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
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.
Anthony Friend
All Responded
2023-0336 18 Sep 2023 Worcestershire
Bluebird Care Divine Health Services Herefordshire and Worcestershire Health…
Concerns summary (AI summary) A complete lack of handover and communication between transferring care agencies meant the new provider was unaware of patient needs and critical equipment concerns.
Action Planned (AI summary) Bluebird Care will now contact the incoming care provider directly to discuss handover, provide customer information sheets to all new customers that can be shared with new providers, and offer/request information on existing appointments. Herefordshire and Worcestershire Health and Care NHS Trust has designed and introduced a leaflet with contact details for patients on initial assessment. They have also introduced a new role to improve communication with external agencies.
Kimberley Sampson and Samantha Mulcahy
All Responded
2023-0338 17 Sep 2023 Central and South East Kent
NHS England Royal College of Obstetricians and Gyna…
Concerns summary (AI summary) Unclear guidance on testing staff for potential infection sources and a lack of national protocols for antiviral therapy in post-partum women with systemic infection, specifically for Herpes Simplex, put patients at risk.
Action Planned (AI summary) NHS England is working to update guidelines on sepsis in pregnancy to include guidance on timely identification and treatment of herpes simplex, scheduled for publication in March 2024; and has a working group to ensure learnings around preventable deaths are shared across the NHS. The RCOG is updating its Green-top Guidelines on maternal sepsis (publication scheduled for March 2024) to include guidance on the timely identification and treatment of herpes simplex.
Sienna Monterio
Historic (No Identified Response)
2023-0344 16 Sep 2023 Blackpool & Fylde
National Institution for Health and Car… Royal College of Obstetricians and Gyna… Royal College of Paediatrics and Child …
Concerns summary (AI summary) A lack of national standardisation means blood gas analysers in neonatal resuscitation settings often fail to analyse haemoglobin levels, hindering critical decision-making and risking preventable infant deaths.
Geoffrey Brooks
All Responded
2023-0351 15 Sep 2023 Exeter and Greater Devon
Royal Devon University Healthcare Found…
Concerns summary (AI summary) An ambiguous hospital discharge summary on fluid intake targets caused nursing home staff to misinterpret instructions, leading to the patient's critical dehydration and contributing to his death.
Action Taken (AI summary) The Royal Devon University Healthcare NHS Foundation Trust now uses an electronic patient record (Epic) which includes a 'Hospital course function' and 'discharge navigator' to ensure discharge documentation includes a summary of ongoing care needs.
Riya Hirani
All Responded
2023-0339 15 Sep 2023 Inner North London
Department of Health and Social Care NHS England
Concerns summary (AI summary) A junior doctor failed to escalate care for a rapidly deteriorating child, dismissing a mother's accurate and persistent concerns. There was also no clear mechanism for families to obtain a second medical opinion.
Action Taken (AI summary) Point of care testing is fully operational for measuring Streptococcus A and respiratory illness in children; and the Paediatrics service holds weekly meetings to discuss children with complex medical needs. Point of care testing is fully operational for measuring Streptococcus A and respiratory illness in children; and the Paediatrics service holds weekly meetings to discuss children with complex medical needs.
Eclipse Morrison
Historic (No Identified Response)
2023-0334 15 Sep 2023 Warwickshire
Department of Health and Social Care George Eliot Hospital NHS Trust National Institute for Health and Care … +2 more
Concerns summary (AI summary) Policies for high-risk pregnancies were not followed, leading to a failure to consider elective Caesarean Section. There's inadequate training and assessment for junior and locum doctors on identifying serious risk factors.
Jack Farrington
Partially Responded
2023-0436 14 Sep 2023 Hampshire, Portsmouth and Southampton
NHS England Portsmouth Hospitals University NHS Tru… Solent NHS Trust
Concerns summary (AI summary) Fragmented electronic medical record systems prevent timely access to patient history across NHS trusts, impacting clinical decision-making. Handover records are not consistently integrated into electronic systems, and some records remain paper-based.
Action Planned (AI summary) Solent NHS Trust is working to transfer the nursing handover from a Word document onto SystmOne, with staff to be trained in its use by the end of January 2024; and paper-based clinical observation forms will be replaced with an electronic form that feeds directly into SystmOne, planned to be implemented by 01st April 2024. Portsmouth Hospitals University NHS Trust has updated its Mental Health Liaison Policy and associated training to ensure a structured handover process for patients arriving at the Emergency Department under the Mental Health Act.
