2023

PFD Reports
Reports: 552 Areas: 65

85% response rate (above 63% average).

552 results
Vivienne Greener
All Responded
2023-0531 18 Dec 2023 North Wales East and Central
Betsi Cadwaladr University Health Board Department of Health and Social Care
Concerns summary (AI summary) A lack of out-of-hours emergency endoscopy and insufficient Emergency Department staff contribute to ineffective triage and ambulance offloading delays. Unclear clinical protocols and inadequate sharing of investigation learning also pose risks.
Action Planned (AI summary) Betsi Cadwaladr UHB updated the Upper GI Bleeding – Management and Principles of Care pathway in July 2023 and will review it again in April 2024. A new incident process is being developed and will be implemented in April 2024, including a new report template to clarify the final version. The Welsh Government is holding health board chairs accountable for ambulance patient handover improvements and has incorporated this as a key objective for all chairs for 2023/2024. They have established national mechanisms for monitoring the quality, safety and effectiveness of services provided by health boards across Wales. Over £500,000 of additional funding was made available to Betsi Cadwaladr University Health Board in December 2023 to support upgrades and improvements in their emergency departments.
Nuel-Junior Dzernjo
All Responded
2023-0530 18 Dec 2023 Suffolk
National Institute for Health and Care … Royal College of Paediatrics and Child …
Concerns summary (AI summary) A lack of clear guidance for prescribing intravenous Acyclovir, instead of ineffective oral medication, potentially led to incorrect treatment and preventable death for the patient.
Noted (AI summary) NICE clarifies that it has not published a guideline on managing chickenpox, but it does publish a Clinical Knowledge Summary (CKS) on its website. They have shared the report with Agilio Software, the external company who develop the CKS. The Royal College of Paediatrics and Child Health (RCPCH) will share information and suggestions for local improvement from the coroner's report with its members via its patient safety portal. They are engaging with NHS England and the Patient Safety Commissioner on implementing Martha's Rule nationally and support the recommendation for a universal varicella vaccination programme.
David Hemmings
Historic (No Identified Response)
2023-0529 18 Dec 2023 Inner West London
Choice Support
Concerns summary (AI summary) Severe staff shortages in the care home led to reduced contact time and checks for a vulnerable resident, contributing to an accidental fall and subsequent fatal complications from surgical treatment.
Peter Kelly
All Responded
2025-0419 15 Dec 2023 South Yorkshire East
South Yorkshire Police
Concerns summary (AI summary) Custody sergeants lacked understanding of Liaison and Diversion team processes, available information, and how to complete pre-release risk assessments. This indicates a training need for recognizing vulnerability at discharge.
Action Planned (AI summary) South Yorkshire Police will circulate clarification to custody sergeants and staff on involving Liaison and Diversion, provide a flowchart for completing Pre-Release Assessments, and provide further guidance on entering the "L&D" flag on the CONNECT system; they will also hold one-to-one discussions with Custody Sergeants A and B involved in the detention of PK.
Terence Hines
All Responded
2024-0013 15 Dec 2023 Worcestershire
Worcestershire Acute Hospitals NHS Trust
Concerns summary (AI summary) Failures in hospital cleaning protocols led to a patient acquiring MRSA from a previously occupied room. Multiple failures to perform routine MRSA screening before and during his inpatient stay also contributed to a fatal infection.
Action Taken (AI summary) The Trust updated its Isolation Policy to require a Red clean for every known case of MRSA and distributed a "lessons learned" poster to wards to highlight learning from the incident.
John Thomas
All Responded
2023-0527 15 Dec 2023 North Wales East and Central
Denbigshire County Council
Concerns summary (AI summary) Known highway defects, including surface water and flooding, were not remedied by the local authority, posing a clear risk of future fatal road incidents.
Action Taken (AI summary) Denbighshire County Council has cleared drainage gullies and channels on the A539, erected warning signs alerting motorists to the possibility of water or ice and this culvert will now be added to a list of critical culverts which are known to require higher maintenance standards and this feature will now be added to it a monitored more closely.
