2024

PFD Reports
Reports: 689 Areas: 67

98% response rate (above 63% average).

Clear 604 results
Jeffrey Marshall
All Responded
2024-0450 13 Aug 2024 Surrey
National Institute for Health and Care … NHS England
Concerns summary (AI summary) A lack of national guidance on when to recommence anticoagulation after a traumatic head injury and no requirement to discuss risks with patients creates uncertainty and impacts informed decision-making.
Noted (AI summary) NHS England acknowledges the coroner's concerns but states that NICE is the appropriate body to provide clinical guidance. NHS England will review NICE's response and consider any resultant actions, while noting the need for individualised care in such cases. They are also gathering information on a delay in reporting a CT scan result. NICE acknowledges the lack of specific guidance on restarting anticoagulants after traumatic intracranial haemorrhage. NICE will consider the issues raised through their guidelines surveillance process and discuss a consensus statement with relevant specialist societies.
Daphne Austin
All Responded
2024-0447 13 Aug 2024 Cumbria
North Cumbria Integrated Care NHS Trust
Concerns summary (AI summary) Insufficient contingency planning during industrial action led to inadequate medical cover, with one consultant managing 25 patients and the deceased receiving no medical input on a strike day.
Action Taken (AI summary) North Cumbria Integrated Care NHS Trust issued an urgent patient safety alert mandating fluid balance charts for specific adult patients and is developing a trust-wide improvement plan for fluid/hydration, including additional safety MDT huddles and twice daily visits from the Operational Teams/Matrons during periods of industrial action.
Angela Mittal
All Responded
2024-0446 13 Aug 2024 Berkshire
National Police Chiefs’ Council Thames Valley Police
Concerns summary (AI summary) Police staff lack understanding of coercive control and its psychological harm. A new, improved national domestic abuse risk assessment tool has not been adopted due to financial and compatibility issues.
Action Planned (AI summary) The NPCC highlights the national launch of the Domestic Abuse Risk Assessment (DARA) tool in November 2022 and ongoing work with forces and IT providers to drive implementation, in addition to various supporting products available to deliver against the curriculum. Thames Valley Police will replace current questions in the DOM 5 with questions from the DARA, include reference to the College of Policing definition of serious harm, and train every front line officer in its use.
Parminder Sanghera
All Responded
2024-0516 12 Aug 2024 Black Country
Midlands Partnership Trust West Midlands Police
Concerns summary (AI summary) Hospital and police custody failed to recognise a mental health crisis and conduct a Mental Health Act assessment, leading to inadequate risk assessments that missed suicide/self-harm concerns before release.
Noted (AI summary) West Midlands Police has implemented actions including the development of additional guidance for officers regarding mental health assessments, a review of risk assessment documentation, and ensuring access to Summary Care Records for healthcare providers in custody suites. They are working with mental health trusts to improve mental health service provision in custody. Wolverhampton NHS Trust states that it does not provide direct mental health services, but refers patients to the Black Country Healthcare NHS Foundation Trust. They outline the referral process to the Mental Health Liaison Service and state that appropriate referrals were made in this case.
Geoffrey Toase and Michael Midgley
All Responded
2024-0507 12 Aug 2024 Kingston Upon Hull and the East Riding of Yorkshire
Driver and Vehicle Licensing Agency
Concerns summary (AI summary) DVLA's license re-issue process is flawed due to insufficient gathering of medical history from specialists and GPs, tick-box forms, and lack of verification for self-declarations. This prevents full assessment of applicants' fitness to drive.
Noted (AI summary) The DVLA acknowledges the coroner's concerns, explains the current driver licensing requirements, and states that their processes and policies are kept under review. They mention a call for evidence to gather views on the medical driver licensing process, and the responses are being analyzed.
Nimo Osman
All Responded
2024-0444 12 Aug 2024 Inner North London
East London NHS Foundation Trust
Concerns summary (AI summary) A significant delay in calling an emergency ambulance after a patient's collapse was exacerbated by a senior nurse's continued belief that nurses cannot call 999 without a doctor's approval, undermining training efforts.
