2023
PFD Reports
Reports: 552
Areas: 65
85% response rate (above 63% average).
Iris Fordham
All Responded
2023-0373
5 Oct 2023
East London
Barts Health NHS Foundation Trust
Department of Health and Social Care
Concerns summary (AI summary)
Inadequate clinical record keeping and a failure to perform falls risk assessments, compounded by staff not properly reviewing patient records, suggests a systemic culture of indifference within the Trust.
Action Planned
(AI summary)
Barts Health NHS Foundation Trust will implement actions to improve practices for patients with dementia and/or at risk of falls, including ensuring up-to-date Enhanced Care Assessments, using fall risk ID bands, and mandatory falls risk assessment training for staff. The Trust is conducting a diagnostic assessment on essentials of care and associated patient risk assessments (including falls).
Jessica Baker
All Responded
2023-0369
5 Oct 2023
Liverpool and Wirral
Department for Education
Department for Transport
Concerns summary (AI summary)
Concerns exist regarding the lack of clear government advice to schools on seatbelt use in commuter coaches and insufficient public information campaigns promoting seatbelt safety for children.
Action Planned
(AI summary)
DfT is launching a national seat belt campaign in March 2024 targeting young men. DfE will share education materials on seat belt compliance with education settings, including DfT’s updated guidance on seat belt compliance. DfE also proposes to make a small amendment to the existing statutory guidance on home-to-school travel.
Lilian Board
All Responded
2023-0368
5 Oct 2023
Lincolnshire
United Lincolnshire Hospitals NHS Trust
Concerns summary (AI summary)
A critical lack of checks allowed duplicate prescriptions of the same medication from both a GP and hospital, enabling the deceased to accumulate an excessive amount that she used to end her life.
Noted
(AI summary)
United Lincolnshire Hospitals NHS Trust expresses condolences and clarifies the policy for supplying patients with 14 days of medication upon discharge. They argue that the current policy appropriately balances patient needs with potential risks, given that the patient had a supply of medication that was likely fatal in overdose.
Janet Spencer
All Responded
2023-0541
4 Oct 2023
Nottingham City and Nottinghamshire
Nottinghamshire County Council
Concerns summary (AI summary)
Critical patient information was inadequately shared between care facilities during hasty transfers, leading to medication errors. The receiving care home also lacked the authority to refuse referrals despite insufficient information.
Action Taken
(AI summary)
Nottinghamshire County Council has implemented a new process and referral/assessment form for hospital and community admissions into Assessment Flat accommodation at Gladstone Court to outline a person's care and support needs, any risks, and updated medical information. They also hold weekly meetings for the Discharge to Assessment Team Managers to review practice and share improvements.
Ronald Harris
All Responded
2023-0371
4 Oct 2023
Herefordshire
Hereford Medical Group
Concerns summary (AI summary)
Incomplete triage documentation, failure to contact the patient, and a lack of awareness by the triage doctor regarding appointment waiting times and call details, resulted in no revised mental health triage protocol after the incident.
Action Taken
(AI summary)
Hereford Medical Group implemented a new process allowing clinicians to listen to phone calls when online forms are unavailable, changed the staff newsletter to include the most up to date waiting times for appointments, and will include a Mental Health focus session over the next month during regular training for GPs. A protected education time in January will also focus on triaging, including clinical considerations and the triage process and protocols.
Michelle Whitehead
All Responded
2023-0370
4 Oct 2023
Nottingham City and Nottinghamshire
Nottinghamshire Health NHS Foundation T…
Concerns summary (AI summary)
Staff lacked sufficient training and awareness of the Rapid Tranquilisation policy, which was also unclear on monitoring unconscious patients and deviated from national guidelines, alongside a lack of guidance for Psychogenic Polydipsia.
Action Taken
(AI summary)
Nottinghamshire Healthcare NHS Foundation Trust has taken immediate actions including a teaching session on Psychogenic Polydipsia within the ‘Trustwide 2-day Physical healthcare Training’, sharing learning from Michelle’s inquest, and reviewing cases of polydipsia in secure settings. The Trustwide Nutrition and Hydration Policy is also under review to specifically reference psychogenic polydipsia.
Kellie Poole
All Responded
2023-0364
4 Oct 2023
Derby and Derbyshire
Health and Safety Executive
Concerns summary (AI summary)
There is a significant lack of regulatory oversight and clear safety guidance for cold water immersion businesses, leading to inadequate risk assessments, inconsistent leader training, and insufficient safety measures for participants.