John Taylor
All Responded
2023-0525 15 Dec 2023 Teesside and Hartlepool
North East Ambulance Service NHS Founda…
Concerns summary (AI summary) Paramedics failed to adequately check an unlocked door, leading to a 30-minute delay awaiting police entry, an issue not addressed in the internal investigation. Alternative transport options were also not considered.
Noted (AI summary) The North East Ambulance Service details their procedures for checking doors and alternative transport options, noting that welfare calls are prioritized for patients who are alone.
Olivia Russell
All Responded
2023-0528 14 Dec 2023 Cheshire
Stretton Medical Centre
Concerns summary (AI summary) GPs may not routinely discuss medication risks, such as relapse or initial worsening symptoms, contradicting NICE guidance, due to varied approaches and time limitations. A significant event meeting regarding the death was also delayed for over two years.
Action Planned (AI summary) The practice will audit care plans every 6 months, request GP review earlier than 2 weeks if needed, refer to CRISIS team for deterioration, have the Clinical pharmacist assist with medication review and arrange a follow-up appointment for any patients that DNA.
Reece Nelson
All Responded
2024-0001 12 Dec 2023 North Lincolnshire and Grimsby
Navigo
Concerns summary (AI summary) Mental health services lacked a system to inform families of staff absence or provide alternative contacts, preventing a family from seeking assistance during a crisis.
Action Taken (AI summary) Navigo has revised its Community Mental Health and Wellbeing Services Operational Policy to improve staff cover arrangements and inform patients of crisis contact details. Voicemail messages on work phones will include contact details for urgent assistance.
Ruth Perry
All Responded
2023-0524 12 Dec 2023 Berkshire
Department for Education Ofsted Reading Borough Council
Concerns summary (AI summary) Ofsted's inspection system lacks transparency, negatively impacts school leader welfare, and has insufficient training for managing distress or clear channels for raising concerns. Local authority support also lacks formal policy.
Action Planned (AI summary) The Department for Education will write to all Responsible Bodies setting out their responsibilities and committing to working closely with local authorities and academy trusts to ensure school leaders are well supported, particularly following an adverse inspection result. DfE officials will ask the Responsible Body of the school to ensure that appropriate support is in place to support the headteacher and broader school’s workforce where a school faces an adverse inspection judgement. Ofsted has taken action to ensure inspectors are aware of the support available to school leaders, reinforcing the expectation that they share this information at the beginning of an inspection and ensuring this information is included in documents shared with providers. They will also use existing channels to share information about support for leaders. Reading Borough Council, through Brighter Futures for Children Ltd, has consulted with head teachers and will proactively challenge Ofsted inspections on a school's behalf. They have already written to school leaders, have written into the School Effectiveness Framework the Council’s approach to challenging an inspection, and appointed reviewers to conduct an independent learning review.
Paul Perrott
Partially Responded
2023-0522 11 Dec 2023 Plymouth, Torbay and South Devon
Devon Partnership NHS Trust Langdon Hospital
Concerns summary (AI summary) Inadequate observation charting, unclear staff responsibility for checks, and a lack of historical risk analysis meant staff were unaware of the patient's critical suicide risk history.
Action Taken (AI summary) Devon Partnership NHS Trust highlights existing policies and practices: ward managers are responsible for ensuring staff are familiar with policy and trained, daily risk meetings take place, and the hospital operates a risk recording system. It will conduct monthly audits of patient observation charts and update patient information sharing procedures.
Amarnih Lewis-Daniel
All Responded
2023-0518 11 Dec 2023 East London
NHS England
Concerns summary (AI summary) Extremely long waiting lists for Gender Identity Clinics, coupled with a severe lack of local support and specialist knowledge in mental health services, and unclear responsibilities for patient welfare, are intensifying distress.
Noted (AI summary) NHS England expresses condolences and acknowledges the concerns raised. The response focuses on the NHS pathway of care for adults with gender dysphoria, national policy on mental health services for young people up to 25, and existing guidance for GPs. Together UK has information sharing agreements with NELFT and ELFT and follows a Standard Operating Procedure for Liaison and Diversion. The agency social worker would have received risk management, information sharing, and safeguarding training as part of their professional training.