Action Taken (AI summary) ELFT has taken several actions, including conducting reflective practice sessions, disseminating key learning points to staff, and incorporating VTE risk screening into the nurses' observation form. They are updating their Physical Healthcare Policy to clarify VTE assessment procedures, expected November 2024.
David Thompson
All Responded
2024-0443 12 Aug 2024 Manchester North
NHS Greater Manchester Integrated Care … Pennine Care NHS Foundation Trust Priory Group
Concerns summary (AI summary) The Priory Dorking's incident review indicated no My Safety Plan was commenced or completed prior to discharge, no engagement with the local Home Based Treatment Team occurred, and there was no consultation with consultants from the Priory in Altrincham; consultant-to-consultant communication was also absent across NHS and private care.
Action Taken (AI summary) The Priory Group outlined several actions taken in response to the coroner's concerns including audits of patient records, reminders to staff regarding procedures, and reviews of policies related to patient safety plans, discharge processes, and communication with families. They will continue monthly audits and share outcomes in clinical governance reports. Pennine Care NHS Foundation Trust outlined existing procedures for consultant communication, out-of-area placements, and quality assurance in private hospitals. They highlighted the role of Out of Area Practitioners in monitoring inpatient stays and linking with providers and consultants. NHS Greater Manchester Integrated Care has implemented a Multi-Agency Discharge Event (MaDE) process for overseeing Out of Area Placements (OAPs). Since April, they have seen a significant decrease in the amount of patients admitted to 'stop' providers.
Douglas Armstrong
All Responded
2024-0440 12 Aug 2024 Liverpool and Wirral
Medequip UK
Concerns summary (AI summary) Care agency responders lacked sufficient training to identify a fractured neck of femur, over-relied on patient self-assessment, and inadequately communicated with ambulance services, resulting in a missed diagnosis.
Action Taken (AI summary) Medequip reviewed and updated emergency responder procedures, implemented digital responder forms with risk assessments, completed first aid training for all responders, and is rolling out a bespoke People Manual Handling Training program with completion expected by January 2025.
Emma, Ellette and George Pattison
All Responded
2024-0438 8 Aug 2024 Surrey
Department of Health and Social Care National Police Chiefs’ Council Surrey Police +2 more
Concerns summary (AI summary) The process for obtaining shotgun certificates is flawed, as online doctors enable applicants to hide relevant medical history. Licensing authorities also lack methods to fully uncover coercive controlling behaviour.
Action Planned (AI summary) DHSC describes the rollout of a system by May 2023 to alert GPs when a patient with a shotgun certificate experiences a relevant medical condition, enabling them to flag it to the police. National FEO training will encourage positive engagement with the applicant and their family to ascertain their “domestic health and wellbeing”, and revised guidance may require interviews and engagement with families; the police are also looking to introduce the right to draw adverse inference if an applicant is evasive about family/previous partners. Surrey Police has revised its practice so FEOs now ask about the use of other medical services during visits to elicit information from applicants, and notes a national initiative to rewrite questions to be more explicit. The GPC will update its guidance to GPs to highlight the potential information gap in firearms licensing if external prescribers don't share relevant information or patients withhold it. The Home Office plans to issue a refreshed version of the Statutory Guidance early in 2025, which will include additional guidance for the police to help ensure that perpetrators of domestic abuse, coercive or controlling behaviour do not have access to firearms.
Mary Horgan
All Responded
2024-0437 8 Aug 2024 Greater Manchester South
Northern Care Alliance NHS Foundation T…
Concerns summary (AI summary) Discrepant understandings between medical teams regarding Patient Pass operations create confusion and a risk of future patient harm, highlighting a need for clearer inter-hospital transfer protocols.
Action Taken (AI summary) The Northern Care Alliance is collaborating with Patient Pass developers to make changes to the system, including a mandatory telephone number field, a mandatory box for consultant discussion confirmation, and a screen outlining user responsibilities. They are also creating a briefing document to share learning across Greater Manchester regarding transfer policies and the Patient Pass system.
