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)
Clear 413 results
Margaret Austin
All Responded
2024-0065 27 Nov 2023 County Durham and Darlington
Stanley Park Care Centre
Concerns summary (AI summary) The care home exhibited inadequate falls risk management with inconsistent documentation, no plan reviews for changing risks, and a majority of staff lacking essential falls training.
Action Taken (AI summary) Stanley Park care home has taken steps to improve documentation around assessment and management of falls, including documentation to reflect the rationale sitting behind clinical decision making, and has incorporated a falls specific package into the mandatory training programme.
Luke Whitelaw
All Responded
2023-0486 27 Nov 2023 Inner North London
Oxleas NHS Foundation Trust
Concerns summary (AI summary) Missed opportunities for urgent psychiatric review and readmission occurred, alongside a lack of "professional curiosity," poor documentation, and inadequate risk assessment formulation in patient care.
Action Taken (AI summary) Oxleas NHS Foundation Trust updated its Acute Mental Health Patient Flow and Bed Management policy in December 2023, and introduced a single crisis assessment form on 22 January 2024. They also reinforced documentation standards and protected time for complex case discussions, with clinical leadership and psychology support.
Gracie Spinks
All Responded
2023-0479 27 Nov 2023 Derby and Derbyshire
Derbyshire Constabulary Home Office
Concerns summary (AI summary) Derbyshire Constabulary showed serious failings in investigating stalking, with inadequate officer training and understanding, alongside a lack of comprehensive and ongoing risk assessments.
Action Planned (AI summary) The Home Office is exploring with stakeholders where Government intervention could improve the criminal justice response to stalking and support for victims, including within the Victims and Prisoners Bill; officials will review statutory guidance on coercive and controlling behaviour and work with the NPCC to gather examples of best practice in policing stalking cases. Derbyshire Constabulary has updated training and guidance, reinforced requirements for record keeping, and reviewed policies regarding found weapons, including issuing specific policy relating to found weapons in October 2023.
Glyn Ackerley
All Responded
2023-0478 27 Nov 2023 Cheshire
Department of Health and Social Care
Concerns summary (AI summary) The NHS Pathways system fails to differentiate between high and low-risk overdoses, potentially delaying urgent treatment for fatal opiate overdoses, and the implementation of proposed changes is unclear.
Noted (AI summary) NHS England explains the NHS Pathways system and its governance, noting that NHS Pathways is owned by DHSC and that all reports received are discussed by the Regulation 28 Working Group.
Jennifer Whinney
All Responded
2023-0477 27 Nov 2023 Inner North London
Queens Hospital Royal London Hospital
Concerns summary (AI summary) Critical patient notes were not sent to an external appointment due to non-electronic records and a lack of clear responsibility for ensuring their transfer, risking incomplete medical history.
Action Taken (AI summary) Barts Health NHS Trust has undertaken several actions to reduce line infections at the Royal London Hospital, including providing education and training sessions for multidisciplinary surgical staff, and updating IPC statutory and mandatory training. They are also in the process of re-writing the ANTT policy with the microbiology and Infection Prevent and Control (IPC) teams. Barking Havering and Redbridge University Hospitals NHS Trust has revised its policy for sending patient notes to external hospital visits, with the updated policy approved on 22 January 2024. The revised policy includes explicit responsibilities, a checklist, and a signature section for acknowledging receipt of notes.
Mohammed Akram
All Responded
2023-0474 27 Nov 2023 Inner North London
Barnet Enfield and Haringey Mental Heal…
Concerns summary (AI summary) A lack of routine cross-referencing between prescribed and collected medication, and the failure to notify GPs when patients don't collect essential prescriptions, poses a significant risk.
Noted (AI summary) Barnet Enfield and Haringey Mental Health NHS Trust describes its usual procedures for when a client is not taking their medication as prescribed. They state that the expected standard is for the GP to be notified via email within 48 hours of the medical review when there are any changes to the client’s prescription or treatment plan.
Katie Williams
All Responded
2023-0512 24 Nov 2023 Plymouth, Torbay and South Devon
Intensive Care Medicine
Concerns summary (AI summary) The unexpected interaction of a specific medication with common overdose complications re-precipitated serotonin syndrome, highlighting a risk that other NHS organisations may not fully appreciate these medication interaction risks.