Jessica Eastland-Seares
All Responded
2023-0520 10 Dec 2023 West Sussex, Brighton and Hove
Department of Health and Social Care
Concerns summary (AI summary) Critically inadequate community provision and insufficient financial investment for autistic individuals force unnecessary inpatient admissions and A&E attendances due to a severe lack of suitable support placements.
Action Planned (AI summary) The Department of Health and Social Care is prioritising updating the Autism Act statutory guidance to support the NHS and local authorities to deliver improved outcomes for autistic people. They expect to publish the updated draft Statutory Guidance for public consultation this year.
Catherine Jones
All Responded
2023-0526 8 Dec 2023 North Wales East and Central
Betsi Cadwaladr University Health Board Welsh Government
Concerns summary (AI summary) Undocumented surgical protocols led to a lack of cohesive care, as communication between surgeons and patient consultants was not a formal system, risking future harm.
Action Planned (AI summary) Betsi Cadwaladr University Health Board will develop a clear and consistent policy for surgical lists across the organisation, led by a task group meeting monthly starting in February 2024, with completion estimated within six months. The Welsh Government describes the implementation of the new Cancer Informatics Solution (CIS) which makes available a number of new clinical records that can be viewed through the Welsh Clinical Portal. It also includes functionality to notify the clinician of any new histopathology reports they have requested.
Charlene Roberts
All Responded
2023-0516 8 Dec 2023 Manchester North
Greater Manchester Health and Social Ca… Medicines and Healthcare Products Regul… NHS England +1 more
Concerns summary (AI summary) The report identifies a lack of treatment options for the deceased's cyclizine addiction and eating disorder, with multiple rejections from specialist services and no clear plan for managing her complex needs.
Action Planned (AI summary) NHS England is developing a joint action plan with the Department of Health and Social Care to improve the provision of mental health treatment for people with drug dependence, to be published and implemented later in 2024. The MHRA will consider the case and wider evidence regarding the misuse of cyclizine and determine whether the current risk minimisation measures are sufficient, communicating further action to healthcare professionals and patients if required. A GM level review of phlebotomy provision has been undertaken recently which has identified the variation in provision and sets out the intention to improve the consistency of offer to patients across Greater Manchester. This is also a priority deliverable of the Greater Manchester Primary Care Blueprint. The Royal College of Psychiatrists will communicate the potential risk of cyclizine addiction to its members through newsletters and faculty communications, and will raise the issue with mental health organisations and those responsible for the mental health system.
Lindy Aston
All Responded
2023-0515 8 Dec 2023 Leicester City and South Leicestershire
Kettering General Hospitals NHS Trust
Concerns summary (AI summary) A critically ill patient requiring urgent splenectomy was not operated on at Kettering General Hospital, despite the capability, resulting in a 24-hour delay and transfer that likely contributed to her death.
Action Taken (AI summary) Kettering General Hospital NHS Foundation Trust has implemented a Standard Operating Policy (SOP) addressing emergency theatre capacity and the safe staffing of emergency theatres, monitors theatre use through daily safety huddles, introduced 'Stop the Line', and rewritten its policy regarding mortality reviews.
Claire Briggs
All Responded
2023-0513 8 Dec 2023 Manchester South
British Transport Police Cheshire and Merseyside Integrated Care… Cheshire Constabulary +10 more
Concerns summary (AI summary) A stalled Joint Operating Protocol between emergency services leaves a critical lack of clarity on roles and escalation procedures for drug overdose incidents, risking patient safety.