Noted
(AI summary)
The HSE acknowledges the concerns regarding cold water immersion activities, stating that existing regulations and guidance from other organisations (RNLI, National Water Safety Forum) provide a suitable basis for businesses to operate safely. They will not be publishing specific guidance at this time but will keep the activity under review and raise awareness among local authority enforcement officers.
Jack Zarrop
All Responded
2023-0362
2 Oct 2023
West London
Home Office
National Police Chief’s Council
NHS England
Concerns summary (AI summary)
Custodial Nurse Practitioners lack adequate mental health training for complex patients and suicide risk, and agency staff in prisons receive insufficient training on the ACCT process.
Noted
(AI summary)
NHS England will ensure all staff, including agency and bank staff, have timely access to all joint training, including ACCT, that is necessary for them to undertake their role effectively within the prison environment and regional teams will be asked to give assurance at a meeting planned for June 2024, that the proposed action has been delivered and agency and bank staff have timely access to ACCT training. The NPCC clarifies that Custodial Nurse Practitioners (CNPs) are qualified and trained to work in police custody, with appropriate clinical support and supervision, according to the National Healthcare Specification. They assert the 2003 Home Office circular is outdated and the current healthcare model for police custody is robust. The Home Office states that Home Office Circular 020/2003 is no longer extant and therefore they propose to take no action in response to the report. They note the NPCC response regarding the National Healthcare Specification for police custody and NHS England's response regarding training of prison healthcare staff in the ACCT process.
Paula Lenihan
All Responded
2023-0360
2 Oct 2023
Birmingham and Solihull
Birmingham and Solihull Mental Health F…
Concerns summary (AI summary)
The report identifies a pattern within the Birmingham & Solihull Mental Health NHS Foundation Trust of risk assessments not being completed or updated as expected, which poses a risk due to insufficient risk recording; a task and finish group is addressing the issue, but it is at an early stage.
Action Taken
(AI summary)
Birmingham and Solihull Mental Health Trust has worked closely with teams, supporting with protected dedicated time for staff to update risk assessment documentation, set up a project group to look at the risk assessment process, and completed a review of the risk management policy. Completion rates for risk assessment for CPA patients within community services have increased.
Frederick Le Grice
All Responded
2023-0358
29 Sep 2023
Essex
Department of Health and Social Care
Concerns summary (AI summary)
Patients and clinicians lack awareness regarding the serious lung damage risk from Nitrofurantoin. Current guidance is insufficient to ensure vigilance for symptoms and regular respiratory monitoring.
Action Taken
(AI summary)
NHS England worked with the MHRA to update the Summary of Product Characteristics (SmPC) and Patient Information Leaflet (PIL) for Nitrofurantoin to emphasize the risk of respiratory symptoms. This was communicated to healthcare professionals via a MHRA Drug Safety Update and highlighted in an NHS England Patient Safety Case Study. The MHRA updated warnings in the product information for nitrofurantoin for both healthcare professionals and patients, highlighting the risk of pulmonary adverse drug reactions. They also published a Drug Safety Update bulletin to raise further awareness amongst healthcare professionals.
John Winsworth
All Responded
2023-0357
29 Sep 2023
Norfolk
Department of Health and Social Care
Concerns summary (AI summary)
Critical delays in ambulance response times and subsequent long waits for hospital admission to A&E are causing significant risks due to ongoing pressure on emergency services.
Action Taken
(AI summary)
EEAST is working with the integrated care system to reduce arrival to handover times, has implemented unscheduled care coordination, and has increased referrals into community teams. The government delivered over 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, scaled up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and provided £1.6 billion to support timely and effective discharge from hospital.
Scott Donoghue
All Responded
2023-0363
28 Sep 2023
East Riding and Hull
Department of Health and Social Care
Concerns summary (AI summary)
Inconsistent staffing within Home Based Treatment Teams hinders patient engagement and honesty during fragile periods. Addressing this requires additional funding, recruitment, and retention to ensure continuity of care.
Action Taken
(AI summary)
NHS England and local services have made strides in minimising staff turnover and foster effective communication and collaboration between CRHTT and Community Teams, with continuous training for CRHTT members. The government has also increased NHS spending on mental health and invested in the recruitment and retention of more mental health workers.
Robert Leigh
All Responded
2023-0464
25 Sep 2023
Manchester West
Greater Manchester mental Health NHS Fo…
Concerns summary (AI summary)
Planned mental health visits were missed due to the absence of a care coordinator, and there were no interim arrangements or resilience plans in place to cover such absences.