Richard Griffiths
All Responded
2023-0333Deceased 14 Sep 2023 North Wales East and Central
Betsi Cadwaladr University Health Board
Concerns summary (AI summary) The coroner raises concerns about deficiencies in the Health Board's investigation process, the lack of detail in the Transfer of Care document, and the continued use of paper-based patient notes for mental health.
Action Planned (AI summary) Betsi Cadwaladr University Health Board is undertaking an addendum investigation regarding the transfer of care, and a strategic outline case for an Electronic Patient Record system(s) is being developed on a Health Board wide level to address the issue of fragmented care records; the deadline for the strategic outline case is the end of January 2024.
Marcel Wochna
All Responded
2023-0332 14 Sep 2023 Hampshire, Portsmouth and Southampton
Hampshire & Isle of Wight Constubulary
Concerns summary (AI summary) Police staff lacked critical awareness of cold water shock, water rescue procedures, and the risks of handcuffing near water, alongside poor dissemination of relevant safety protocols.
Action Planned (AI summary) Hampshire and Isle of Wight Constabulary is rectifying an absence of Cold Water Shock information in the E-Learning Training package, and an updated 'Working Near Water Procedure' will be made available to officers and staff by the end of November 2023. Hampshire and Isle of Wight Constabulary is rectifying an absence of Cold Water Shock information in the E-Learning Training package, and an updated 'Working Near Water Procedure' will be made available to officers and staff by the end of November 2023.
Melissa Kerr
All Responded
2023-0330 13 Sep 2023 Norfolk
Department of Health and Social Care
Concerns summary (AI summary) Patients traveling abroad for Brazilian Buttock Lift surgery are unaware of high mortality risks and lack of safety controls, including inadequate pre-operative assessment and surgeon consultation.
Action Planned (AI summary) The Department of Health and Social Care is investigating global medical tourism, including visiting Türkiye to discuss regulatory frameworks and protections for UK nationals, and is considering how to better communicate the risks of medical treatment abroad.
Geoffrey Hoad
All Responded
2023-0327 13 Sep 2023 Norfolk
Department of Health and Social Care East of England Ambulance Service NHS T… Spire
Concerns summary (AI summary) Significant ambulance response delays, exceeding 14 hours, stemmed from high call demand and hospital handover issues, despite escalating call categories.
Action Taken (AI summary) East of England Ambulance Service describes actions to improve response times including additional recruitment, increased patient facing hours, and the establishment of an Unscheduled Care Coordination Hub; leading to reduced response times in some categories. Spire Healthcare joined the Inter Facility Transfer Group (IFTG) to improve interfacility transfers through risk stratification and communication, aiming to improve transfer times, and promoting appropriate use of ACCTS. The Department of Health and Social Care published a plan to recover urgent and emergency care services, aiming to reduce Category 2 response times to 30 minutes, delivered 5,000 more staffed hospital beds, scaled up virtual ward bed capacity to over 10,000, and provided £1.6 billion to support timely discharge from hospital.
Isabela Suciu
Partially Responded
2023-0326 12 Sep 2023 Inner South London
British Association Perinatal Medicine NHS England Queen Elizabeth Hospital Trust +1 more
Concerns summary (AI summary) Conflicting guidelines for newborn hypothermia led to delayed antibiotic administration and create ongoing confusion and risk of missed clinical signs in neonatal units.
Action Planned (AI summary) Lewisham and Greenwich NHS Trust provided education sessions on escalating low and high temperatures in neonates, reinforced the Kaiser Permanente pathway, and included Kaiser scoring assessment in neonatal notes. The Royal College of Paediatrics and Child Health will share information and suggestions for local improvement from the report with its paediatric members via its patient safety portal and at the next RCPCH Clinical Quality in Practice committee.
Rashdah Bhatti
All Responded
2023-0325 12 Sep 2023 North Wales East and Central
Welsh Ambulance Services NHS Trust
Concerns summary (AI summary) Human error led to critical first aid advice for a varicose vein bleed not being given during emergency calls, highlighting a risk of future deaths from handlers not following MPDS protocols.
Action Planned (AI summary) Following an internal audit, the Welsh Ambulance Service will issue a reminder to all call handlers regarding the use of Post-Dispatch Instructions (PDIs), specifically related to haemorrhage/laceration calls, and will undertake a further targeted audit in February 2024.