Gillian Stokes
All Responded
2024-0436 8 Aug 2024 Surrey
Ashford and St Peter’s Hospitals NHS Fo… Department of Health & Social Care Royal College of Nursing +1 more
Concerns summary (AI summary) Insufficient clinical guidance for diagnosing radiation-induced sarcoma in breast implant patients and an inadequate 5-year surveillance period. A crucial follow-up appointment after an aspiration was also not carried out.
Noted (AI summary) The DHSC will explore with MHRA and NHSE raising awareness of angiosarcoma following radiation with patients and clinicians. They note that surveillance guidance for angiosarcoma may do more harm than benefit. The RCN supports the coroner's concerns regarding lack of guidance and pathways for radiation induced sarcoma, implants, and the current surveillance period. However, as a professional body, they do not comment on individual cases. Ashford and St Peters Hospitals NHS Foundation Trust is developing a Standard Operating Procedure (SOP) for the Breast One Stop Shop Clinic that will outline guidelines for patient follow-up care, including accommodating patients requiring earlier follow-up in some circumstances. The RCR has tasked the authors of their 'Guidance on screening and symptomatic breast imaging' to consider the coroner's concerns during the current review and ensure all modalities are considered.
Martyn Stringer
All Responded
2024-0448 7 Aug 2024 Oxfordshire
NHS England
Concerns summary (AI summary) A severe and frequent lack of suitable beds for compulsory mental health detention prevents patients from receiving critical care, with beds sometimes denied due to anticipated demand.
Action Planned (AI summary) NHS England is addressing mental health bed availability through investment in community, crisis, and acute mental health services, and directing systems to reduce average length of stay in adult acute mental health wards. They are supplementing this with further investment to recommission inpatient care and have established a Quality Transformation Programme to improve access and quality of mental health pathways.
Mavis Dewey
All Responded
2024-0435 7 Aug 2024 South Yorkshire West
Monarch Health Care C/O Heeley Bank Car…
Concerns summary (AI summary) Agency staff's admitted failure to consistently read care plans jeopardises resident safety by hindering the provision of appropriate and individualised care.
Action Planned (AI summary) Monarch Healthcare is implementing a new clinical oversight form for moving and handling, monitoring staff via CCTV, auditing resident bedrooms for equipment, and requiring staff signatures at handover meetings, with implementation by August 31, 2024 and review by September 30, 2024.
Kevin McDonnell
All Responded
2024-0433 7 Aug 2024 Nottingham City and Nottinghamshire
HM Prison and Probation Service
Concerns summary (AI summary) Prison staff failed to conduct meaningful ACCT observations and share critical risk information for at-risk prisoners. Furthermore, there was a failure to secure and retain accurate documentary evidence following a death in custody.
Action Taken (AI summary) HMP Nottingham has increased SASH/ACCT awareness training for staff and introduced a 'trigger' database for sharing pertinent risk information. ACCT books are no longer removed from the wing during quality checks to ensure contemporaneous entries.
Malika Hibu
All Responded
2024-0432 7 Aug 2024 Inner North London
Islington Borough Council Mayor of London Ministry of Housing, Communities and Lo… +1 more
Concerns summary (AI summary) Peabody Housing Association failed to address an unsafe canal barrier, demonstrating a lack of boundary knowledge, neglected risk assessments, ignored resident complaints, and inaction on known safety hazards.
Action Planned (AI summary) Peabody has implemented emergency temporary fencing and developed proposals for permanent safety railings at the canal edge, while working with the London Borough of Islington and CRT/CIC for required approvals. They have also strengthened internal policies and procedures relating to resident safety and reporting concerns. Islington Council is working with Peabody on a planning application for safety fencing around the canal side area of the Crest Buildings development. Urban design lessons from this incident have been shared with Development Management Officers, and a planning application for another canal side residential development includes fencing. The Mayor of London will consider the concerns raised in the PFD report through his review of the London Plan, with public consultation planned for the second half of 2025 and adoption of the revised Plan in 2027. Any changes made to the NPPF by the government will also be considered. The government published an updated NPPF on 12 December 2024 that includes additional policy to consider the safety of children and other vulnerable users in proximity to open water, railways and other potential hazards.