Action Taken (AI summary) The trust has been in contact with The Faculty of Intensive Care Medicine to assist with sharing information nationally regarding the risks associated with fentanyl. It has also communicated the issue with the SW Critical Care Network lead to help them produce a regional advisory notice.
Jane Bennett
All Responded
2023-0495 24 Nov 2023 Nottingham City and Nottinghamshire
Mansfield District Council
Concerns summary (AI summary) Mould in council-owned properties, including the deceased's, poses a risk to tenant health, requiring urgent inspection and action to minimize exposure.
Action Taken (AI summary) The council has updated its website to provide further guidance on damp, mould and condensation, trialling environmental monitoring devices for placement in tenant’s homes, increased the capacity of the inspection team and contractors, and procured mould kits for tenant usage. It has also updated its triage system with scripted prompts for all reported damp, mould and condensation cases reported by the tenant.
Zulfiqar Hussain
All Responded
2023-0476 24 Nov 2023 Manchester North
Croft Shifa Health Centre
Concerns summary (AI summary) Administrative staff handle GP correspondence without robust medical oversight, and adverse medication markers are missing from records, risking contraindicated prescriptions and inadequate patient care.
Action Taken (AI summary) The practice reviewed its document management in Nov 2021 and updated its Document Management Policy to include suspected cancer referrals, learning disabilities, mental health/depression, safeguarding notifications, addiction and patients on Gold Standard Framework to be sent to GPs. An alert was added to Mr Hussain's record alerting clinicians to potential medication misuse.
Michael Daft
All Responded
2023-0475 24 Nov 2023 Nottinghamshire
Nottingham University Hospitals NHS Tru…
Concerns summary (AI summary) There is a lack of effective communication between multi-disciplinary teams from different specialisms, leading to fragmented care for patients on multiple treatment pathways.
Action Planned (AI summary) The trust is developing an updated Infoflex system for MDT coordinators, holding regular MDT excellence meetings, and providing monthly updates to Divisional Management Teams. An MDT Oversight Group will be established in February 2024 to review the project status.
Hazel Pearson
All Responded
2023-0471 24 Nov 2023 North Wales East and Central
Betsi Cadwaladr University Health Board
Concerns summary (AI summary) Inadequate management of food intolerances and allergies, including slow implementation of safety measures and a lack of proper incident investigation and Datix reporting, poses a serious risk.
Action Planned (AI summary) The Health Board is exploring how to access expert advice in relation to compliance. A revised training programme for incident reporting is in place for all staff with dates confirmed across North Wales for the next quarter alongside “how to” guides and videos for staff to access at any time via the BetsiNet intranet and a new incident process will be introduced in April 2024.
Teresa Chmielek
All Responded
2023-0470 24 Nov 2023 Manchester North
Pennine Care NHS Foundation Trust
Concerns summary (AI summary) The coroner raises concerns about the screening process for mental health referrals, including inadequate risk assessment, lack of multi-team discussion, and absence of direct contact with the deceased before referral rejection; there is also no standard operating procedure or audit system for referral management.
Action Taken (AI summary) The trust integrated the Single Point of Entry (SPoE) function into the Home Intensive Treatment Team (HITTS) and reviewed the Multidisciplinary Team (MDT) meeting to record all decisions on the electronic patient record. A Standard Operating Procedure on how referrals into the SPoE Older Adults should be managed has been drafted and is currently under final review.
Kenneth Heard
All Responded
2023-0473 23 Nov 2023 Cornwall and the Isles of Scilly
Department of Health and Social Care
Concerns summary (AI summary) Ambulance response times are severely impacted by extensive and persistent handover delays at Treliske and Derriford hospitals, with patients still waiting over 12 hours in ambulances despite mitigating measures.
Action Taken (AI summary) The Department acknowledges concerns about ambulance response times and handover delays. They highlight the 'Delivery plan for recovering urgent and emergency care services' which aims to improve A&E waiting times and reduce Category 2 ambulance response times, and point to improvements already made.
