2023

PFD Reports
Reports: 552 Areas: 65

85% response rate (above 63% average).

Clear 413 results
Christopher Locke
All Responded
2023-0310 24 Aug 2023 Swansea Neath Port Talbot
JD Wetherspoon PLC
Concerns summary (AI summary) Pub staff lack CPR training, leaving them unable to provide lifesaving treatment in emergencies, especially given the increased risk of injuries and potentially impaired bystanders in such environments.
Noted (AI summary) JD Wetherspoon expresses condolences but states they will not change their policy of relying on emergency services for medical care, rather than providing CPR training to staff, citing advice from their Primary Authority.
Gordon Rodger
All Responded
2023-0292 24 Aug 2023 Cumbria
National Rail Infrastructure Limited
Concerns summary (AI summary) Network Rail declined to install anti-trespass measures at Askam station, despite unusual accessibility points near a golf club, raising concerns about easy access for individuals intending self-harm.
Disputed (AI summary) Network Rail expresses condolences but states that boundary fencing in the area inspected meets required standards and no further action is needed regarding boundary integrity. They highlight their work with industry partners and charities to manage rail suicide risks.
Lawson Bond
All Responded
2023-0335Deceased 22 Aug 2023 Worcestershire
Wychavon District Council
Concerns summary (AI summary) Worcestershire Regulatory Services' lack of proactive monitoring for unlicensed dog breeders on websites allows unscrupulous sellers to operate undetected, increasing the risk of dangerous puppies being sold to the public.
Action Planned (AI summary) Wychavon District Council will undertake continuous, business-as-usual intelligence gathering for a minimum of 12 months, covering a larger number of key selling sites and including searches for approximately 65 breeds classed as "large" by the Kennel Club.
Audrey King
All Responded
2023-0312 22 Aug 2023 Cornwall and the Isles of Scilly
Royal Cornwall Hospital Trust
Concerns summary (AI summary) Inconsistent record-keeping, a faulty process for cross-referencing digital and handwritten notes, and a lack of alerts for reviewing suspended medications pose significant risks in patient care.
Action Planned (AI summary) Royal Cornwall Hospitals NHS Trust will run Snapcoms about the importance of checking ePMA along with written entries which will be aimed all staff working within the Trust. They are also working with specialties to look at record-keeping policies.
David Celino
All Responded
2023-0303 21 Aug 2023 West Yorkshire (Eastern)
Department for Culture, Media and Sport Festival Republic Home Office +2 more
Concerns summary (AI summary) Lack of accurate attendance data for under-18s at festivals, no national oversight of drug casualties, and inadequate staff training for identifying drug reactions contribute to preventable deaths.
Noted (AI summary) Leeds City Council, via its Licensing Committee, detailed enhancements made by Festival Republic for the 2023 Leeds Festival, including improved security and stewarding, SIA-accreditation checks on security staff, enhanced staff manuals, daily briefings, and new AIR Hubs. Arrest data analysis suggests Festival Republic's drug security strategy was effective, with increased arrests and drug-related arrests in 2023. Festival Republic implemented improvements for Leeds Festival 2023, including enhanced security at gates, search operations, presence of dogs, visible messaging, and covert operations. They addressed medical facilities concerns by improving the Forward Operating Base, triage processes, ambulance resourcing, and welfare support. They also plan to consider further improvements for the 2024 festival. Festival Republic provides updated arrest statistics from West Yorkshire Police regarding drug offenses at an event. West Yorkshire Police increased measures to combat drug supply at the 2023 Leeds Festival, including a dedicated intelligence researcher, liaison with other festivals, robust searches at ingress points, increased use of drug dogs, covert operations, and a WYP officer stationed in the Festival Republic Control Room, resulting in more arrests. They will also ensure a dedicated detective inspector attends the hospital with the ill person in future. The Home Office highlights government efforts to tackle illegal drugs through police action, reducing demand, and improving treatment. It notes that organisations wishing to deliver back-of-house drug checking facilities at festivals can apply for a license.
Devon Turner
All Responded
2023-0353 18 Aug 2023 Berkshire
Berkshire Integrated Care Board Medication and Healthcare Products Regu… Medtronic +2 more
Concerns summary (AI summary) Unreliable and difficult-to-use home SATS machines, coupled with inadequate parent training on specific models, created a false sense of security and failed to alert parents to critical oxygen drops.