Action Planned
(AI summary)
The Service Manager will update the Older Adult Community Mental Health Team Standard Operating Procedure by the end of November 2023, and the Operational Manager will undertake an audit in three months to ensure the process is embedded.
Brian Moreton
All Responded
2023-0352
25 Sep 2023
Newcastle upon Tyne and North Tyneside
North Cumbria Integrated Care NHS Found…
Concerns summary (AI summary)
Radiologists lack direct access to patient medical notes, relying on inadequate summary documents, and there is a pervasive issue of poor and misleading communication between clinicians and departments impacting patient care.
Noted
(AI summary)
The trust has introduced MDTs to improve communication, and changed the on-call system to ensure a dedicated colorectal surgeon is available during the week. An IBD SOP will ensure involvement of general surgery and gastroenterology teams. DAC Beachcroft clarifies the communication processes between North Cumbria and Newcastle hospitals, explaining the roles of different teams and when direct specialist advice is sought, and highlighting that North Cumbria now take part in a regular Inflammatory Bowel Disease MDT at Newcastle.
Shaun Houghton
All Responded
2023-0350
25 Sep 2023
Manchester West
Greater Manchester Mental Health NHS Fo…
Concerns summary (AI summary)
A junior doctor allowed a high-risk patient with impulsivity and suicidal intent to self-discharge against medical advice, without consulting senior clinicians, raising concerns about the decision-making process.
Action Planned
(AI summary)
GMMH is developing a Standard Operating Procedure (SOP) for self-discharge against medical advice, including a checklist for ward staff. The SOP will be submitted for ratification in January 2024 and disseminated to staff by February 2024.
Carol Leeming
All Responded
2023-0347
25 Sep 2023
Newcastle upon Tyne and North Tyneside
Totally Urgent Care
Concerns summary (AI summary)
A lack of mandatory induction training and online facilities for out-of-hours GPs, coupled with staff confusion over call centre systems and high GP turnover, compromises service quality.
Action Planned
(AI summary)
Vocare has reviewed and updated its induction process, including online training availability and improved system training. They have also implemented processes for supervision and mentoring of GP trainees and new GPs, with robust clinical governance processes to identify and address incidents of concern. NHS England is developing a new Sepsis Improvement Programme, aiming to support local systems to implement improvements and address key areas identified in the national learning review. The updated NICE guidance on sepsis recognition and management is expected to be published in December 2024.
Sebastian Daniels
All Responded
2023-0346
22 Sep 2023
Hampshire, Portsmouth and Southampton
Hampshire Hospitals NHS Foundation Trust
Southern Health NHS Foundation Trust
Concerns summary (AI summary)
Critical blood test results were not escalated, discharge summaries to GPs were unclear, and clozapine patients missed vital annual blood tests due to inconvenient separate phlebotomy appointments.
Action Planned
(AI summary)
The trust has updated procedures to include telephone escalation of raised triglyceride levels. The junior doctors induction program is being updated from 6 December 2023 to include changes in the discharge process. The Trust plans to introduce venous blood sampling during annual health checks for Clozapine patients, with the Mid and North area acting as early adopters. A pharmacy-led project will review service variations across all Clozapine clinics, and the Clozapine Policy will be amended.
Chantelle Reed
All Responded
2023-0349Deceased
21 Sep 2023
Cambridgeshire and Peterborough
NHS England
Royal College of Emergency Medicine
Royal College of Radiologists
Concerns summary (AI summary)
Emergency medicine guidelines lack emphasis on specific chest pain symptoms indicating acute aortic dissection, and national radiologist shortages cause critical delays in reviewing urgent scans.
Disputed
(AI summary)
NHS England notes the concerns and highlights national work to raise awareness of aortic dissection and improve image reporting turnaround times. They also mention the NHS Long Term Workforce Plan and the Regulation 28 Working Group. The Royal College of Radiologists disputes that chest pain radiating to the neck or jaw should mandate investigation for Thoracic Aortic Dissection. However, they commit to working with the Royal College of Emergency Medicine to promote evidence-based best practice in diagnosis.
Melvyn Blount
All Responded
2023-0345
21 Sep 2023
Derby and Derbyshire
Lister House Oakwood
Concerns summary (AI summary)
A lack of clear policy for communicating drug alerts when a GP prescribes for a patient not seen directly by them, but by a non-prescriber, risks patients missing crucial medication information.
Action Taken
(AI summary)
The practice has implemented several reviews and changes to prescribing practices and supervision, including a new policy and flow chart for drug alerts, improved documentation, a new consultation booking system and training. An educational event was held to discuss recognition and management of psychotic depression.