Kevin O’Hara
All Responded
2023-0472 23 Nov 2023 Surrey
Surrey County Council
Concerns summary (AI summary) Inexperienced staff conducting Safe and Well Visits without audit or oversight, coupled with a lack of consistent risk assessment follow-ups, results in missed opportunities to identify and address safety issues.
Action Planned (AI summary) Surrey County Council and Surrey Fire and Rescue Service acknowledge mistakes and outline planned improvements. These include quality assurance for Safe and Well Visits, a new risk assessment process within Adult Social Care, and updated training programs with timelines provided.
Philip Malone
All Responded
2023-0469 23 Nov 2023 Birmingham and Solihull
Birmingham and Solihull Mental Health F… Department of Health and Social Care NHS Birmingham and Solihull Integrated …
Concerns summary (AI summary) A persistent and chronic lack of psychiatric bed capacity in Birmingham and Solihull continues to pose a significant risk, despite previous reports and insufficient remedial actions.
Action Planned (AI summary) The Trust acknowledges bed availability issues and highlights ongoing work with system partners and the ICB. Planned actions include continuing to work with system partners and developing a business case for new acute hospital capacity with additional wards. NHS Birmingham and Solihull ICB acknowledge BSMHFT's actions and state that they are working collaboratively to increase mental health inpatient bed capacity, with a business case for a new build supported in principle. The Department of Health and Social Care acknowledges concerns about psychiatric bed capacity in Birmingham and Solihull. They note BSMHFT's 12-month project to address bed shortages, the implementation of a locality model, and progress in developing bed capacity.
John Seagrove, Pauline Humphris and Patricia Steggles
All Responded
2023-0468 23 Nov 2023 Cornwall and the Isles of Scilly
Department of Health and Social Care
Concerns summary (AI summary) Chronic and worsening ambulance handover delays at emergency departments are severely impacting response times and leading to staff burnout and recruitment difficulties.
Action Taken (AI summary) The Department of Health and Social Care acknowledges concerns about ambulance response times and handover delays, highlighting the 'Delivery plan for recovering urgent and emergency care services'. They note increased ambulance staff since 2010 and improvements in response times in winter 2023-24, and mention SWAST's Tier 1 support for performance improvement.
David Lewsey
All Responded
2023-0463 22 Nov 2023 Cornwall and the Isles of Scilly
National Institute for Health and Care … Old Bridge Surgery
Concerns summary (AI summary) Critical pain information was not accurately relayed from reception staff to clinical practitioners, and a need for improved staff training on recognizing and escalating high-risk pain symptoms was identified.
Noted (AI summary) The practice reviewed the call recording and held a training afternoon on telephone triage and call handling. They highlighted the process of flagging calls for concern and discussed presentations of pulmonary emboli, and intend to audit details recorded by reception staff. NICE acknowledges the concerns, explains the guideline development process for venous thromboembolism prophylaxis, and notes that guidelines are not mandatory and are reviewed periodically.
Kathleen Booth
All Responded
2023-0462 22 Nov 2023 Staffordshire and Stoke on Trent
NHS England Royal Stoke University Hospital
Concerns summary (AI summary) A significant delay in critical surgery was caused by NHS-wide understaffing, underfunding, and limited weekend cover, disadvantaging patients with injuries sustained on Fridays.
Noted (AI summary) NHS England acknowledges concerns about understaffing/funding and the impact of weekend care. They describe national programs like the 7-Day Hospital Services Programme and the Delivery plan for recovering urgent and emergency care services, without committing to specific new actions. The Trust outlines the circumstances of the death and explains surgical prioritisation. They have introduced a dedicated fragility fracture theatre list 5 days per week and are reviewing the need for weekend provision.
Gareth Etchells-Height
All Responded
2023-0517 20 Nov 2023 South Yorkshire (Western)
Sheffield Health and Social Care Trust
Concerns summary (AI summary) Failures in discharge planning, inconsistent medical note review, outdated risk assessments, and poor record-keeping without audit systems led to fragmented care and a lack of understanding of the patient's condition.