Disputed (AI summary) Medtronic believes the PM100N device was functioning appropriately, accurately recording data, and suitable for home use, so no modification or change is required. NHS England shared the report with patient safety and children & young people's teams and is in contact with the MHRA regarding the concerns raised about the SATS machine. Regional colleagues are engaging with Berkshire Integrated Care Board (ICB) to ensure learnings are acted upon. Buckinghamshire Oxfordshire and Berkshire West ICB held a Joint Agency Response meeting and a Child Death Review meeting with partner organisations and sought clarification from Berkshire Healthcare NHS Foundation Trust regarding the equipment provided. Berkshire Healthcare NHS Foundation Trust confirms that all equipment supplied to Devon had been checked by the CCN before allocation, all were within their service dates and had been serviced annually as per manufacturers guidelines.
Louis Thorold
All Responded
2023-0311 18 Aug 2023 Cambridgeshire and Peterborough
Cambridge County Council Department for Transport
Concerns summary (AI summary) The self-certification process for driving licence renewal for drivers aged 70+, without independent medical scrutiny, risks allowing individuals with undiagnosed conditions like dementia to continue driving.
Action Planned (AI summary) Cambridgeshire County Council implemented a reduced speed limit of 40mph and improvements including a pedestrian crossing and enhanced walking/cycling provision on the A10. The County Council and the Cambridgeshire and Peterborough Combined Authority are developing an Outline Business Case to implement strategic enhancements of the A10 corridor, with route safety as a key consideration; due to report in Summer 2024. The Department for Transport acknowledges the concerns about drivers over 70 and notes that drivers must self-declare medical conditions. The DVLA recently published a Call for Evidence on driver licensing for people with medical conditions, with the results currently being analyzed. RoSPA has developed an older drivers website with information and advice.
William Nichols
All Responded
2023-0308 18 Aug 2023 Gateshead and South Tyneside
Gateshead Health NHS Foundation Trust Newcastle Upon Tyne Hospitals NHS Found…
Concerns summary (AI summary) Inconsistent understanding between hospital and community teams, inadequate patient discharge advice, and poor communication/record-keeping for post-vascular surgery complications risked catastrophic deep patch infection.
Action Taken (AI summary) Newcastle Upon Tyne Hospitals NHS Foundation Trust provides patients with a Femoral Endarterectomy Patient Information Leaflet pre-admission and post-discharge, including contact points. They have also implemented changes following a Serious Incident Investigation to ensure documented advice is provided to patients on discharge and that community teams have points of access for concerns or complications. Gateshead Health NHS Foundation Trust educated staff on risks following femoral endarterectomy and improved communication with Newcastle Trust, creating a professional information leaflet for district nurses outlining postoperative awareness, escalation and intervention. They enhanced their electronic record system to improve record keeping.
Juanita Nti
All Responded
2023-0301 18 Aug 2023 Inner South London
NHS England
Concerns summary (AI summary) Unclear morphine prescription details and an EMIS system lacking correct drug strengths led to a GP and pharmacist dispensing an incorrect, higher dose, resulting in a child's fatal overdose.
Action Planned (AI summary) NHS England is undertaking national work by paediatric experts to reduce the likelihood of incorrect oral morphine preparations being prescribed, including a specials formulary, standardisation of strengths of paediatric oral liquids, national guidelines, and a national approach to GP prescribing systems. The London region Controlled Drugs Accountable Officer will discuss this issue with all London ICB medications safety representatives and ensure regional oversight of implementation of action plans.
Luke Brooks
All Responded
2024-0326 17 Aug 2023 Manchester North
Department of Health and Social Care Ministry of Housing, Communities & Loca…
Noted (AI summary) North West Ambulance Service has revised its 111 policy to remove exclusions for self-conveyance to hospital, save for Category 1 incidents, and to directly confirm patient refusal of an ambulance where possible. The updated SOP went live on 5th September 2023 and staff were informed. The Department for Levelling Up, Housing and Communities will pilot measures to improve enforcement of damp and mould with £10m funding and intends to introduce the Decent Homes Standard to the private rented sector. They will also introduce new regulations following a review of the Housing Health and Safety Rating System (HHSRS). The Department of Health and Social Care states that NHS England has confirmed with ambulance trusts that no blanket policies are in place advising patients with chest pain not to travel to A&E. NHS111 calls are dealt with on a case-by-case basis, and patients are provided with interim advice.
Malcolm Unwin
All Responded
2023-0298 17 Aug 2023 North Wales East and Central
Betsi Cadwaladr University Health Board
Concerns summary (AI summary) The absence of bed rail assessments from the Welsh Nursing Care Record risks these critical safety evaluations being missed, potentially leading to patient falls and future deaths.
Action Planned (AI summary) The Health Board has reminded ward managers about paper-based assessment forms while awaiting a national update to the Welsh Nursing Care Record. They are also finalising an updated Bed Rails Procedure and are working to comply with a National Patient Safety Alert regarding bed rails.
