Action Taken (AI summary) The Trust has introduced a senior nurse care review in the ED, developed and piloted a local competency package for pressure area care (starting with the Frailty service), refreshed Tissue Viability link nurse roles with additional training, and holds a weekly Pressure Ulcer panel to discuss incidents of pressure damage.
Hilary Thomas
All Responded
2023-0216 28 Jun 2023 Birmingham and Solihull
Department of Health and Social Care University Hospitals Birmingham NHS Fou…
Concerns summary (AI summary) Overwhelmed hospital resources led to delayed test results, critical national guidance for consultant review of high-risk patients was not followed, and staff lacked awareness regarding CT scan requirements.
Noted (AI summary) The Trust will display laminated posters of joint guidance in acute surgical areas, publish and disseminate a new trust policy, update the online requesting system, engage with the West Midlands Postgraduate School of Surgery to inform trainees, and report the incident to CORESS, with completion expected by 31st October 2023. The Department of Health and Social Care acknowledges the concerns about capacity at Birmingham Heartlands Hospital and outlines national plans to improve A&E waiting times, increase hospital capacity, and support timely discharge from hospital, but doesn't detail specific actions beyond those already in place.
Carol Hatch
All Responded
2023-0215 28 Jun 2023 West Yorkshire (Eastern)
Spire Healthcare Limited
Concerns summary (AI summary) Hospital staff failed to recognise and escalate a patient's critical deterioration, compounded by an un-inducted agency nurse misinterpreting observations, delayed diagnostics, and overall systemic communication and competency breakdowns.
Action Taken (AI summary) Spire Healthcare conducted a Root Cause Analysis investigation, implemented a new checklist for agency staff, and took other actions to address concerns raised in the report, including measures related to escalation to consultant, deteriorating patient care, and recruitment.
Rachel Garrett
All Responded
2023-0218 27 Jun 2023 West Sussex
Integrated Health Board NHS Sussex NHS England
Concerns summary (AI summary) A technical issue regarding the employment status of Mental Health Liaison staff prevents them from detaining patients under the Mental Health Act in acute hospitals, creating a serious risk of vulnerable patients absconding.
Action Planned (AI summary) NHS England notes that pathway reviews are being undertaken, SPFT is in the planning stages of putting together a business case for direct employment of Mental Health Staff by the acute providers and Sussex ICB are investigating the issues raised in the Report with SPFT and considering any improvements that can be made to the safety of patients. NHS England will also raise the case with the Department for Health and Social Education. NHS Sussex will make contact with other ICBs to explore how they are addressing the employment of Mental Health Liaison Teams within the Acute Care Hospitals and also to look at workforce and practices with their Providers to try to resolve these issues on a local level.
Richard Littlewood
All Responded
2023-0214 27 Jun 2023 East Riding and Hull
Highways Department
Concerns summary (AI summary) Repeat fatal incidents on a specific road bend highlight concerns about inadequate safety measures and a lack of clear timescales for assessing and implementing additional road markings despite discussions between authorities.
Action Taken (AI summary) The Serious Collisions Unit confirms that new signage has been installed to pre-warn drivers of bends at the collision scene. The council has replaced chevron signs warning of bends and undertaken winter and summer visibility surveys.
Anthony Rockall
Unknown
2023-0287 26 Jun 2023 Buckinghamshire
Concerns summary (AI summary) Unsafe unloading practices using an incompatible pallet truck and heavy loads on tailgates persist without review, despite previous warnings, creating a significant risk of falls and fatal injuries.
Matthew Power
All Responded
2023-0213 26 Jun 2023 Surrey
EMIS Health
Concerns summary (AI summary) The EMIS prescribing system has flaws, including repeat prescriptions remaining 'pending' after cancellation, confusing grouping of dosages, and difficulty in accurately auditing prescribing history, posing a risk of medication errors.
Noted (AI summary) EMIS reviewed its EMIS Web system and believes no software developments are required beyond existing functionality. They offer further training to the Practice on optimal use of the system.
Ginger Wright
All Responded
2023-0212 26 Jun 2023 Surrey
Department of Health and Social Care South East Coast Ambulance Service
Concerns summary (AI summary) The ambulance service (SECAMBS) is consistently operating at a critical surge level, where demand significantly exceeds resources, leading to a failure to meet target response times and risking future deaths.
Noted (AI summary) South East Coast Ambulance Service NHS Foundation Trust acknowledges concerns about operating at Stage 4 of its Surge Management Plan and outlines factors contributing to increased demand and changes in patient profiles. It states they will continue to work with partners on local and national programmes and a full system-wide review is required. The Department of Health and Social Care highlights its 'Delivery plan for recovering urgent and emergency care services', investments in ambulance workforce, and funding to improve patient flow. They report improvements in ambulance response times nationally and in the SECAmb region, and improvements in patient handover times.
Keith Nielsen
All Responded
2023-0211 26 Jun 2023 Surrey
Department of Health and Social Care South East Coast Ambulance Service
Concerns summary (AI summary) The ambulance service (SECAMBS) is consistently operating at a critical surge level, where demand significantly exceeds resources, leading to a failure to meet target response times and risking future deaths.
Action Planned (AI summary) SECAmb is working with partners on local and national programmes, focusing on call handling, Category 2 response times, and hospital handover times, and plans a full system-wide review to develop a new care delivery model. The Department of Health and Social Care highlights its 'Delivery plan for recovering urgent and emergency care services', investments in ambulance workforce, and funding to improve patient flow. They report improvements in ambulance response times nationally and in the SECAmb region, and improvements in patient handover times.