Amanda Kramer
All Responded
2023-0328 11 Sep 2023 East London
Department of Health and Social Care North East London Foundation Trust Wood Street Medical Centre
Concerns summary (AI summary) A patient was prescribed Zoplicone for 18 years without review, despite the drug's short-term license and her high-risk overdose behaviour, raising concerns about medication management.
Noted (AI summary) Wood Street Health Centre audited patients prescribed Zopiclone/Zolpidem, is reviewing their medication, has moved to acute prescriptions only (max 2-week supply), instructs 'as required' use on prescriptions, informed local pharmacists, and prepared a new shared care policy; 69 patients have had their medication stopped. North East London NHS Foundation Trust (NELFT) audited prescribing practice and revised its prescribing policy for hypnotics, is participating in a working group to improve medication monitoring across primary and secondary care, increased staffing in Crisis and Home Treatment teams, and ensured comprehensive documentation of patient information at handover. The Department of Health and Social Care acknowledges the concerns raised and notes that NHS England is working to support prescribers in managing repeat prescribing; it also acknowledges actions being taken by Wood Street Health Centre and North East London NHS Foundation Trust.
Kristopher Tilbury
Historic (No Identified Response)
2023-0331Deceased 8 Sep 2023 Hertfordshire
HMP The Mount Ministry of Justice
Concerns summary (AI summary) HMP The Mount failed to control illicit drug supply, including psychoactive substances, leading to high availability even on a 'Wellbeing Wing' and multiple subsequent drug-related deaths.
Cherry Garland
All Responded
2023-0324 8 Sep 2023 Avon
University Hospitals Bristol Weston NHS Foundation Trust
Concerns summary (AI summary) The provided text indicates an extremely important concern was identified, but its specific nature or the risks it poses for future deaths are not detailed.
Action Taken (AI summary) The Trust will invest in additional pharmacy staff for adult ITU to ensure medicines reconciliation at step down is completed by a trained individual five days a week, and to provide a safety net review of weekend medicines reconciliation.
Lynsey Smalley
All Responded
2023-0322 8 Sep 2023 North West Wales
Barts Health NHS Foundation Trust
Concerns summary (AI summary) Fragmented governance processes and significant delays in acting on investigation findings impede learning. The lack of electronic medical records across mental health teams risks lost notes and poor continuity of patient care.
Action Planned (AI summary) The Health Board is developing a Strategic Outline Case for a Health Board wide Electronic Patient Record system to address fragmented care records with a deadline of end of January 2024, and will undertake a significant piece of work to make long term, substantial changes regarding investigations.
Lamont Roper
All Responded
2023-0381 7 Sep 2023 North London
Metropolitan Police Service
Concerns summary (AI summary) Concerns include insufficient and cumbersome water rescue equipment for police, inadequate training for cycle patrols near water, and limited awareness of dive team availability and capacity.
Action Taken (AI summary) The MPS reviewed and refreshed its cycle training at the beginning of 2022 and now maintains training and resourcing records, for the deployment of officers and staff who have received this training.
Graham Smith
All Responded
2023-0323 7 Sep 2023 Birmingham and Solihull
NHS England
Concerns summary (AI summary) There is a significant lack of awareness among clinicians about the seriousness of Myasthenia Gravis and dangerous medication interactions, posing a risk beyond the local Trust.
Action Planned (AI summary) NHS England is developing new guidance to address omitted and delayed medications and will update the coroner once published; the Royal College of Emergency Medicine (RCEM) are preparing a Safety Flash to raise awareness of delivering time critical medications in Emergency Departments.
Sultana Choudhury
All Responded
2023-0321 7 Sep 2023 East London
Barts Health NHS Foundation Trust Department of Health and Social Care
Concerns summary (AI summary) Failures included not diagnosing an obvious renal haemorrhage, administering VTE prophylaxis with active bleeding, and inadequate patient monitoring, leading to preventable deterioration.
Action Taken (AI summary) The Trust produced a Comprehensive Investigation Report and developed a robust action plan to share learning across the Trust regarding themes relating to continuity, and always ensuring effective communication during handover.
James Jones
Historic (No Identified Response)
2023-0320 6 Sep 2023 North West Wales
Betsi Cadwaladr University Health Board
Concerns summary (AI summary) Persistent pressures and insufficient staffing in the A&E department lead to review delays, risking missed opportunities and potential future deaths in life-threatening situations.