Odichukwumma Igweani
All Responded
2023-0296 16 Aug 2023 Milton Keynes
BLMK Integrated Care Board North West London NHS Foundation Trust Red House Surgery
Concerns summary (AI summary) A critical lack of clear information and guidance prevented an individual from accessing urgent out-of-hours mental health assessment and care, despite their obvious deteriorating condition.
Noted (AI summary) The ICB will work with primary care practices to ensure patients declined registration receive details on how to find and register with a GP and ensure practices are aware of the mental health single point of access. They will also work with CNWL to ensure mental health crisis information is available in surgery waiting areas and continue to work with 111 providers on the dedicated process for mental health due in Spring 2024. Red House Surgery states it was unable to register the patient due to their address being outside the practice catchment area, and this is practice policy. They assert they provided the mother with the number for the crisis centre, which is practice policy for anyone raising a mental health concern who cannot access a GP. CNWL will discuss the case in a Care Quality Improvement Forum meeting, cascade a learning leaflet to local GPs via the Primary Care Network (PCN) alliance, and supply posters to GP surgeries with information on how to access mental health services via the ED at MKUH. Nationally, NHS England are working with NHS 111 to create a dedicated process to access MH services due in April 2024.
Absolom Duffy
All Responded
2023-0295 16 Aug 2023 Lincolnshire
Lincolnshire County Council
Concerns summary (AI summary) The "give way" signage at a junction with restricted visibility may be insufficient, as drivers must stop to ensure safety, raising concerns that a "stop" command would be safer.
Noted (AI summary) Lincolnshire Council will assess vegetation at the junction regularly to ensure maximum visibility. However, they are not proposing to change the existing GIVE WAY signage as the visibility at the junction exceeds requirements.
Barry Lall
All Responded
2023-0385 15 Aug 2023 Central and South East Kent
General Dental Council
Concerns summary (AI summary) The General Dental Council's practice of publishing extensive, detailed allegations on its website for unconcluded cases can cause significant mental health distress to practitioners who are contesting them.
Action Planned (AI summary) The GDC is undertaking a review of its policy on publishing Interim Order determinations and holding hearings in public, aiming to balance public interest with the interests of the registrant, with the first stage of the review expected to complete by early next year.
Haik Nikolyan
All Responded
2023-0340 15 Aug 2023 Buckinghamshire
Prison and Probation Service
Concerns summary (AI summary) HMP Aylesbury's transition to a Category C prison is challenged by recruitment and retention issues among experienced staff, impacting daily operations, training, incident response, and the management of vulnerable prisoners.
Action Taken (AI summary) HMP Aylesbury has improved staffing levels, expanded key work provision, appointed a Neurodiversity support manager, reviewed the adjudication tariff for drug-related incidents, and reconfigured the safety team. Nationally, a TV and radio advert has been launched to support recruitment.
Ian Darwin
All Responded
2023-0291 15 Aug 2023 County Durham and Darlington
Tees, Esk and Wear Valleys NHS Foundati…
Concerns summary (AI summary) Tees Esk and Wear Valleys NHS Foundation Trust routinely fails to conduct timely serious incident investigations, allowing hazards to persist and compromising learning, despite past assurances and national guidelines for 60-day completion.
Action Taken (AI summary) The Trust has contracted additional expert capacity for incident reviews, implemented weekly sitrep meetings, modified documentation and report templates, and is introducing more flexibility to Serious Incident Review Panels, and is contracting with an external incident review company. They anticipate being able to allocate an SI review within the month the incident occurs from November 2023. The Trust has contracted additional expert capacity for incident reviews, implemented weekly sitrep meetings, modified documentation and report templates, and is introducing more flexibility to Serious Incident Review Panels, and is contracting with an external incident review company. They anticipate being able to allocate an SI review within the month the incident occurs from November 2023.
Linda Oldland
All Responded
2023-0293 14 Aug 2023 Surrey
Leonard Cheshire
Concerns summary (AI summary) Hydon Hill Nursing Home failed to share critical patient information with medical staff, delayed antibiotic administration, missed a cardiac arrest, and incorrectly reported a DNAR, indicating policy and training deficiencies.
Action Planned (AI summary) Leonard Cheshire has implemented measures including manager's daily walkarounds, Sepsis training, and is reviewing their training program, service manager/staff induction, and implementing a quality audit plan, with plans to implement electronic care plans by March 2025.
Marie Zarins
All Responded
2023-0290 14 Aug 2023 Leicester City and South Leicestershire
Leicestershire Partnership NHS Trust
Concerns summary (AI summary) Flawed Multi-Disciplinary Team meetings and an inadequate serious incident investigation led to a mental health patient not receiving prescribed anti-depressants or sleeping tablets due to incorrect medication understanding and poor record review.