Stephen Beadman
Historic (No Identified Response)
2023-0210 23 Jun 2023 West Yorkshire (Eastern)
HM Prison Wakefield Ministry of Justice NHS England
Concerns summary (AI summary) A maximum-security prison with many prisoners having significant mental health issues has inadequate consultant psychiatrist resources, falling short of "equivalence of care" and risking insufficient specialist support for long-term inmates.
Stephen Richardson
All Responded
2023-0209 22 Jun 2023 Liverpool and Wirral
Department of Health and Social Care NHS England & NHS Improvement
Concerns summary (AI summary) There is an ongoing national shortage of acute psychiatric beds, preventing patients with severe mental disorders from accessing immediate inpatient assessment and treatment, which has not improved since 2019.
Action Taken (AI summary) NHS England states there is constant pressure on acute psychiatry bed availability. They have taken actions linked to bed management, and all reports received are discussed by the Regulation 28 Working Group. From a CM ICB perspective wider bed management/availability issues are being continually addressed. The Department of Health and Social Care notes NHS England and Cheshire and Merseyside Integrated Care Board have provided a response. Nationally, spending on mental health services has increased by £4.7 billion, including introducing new models of care in the community.
Mason French
All Responded
2023-0208 22 Jun 2023 Sunderland
South Tyneside Council
Concerns summary (AI summary) Despite previous safety improvements, cyclists remain at significant risk at a specific road location, necessitating further measures to prevent future collisions.
Action Planned (AI summary) South Tyneside Council proposes three schemes: improving visibility by moving the stone wall, implementing parking restrictions, and making Lizard Lane 20mph with additional traffic calming. They have applied for a street works permit for the visibility improvements and will undertake a consultation process for the parking restrictions and speed limit change.
Lucy Walles
All Responded
2023-0206 22 Jun 2023 Berkshire
Reading Borough Council, Berkshire Heal…
Concerns summary (AI summary) Systemic issues in safeguarding, mental health provision, and inter-agency communication led to inadequate support for a vulnerable person. Concerns include slow safeguarding referrals, insufficient staff training, and resource adequacy across council and health services.
Action Taken (AI summary) Berkshire Healthcare NHS Foundation Trust describes the 'One Team' program to improve mental health services, including clear care plans, named workers, and connections to meaningful activities. They have implemented measures to improve staff retention and recruitment, and are participating in a Safeguarding Adults Review. Reading Borough Council has made improvements to the management of safeguarding referrals, including a dedicated safeguarding worker and adherence to Berkshire Safeguarding Policy. They have implemented a Quality Assurance Framework with an audit program for safeguarding referrals and will consider recommendations from the Safeguarding Adults Review.
Christopher Stevens
All Responded
2023-0204 22 Jun 2023 Cornwall and the Isles of Scilly
CPFT
Concerns summary (AI summary) Implementation of identified safety improvements, including a new consultant model, standardised documentation, and risk assessment protocols for patient leave, has been significantly delayed, raising concerns about ongoing risks.
Action Planned (AI summary) Lincolnshire County Council will regularly assess vegetation at the junction approaches and take action to ensure maximum visibility. They concluded that the existing visibility exceeds requirements for a STOP sign and will not change the existing GIVE WAY signage. Regenesis Health Travel Ltd is preparing a court case against the Termessos Hospital and the doctor(s) regarding the patient's death, planned to start in the next 3-5 months. They also state they no longer have a contract with the hospital.
Matthew Harris
All Responded
2023-0299 21 Jun 2023 Worcestershire
Dyfed-Powys Police
Concerns summary (AI summary) Police officers failed to document the deceased's recent suicidal ideation on Person Escort Record and Self-Harm warning forms, risking future underestimation or complete disregard of suicide risk for persons in custody.
Action Taken (AI summary) Dyfed Powys Police informed all relevant staff of the omission in this case and instructed Custody Officers to specifically ask interviewing officers about information relevant to risk assessment. Investigators have also been reminded of their duty to inform the custody officer of any relevant information. HMP Swansea introduced a thorough ACCT assurance procedure with additional checks by custodial managers and senior management. Further ACCT training is being rolled out to all ACCT case managers at HMP Swansea, focusing on consistency in case management, information sharing, and record keeping.
Jean Frickel
Historic (No Identified Response)
2023-0203 21 Jun 2023 North Wales East and Central
Betsi Cadwaladr University Health Board North Wales Local Authorities Welsh Ambulance Service Trust
Concerns summary (AI summary) Persistent ambulance delays stem from patient flow issues caused by social care deficiencies, leading to hospital handover delays. Insufficient collaboration between ambulance services, health boards, and local authorities continues to risk future deaths.
Leonard Harmsworth
Historic (No Identified Response)
2023-0202 20 Jun 2023 North Wales East and Central
Betsi Cadwaladr University Health Board North Wales Local Authorities Welsh Ambulance Service Trust
Concerns summary (AI summary) Significant ambulance response and hospital handover delays, extending over many hours, persist due to multifactorial issues including social care deficiencies and patient flow, posing a continued risk of future deaths.
Anita Graves
All Responded
2023-0201 20 Jun 2023 Manchester South
Medicines & Healthcare products Regulat…
Concerns summary (AI summary) The visual similarity of carbimazole tablets of varying strengths, and to aspirin, creates an overdose risk. The community dispensing process fails to mitigate this danger, potentially exacerbating the risk.
Action Planned (AI summary) The MHRA has sought advice from the DHSC, GPhC and RPS and describes planned changes to medicine packaging and dispensing, including the introduction of mandatory Patient Information Leaflets and monitoring of carbimazole overdoses.