Alison Ross
All Responded
2023-0343
21 Sep 2023
West Sussex, Brighton and Hove
University Hospitals Sussex NHS Foundat…
Concerns summary (AI summary)
There is no clear guidance for monitoring patients who self-administer medications but do not take them at the time of dispensing, posing a risk to medication adherence.
Action Taken
(AI summary)
The trust has introduced a daily Safety Huddle on Balcombe Ward, is updating the Trust Medicines Management policy and competency assessment documentation, and is issuing a Medicines Governance Notice regarding bedside medication. Refresher education and training on medication administration has been completed and learning has been discussed with nursing staff.
Mark Bennett
All Responded
2023-0456
19 Sep 2023
South Yorkshire (Western)
Association of Ambulance Chief Executiv…
Yorkshire Ambulance Service
Concerns summary (AI summary)
Paramedics lack clear guidance and protocols on the appropriate duration of resuscitation efforts and criteria for hospital transport for thrombolysis, placing patients at risk.
Action Planned
(AI summary)
YAS will review and update its clinical documentation and include decisions on terminating resuscitation attempts in annual clinical refresher training. AACE is engaged with a National Institute for Health Research study, which may lead to an update to JRCALC guidance regarding termination of resuscitation.
Lauren Bridges
All Responded
2023-0438
19 Sep 2023
Manchester South
Department of Health and Social Care
NHS England
Concerns summary (AI summary)
Underfunding for local mental health beds and reliance on independent providers caused delayed discharges for out-of-area patients. Fragmented IT systems and inconsistent processes created significant communication failures.
Action Taken
(AI summary)
Dorset HealthCare has made changes to the Hospital Overview document, enhanced the daily Hospital Overview situation report, improved communication between Clinical Site Managers and introduced monthly audits to ensure standards are met in patients receiving out of area care. NHS England reports on actions taken by Dorset Healthcare University NHS Foundation Trust: improvement to data and oversight, appointment of an out of area co-ordinator and a programme of quality assurance of providers used by the Trust. They have also secured planning permission to rebuild some of their mental health inpatient facilities and increase the availability of PICU for adults and younger people. The Department of Health and Social Care notes actions taken by NHS England and Dorset Healthcare University NHS Foundation Trust. They are investing in community mental health care and have published statutory guidance for discharge from all mental health inpatient settings.
Stewart Stanley
All Responded
2023-0341
19 Sep 2023
Exeter and Greater Devon
Exeter Prison
Concerns summary (AI summary)
Inconsistent and inaccurately recorded observations for suicide prevention, coupled with staff misinterpretation of guidelines and excessive working hours, posed significant risks in state custody.
Action Taken
(AI summary)
HMP Exeter has introduced an assurance procedure for the ACCT process and allocated a supervising officer to conduct daily checks of observations. They have also received funding for two Band 4 ACCT safety 'Floorwalkers' who conduct upskilling sessions and displayed ACCT V6 observation posters.
Stephen Cassidy
All Responded
2023-0337
19 Sep 2023
Avon
North Bristol NHS Trust
Concerns summary (AI summary)
Hospital staff lacked routine access to patient Summary Care Records, preventing critical allergy information from being integrated into electronic systems and causing avoidable harm.
Noted
(AI summary)
NHS England acknowledges concerns about accessing Summary Care Records and allergy information but primarily describes existing requirements and procedures. They highlight national work to share learnings from PFD reports. The trust is exploring non-smartcard-based access to NCRS, with access planned for all staff in Q1 2024. They are also commissioning EPMA (Electronic Prescribing and Medicines Administration) for deployment in Q3 2024 and planning to implement 'Red Wrist Bands' for patients with allergy alerts by Q3 2024.
Amarjit Singh
All Responded
2023-0342
18 Sep 2023
Inner North London
HM Prison Pentonville
Practice Plus Group
Concerns summary (AI summary)
There was a careless cell sharing risk assessment, inadequate first aid training for prison officers, and no guidance for prisoners on how to respond to a cellmate having a fit.
Action Taken
(AI summary)
HMPPS issued emergency response guides and pocket cards to all prisons. Training for prison staff in how to deal with fits is scheduled to be given at HMP Pentonville in October, and the HMPPS National Health and Safety Arrangements for First Aid and Emergency Aid Manual was published and introduced in August 2023. Practice Plus Group has changed procedures to ensure cell sharing risk assessments are completed effectively, including long term conditions monitoring, and provide the HMP Pentonville prison team with a list of patients with epilepsy/seizures to ensure that custodial staff are also able to identify cell-sharing issues.