Noted (AI summary) North West Fire Control is supporting the embedding of Joint Emergency Services Interoperability Principles (JESIP) and working with partners to implement electronic data transfer for improved information sharing, expected by March 2024. NHS England outlines existing guidance for ambulance services relating to overdoses and suicidal intent issued in April 2021, and describes ongoing work to improve ambulance performance. Cheshire Constabulary has signed the Joint Operating Protocol (JOP) with NWAS and supports its endorsement by other parties, with a coordination meeting scheduled for January 16, 2024. Lancashire and South Cumbria ICB reports that four North West police forces have agreed and gone live with their Joint Operating Protocols (JOPs) with NWAS, with Greater Manchester Police in the final stages of agreement, and learning will be overseen by the NWAS Regional Clinical Quality Assurance Committee. Cumbria Constabulary has signed a regional Information Sharing Agreement (ISA) and has been working under a Joint Operating Procedure (JOP) since October 2023; it also provides clinical support through its "treat and hear" facility. Lancashire Fire and Rescue Service states that it was not involved in the incident, but is committed to improvement and learning. The service outlines its support for JESIP, reviews policies/procedures/training, and has an Immediate Emergency Care SOP with guidance on various areas. The North West Ambulance Service (NWAS) have engaged with all the North West Police Forces to develop a Joint Operating Protocol (JOP). Four forces have agreed and gone live with their JOPs, ensuring clear process for sharing information, primacy understanding, and a clear escalation process for any operational issues. Four of the North West police forces, including Cheshire Constabulary and Merseyside Police, have agreed and implemented Joint Operating Protocols (JOPs) with the North West Ambulance Service to improve information sharing and escalation processes. BTP has adopted the "Ten Second Triage" (TST) tool nationally and is delivering associated training in 2024. They also use ESICTRL radio talk groups for direct communication between emergency service control rooms. NWAS reports that a Joint Operating Protocol (JOP) has gone live with Cheshire, Cumbria, Lancashire and Merseyside Police Forces, and that an updated version has been agreed with Greater Manchester Police and is scheduled for implementation across the whole North West following a meeting in late February 2024; also, the JOP has been extended to include British Transport Police, North West Fire Control, and Fire and Rescue Services. Merseyside Fire and Rescue Service states that its existing procedures for communicating casualty information to NWAS are sufficient, including written instructions and escalation options. Lancashire Police has agreed to Version 1.3 of a Joint Operating Protocol (JOP) with regional forces and NWAS to provide clarity and guidance to Control Room staff regarding escalation of incidents due to delays; awaiting final sign-off from GMP and Fire and Rescue. Response not parsable
William Gray
All Responded
2023-0511 8 Dec 2023 Essex
Association of Ambulance Chief Executiv… Department of Health and Social Care East of England Ambulance Service NHS T… +2 more
Concerns summary (AI summary) Hospital doctors were unaware of JRCALC guidelines for adrenaline in life-threatening asthma. Ambulance guidelines lacked clarity on managing severe asthma attacks, and the trust's investigation failed to learn from repeat incidents.
Noted (AI summary) The Ambulance Service has disseminated posters addressing human factors, developed a new training package on decision-making under pressure, and is providing regular updates on best practice for asthma management. They have removed the skill of intubation for general paramedics and are rolling out Advanced Paramedics in Critical Care cars across the region. They have also implemented the Patient Safety Improvement Response Framework. Mid and South Essex NHS Foundation Trust has shared learning with teams about the JRCALC protocol on managing severe asthma in children and is delivering training sessions focusing on the role of Adrenaline; they have also sent an email to staff regarding the use of Adrenaline in pre-hospital asthma resuscitation. AACE will review the JRCALC asthma guideline and make changes if required, and will share the concerns with their national ambulance service medical directors’ group (NASMeD) to consider further education or awareness for clinicians regarding airway management and adrenaline administration. Essex Partnership University NHS Foundation Trust has implemented several changes in the Asthma & Allergy Children’s and Young Persons Service, including staff training, caseload reviews, translated care plans, smoking cessation courses, and links between universal services and the CAAS to improve education and training. Essex Partnership University NHS Foundation Trust has implemented several changes in the Asthma & Allergy Children’s and Young Persons Service, including staff training, caseload reviews, translated care plans, smoking cessation courses, and links between universal services and the CAAS to improve education and training. The Department acknowledges the concerns and describes the existing framework for healthcare professional training, including the National Capabilities Framework for Professionals who care for Children and Young People with Asthma. They note that employers are responsible for ensuring staff are trained to the required standards.