Action Planned (AI summary) Sheffield Health and Social Care NHS Foundation Trust is commissioning a new clinical record keeping policy and training, aiming for completion by May 2024 with training rollout from June 2024, alongside a clinical audit programme. They will also issue a Blue Light Learning Notice to staff regarding timely and accurate record keeping. Sheffield Health & Social Care NHS Foundation Trust has implemented several changes including instructing Responsible Clinicians to capture diagnoses in the electronic patient record, reviewing the format of discharge summaries, implementing a tool to support clinicians in using patient records, and rolling out a new clinical record keeping training package.
Glenn Lockwood
All Responded
2023-0487 17 Nov 2023 Inner North London
Limehouse Practice
Concerns summary (AI summary) Insufficient monitoring for Pregabalin abuse in a patient with a known drug abuse history was identified, and the review of record-keeping and prescribing issues for the drug was found to be inadequate.
Noted (AI summary) The response provides a summary of the inquest findings, including the deceased's medical history and the coroner's conclusion of a drug-related death. It notes that a report will be issued to the Limehouse Practice regarding medication prescribing and documentation practices. The Limehouse Practice will conduct SEA training for prescribers, review prescribing for patients at risk of dependence, document medication changes, and provide refresher training on EMIS prescribing function. They have contacted CGL/RESET for training and have improved internal communications.
Sarah Read
All Responded
2023-0460 17 Nov 2023 Lancashire and Blackburn with Darwen
NHS England
Concerns summary (AI summary) There is no provision for out-of-hours Thrombectomy Service after 5pm in Lancashire, and a lack of regional coordination means this urgent, lifesaving stroke treatment is unavailable when needed.
Action Taken (AI summary) Since September 2023, the Trust has increased thrombectomy service availability following a recruitment campaign. An investigation was undertaken and led to the formation of a Thrombectomy Operational Group and revision of governance structures.
Raymond Eggleton
All Responded
2023-0457 17 Nov 2023 Wiltshire and Swindon
Department of Health and Social Care Great Western Hospital
Concerns summary (AI summary) Inadequate initial falls risk assessment and lack of dynamic staffing resilience, particularly during night shifts, led to insufficient supervision and preventable falls for vulnerable elderly patients in the hospital.
Noted (AI summary) The Trust has invested in safe staffing levels, achieving a 1:8 nurse to patient ratio, and reduced Health Care Support Worker vacancies. They have also reviewed falls investigations and implemented additional training on falls risk assessments and enhanced supervision procedures. The response expresses condolences and acknowledges concerns about staffing levels and falls risk assessments. It states that staffing is a local responsibility, highlights CQC regulations and NICE guidelines, and notes the local trust's response.
John Singleton
All Responded
2024-0126 16 Nov 2023 Cheshire
NHS England
Concerns summary (AI summary) The electronic patient system (SystmOne) lacks an automated flag for prisoners who are not medication compliant, leading to delayed identification and referral. The manual workaround is inefficient and poses significant risks.
Action Planned (AI summary) NHS England will explore the functionality of the Health and Justice Information Service (HJIS) to flag medication non-compliance and work to facilitate roll out across the estate. In the interim, regional teams will be reminded of the requirement to monitor uncollected medicines.
Harry Colledge
All Responded
2024-0096 16 Nov 2023 Lancashire and Blackburn with Darwen
Lancashire County Council
Concerns summary (AI summary) Highway operatives lack specific training to identify road defects hazardous to cyclists. Additionally, a road's natural geological movement causes defects that current inspections may not adequately identify, posing risks to all road users.
Action Taken (AI summary) Lancashire County Council delivered debrief presentations to staff, undertook additional safety inspections, and implemented a temporary speed reduction. They commissioned a review of the Highway Safety Inspection Policy and a full Geotechnical Survey of Island Lane.
Terence Duncan
All Responded
2023-0458 16 Nov 2023 Berkshire
Department for Transport
Concerns summary (AI summary) Extendable trailers' sideguards, compliant only at their shortest length, leave dangerous gaps when extended. This regulatory loophole creates an equivalent hazard to unprotected road users as fixed trailers.
Action Planned (AI summary) The Department of Transport will propose amendments to international regulations to require sideguards on extendable trailers when extended, where possible, and consider amending UK regulations to ensure required sideguards remain in place.