Action Taken (AI summary) The Trust was awarded accreditation from the Royal College of Psychiatrists’ Serious Incident Review Accreditation Network (SIRAN) for their Serious Incident (SI) processes. They confirm that all identified service actions are robust and completed within the agreed timescales.
Doris Urch
All Responded
2023-0302 11 Aug 2023 Inner North London
Globe Court Care Home
Concerns summary (AI summary) The care home's risk assessment process was inadequate, lacking specific recommendations and not updated after falls. Staff were unfamiliar with care plans, and the system failed to preserve historical records.
Action Taken (AI summary) Staff training on PCS handheld devices has been implemented during induction, and a list of residents at high risk of falls is maintained to inform staff, with documentation being regularly checked for accuracy. They state that all staff are up to date with training except new employee's.
Reginald Bourn
All Responded
2023-0288 8 Aug 2023 Surrey
Health Education England National Institute for Health and Care …
Concerns summary (AI summary) There is a critical lack of national guidance and training for the safe insertion and placement confirmation of nasogastric decompression tubes, unlike feeding tubes, risking fatal misplacement.
Action Planned (AI summary) While NHS England does not routinely provide guidance on nasogastric decompression tubes, they have asked regional colleagues to raise awareness of the concerns raised in the report and learnings from the case with their regional Integrated Care Boards, which can then engage with local NHS Trusts. NICE has shared the report with its topic selection and prioritisation team to consider guidance on small bowel obstruction and nasogastric decompression. The report has also been shared with NICE’s guideline surveillance team to see if an update to recommendations on nutrition support for adults is required. The MHRA has reached out to manufacturers of nasogastric tubing to confirm their primary intended use and to review their instructions for use, expecting to complete the initial review by 4 January 2024, after which they will work with manufacturers to update their IFU where applicable.
Harry Stobie
All Responded
2023-0284 4 Aug 2023 Milton Keynes
Milton Keynes University Hospital
Concerns summary (AI summary) Following PEG tube insertion, a patient's deteriorating condition and abdominal pain were not adequately monitored or escalated to a senior doctor, potentially missing a critical bleed.
Action Planned (AI summary) The hospital is updating its post-PEG insertion procedures to incorporate a pain score and/or AMBER trigger on the NEWS-2 system to prompt earlier escalation and consideration of a CT scan. They will also liaise with the British Society of Gastroenterology to seek excellent practice in post-procedural protocols.
Leah Barber
All Responded
2023-0283 3 Aug 2023 West Yorkshire (Western)
City of Bradford Metropolitan District …
Concerns summary (AI summary) Bradford Council lacked a unified system for overseeing its involvement with vulnerable children, preventing learning from deaths and maintaining departmental disconnect, which risks future fatalities.
Action Taken (AI summary) Following the death, the Council has strengthened processes to ensure organizational oversight where multiple teams are involved and a child dies, with the Director of Children’s Services as the single point of oversight.
Lee Dryden
All Responded
2025-0402 2 Aug 2023 South Yorkshire (West District)
Department of Health and Social Care NHS England
Concerns summary (AI summary) NHS Trusts lack understanding of guidance for external image reporting, and the ambulance service experienced significant delays in responding to a category 2 call due to high escalation and hospital handover issues.
Action Taken (AI summary) NHS England highlights actions taken including publishing recommendations regarding alerts and notification of imaging reports, hosting a national webinar, and noting that the RCR will review guidance. They are also focusing on improving ambulance performance as part of a delivery plan. DHSC notes actions taken by NHS England to clarify guidance around imaging reports, and additional funding to expand ambulance capacity and improve response times. They also highlight measures to improve patient flow and bed capacity within hospitals.
John Shenton
All Responded
2023-0282 2 Aug 2023 Shropshire, Telford and Wrekin
Range
Concerns summary (AI summary) Outstanding recommendations for escalator safety, particularly for vulnerable individuals when lifts are unavailable, were not acted upon, indicating insufficient measures to protect users.
Action Taken (AI summary) The Range has reviewed and updated the escalator and lift risk assessment, and will locate appropriate customer information signage at the lift and escalator in the event of breakdown. They have removed obstructions blocking CCTV coverage of the top of the escalator, and will trial the effectiveness and longevity of high visibility paint to the nosings of the escalator treads during October 2023.
David Andrews
All Responded
2023-0329 1 Aug 2023 Hertfordshire
Hertfordshire County Council
Concerns summary (AI summary) Heavy goods vehicles are permitted to stop and unload on a specific road stretch, effectively blocking the southbound carriageway and creating a hazard.
Action Planned (AI summary) Hertfordshire County Council will promote a Traffic Regulation Order to prohibit loading/unloading on the A4251 Tring Road and will engage with NuYard regarding their safety protocols by the end of November 2023; the Active and Safer Travel team will engage with cycling groups to raise awareness of risks.