Jasbir Pahal
Historic (No Identified Response)
2023-0509 8 Dec 2023 West Yorkshire (Eastern)
NHS England Stroke, East Kent Hospitals University … West Yorkshire and Harrogate Integrated… +2 more
Concerns summary (AI summary) The hyper-acute stroke unit offers a thrombectomy service for only 20.8% of the week, denying patients crucial time-sensitive treatment based on their home address and time of stroke.
Sarah Chappell
All Responded
2023-0523 7 Dec 2023 Inner North London
University College London Hospitals NHS…
Concerns summary (AI summary) Multiple failures including delayed transfer, confusion over lead clinicians, inadequate pain relief, and critical mismanagement of a nasogastric tube led to a fatal aspiration. The hospital failed to conduct a proper investigation.
Action Taken (AI summary) UCLH has strengthened its governance structures, appointed a second learning disability nurse, instigated a process to review all deaths of patients with learning disabilities, convened a weekly incident review group, and actively promoted Learning Disability Awareness Week.
Ian Jacka
All Responded
2023-0519 7 Dec 2023 Cornwall and the Isles of Scilly
University Hospital Plymouth NHS Trust
Concerns summary (AI summary) A critical omission in patient records and inadequate handover from critical care meant surgical teams were unaware of a prior hypoxic brain injury, leading to an ill-timed operation.
Action Planned (AI summary) The intensive care and anaesthetic departments will create a preoperative handover checklist by February 29th, 2024, to ensure the anaesthetic team considers all relevant factors for the patient's ongoing care. The National Trust will contact Cornwall Council regarding installing further signage on the road and will review the risk assessment at Chapel Porth annually. The MHRA will raise the issues with the manufacturers of the Cook Airway Exchange Catheter and Manujet III ventilator and explore if further risk communication or information is required.
Katharine Fox
All Responded
2023-0510 7 Dec 2023 Essex
Essex Partnership University Trust
Concerns summary (AI summary) A critical disconnection between hospital and community psychology services, compounded by a lack of handover and incompatible computer systems, resulted in substantial wait times and impaired continuity of care.
Action Taken (AI summary) Essex Partnership University NHS Foundation Trust has implemented measures to improve handover of care between inpatient and community psychology services, ensure access to clinical systems and robust information sharing, and provide supervision and training for care coordinators regarding safe patient care.
Margaret Heal
Historic (No Identified Response)
2024-0368 6 Dec 2023 Durham & Darlington
The Trust
Concerns summary (AI summary) A vulnerable, elderly patient was not provided with clear documented instructions to resume crucial anti-coagulation medication post-discharge, highlighting a gap in discharge advice for at-risk individuals.
John Lee
All Responded
2023-0505 6 Dec 2023 Surrey
Surrey and Sussex Healthcare NHS Trust
Concerns summary (AI summary) Dementia patients at the Trust are not consistently receiving mouth care after eating, posing a risk of future deaths.
Action Taken (AI summary) The Trust has already undertaken several actions, including updating the dysphagia e-learning module, introducing a rolling training programme, and planning a swallow awareness event in March 2024. It will also review the Meal time policy, relaunch Red Tray guidance, and produce communication materials promoting dysphagia awareness.
Jonathan Goldstein, Hannah Goldstein and Saskia Goldstein
All Responded
2023-0514 5 Dec 2023 Inner South London
UK Civil Aviation Authority
Concerns summary (AI summary) A critical lack of compulsory mountain flying training and guidance for UK PPL(A) license holders means pilots undertake hazardous flights without adequate knowledge of specific risks and tactics.
Action Planned (AI summary) The CAA acknowledges the challenges of mountain flying and states it will publish relevant guidance on its website by 31 July 2024, and a Safety Sense Leaflet on mountain flying by 31 December 2024.