Alfred Sparrow
All Responded
2025-0405 6 Aug 2024 Worcestershire
Cardinal Health
Concerns summary (AI summary) Staff at The Meadows Nursing Home did not always assist Mr. Sparrow with his food and fluid intake as required by his care plan; a false entry in Mr. Sparrow's notes gave rise to concern that staff might have been completing care note entries which did not reflect their actions.
Action Taken (AI summary) Cardinal Healthcare has already implemented several actions, including a manual reminder system for documentation, monitoring via a 'Resident of the Day' system, reflective practice sessions for staff, and a mentorship program for new staff. They are also planning to introduce a multi-layered review process for investigations, train managers, and strengthen collaboration with external bodies.
Peter Gregory
All Responded
2024-0430 2 Aug 2024 Worcestershire
Civil Aviation Authority
Concerns summary (AI summary) The CAA lacks regulations or guidance for the design, testing, and inspection of amateur-built balloons, and does not regulate competition balloon flying, leaving critical safety aspects unaddressed despite known risks.
Action Planned (AI summary) The CAA will publish safety guidance for balloon events to ensure risks are understood and managed, working with the British Balloon and Airship Club (BBAC). They will also continue their review of balloon flying regulation, with a supplemental report due by the end of March 2025. The CAA is developing guidance on design, testing, and inspection of amateur-built balloons and will publish it by March 31, 2026. They are also working with the ballooning community to develop operational safety guidance on ascent/descent rates and event briefings, aiming for public consultation in late 2025.
James Capstick
All Responded
2024-0429 2 Aug 2024 Cumbria
Care Quality Commission Nursing and Midwifery Council Westmorland Court Care Home
Concerns summary (AI summary) Persistent concerns about care quality and unreliable patient notes were noted at Westmorland Court. A registered nurse's failure to perform basic life checks and CPR correctly highlighted training deficiencies and lack of defibrillator availability.
Noted (AI summary) Westmorland Court Care Home states that a number of improvements have taken place since the death, including implementing a Quality Improvement Plan with the ICB and Westmorland and Furness Council. Staff training has been refreshed and updated, and reflective accounts of the incident were completed. The NMC acknowledges the concerns and states they have passed information to their Employer Link Service and New Referrals team to make enquiries and will investigate concerns within their remit. They have also referred the case to the Public Support Service to reach out to the family. The CQC acknowledges the concerns raised and outlines actions taken following previous notifications, including a targeted inspection. They state that mandating defibrillators in care homes falls outside their remit but expect providers to have appropriate policies for resuscitation.
Sophie Wilson
All Responded
2024-0427 2 Aug 2024 Durham and Darlington.
North East Ambulance Service
Concerns summary (AI summary) Ambulance crews lacked crucial patient information from multi-agency plans due to electronic device data limits, necessitating manual contact with control. This compromises accessibility in emergencies for vulnerable individuals.
Action Planned (AI summary) The North East Ambulance Service acknowledges the concerns regarding ambulance crews not being aware of the 'familiar faces plan'. They are instructing dispatch teams to verbally notify staff of any 'flags' placed against each case and cascading information about accessing additional information. They will also work with partners to develop more effective centralised means of region wide flagging and care plan sharing.
Thomas McAuley
All Responded
2024-0426 2 Aug 2024 Dorset
Health and Safety Executive
Concerns summary (AI summary) The dangerous practice of roadwork crews urinating between LGV axles risks fatal injuries. Despite a previous death, no industry-wide safety notices or publicity have addressed this ongoing hazard.
Noted (AI summary) The HSE acknowledges the coroner's concerns regarding welfare provision and workplace transport safety on construction sites, but asserts that existing legislation and guidance are sufficient and well-known within the industry. They will continue to raise awareness through stakeholder engagement and inspections.
Raymond Brattley
All Responded
2024-0424 2 Aug 2024 Kingston Upon Hull and the County of the East Riding of Yorkshire
Royal Society for the Prevention of Acc…
Concerns summary (AI summary) There are inadequate fire prevention measures for vulnerable, heavy-smoking residents in care settings. Organisations should consult the Fire Service for advice on mitigating risks, such as using metal bins and fire-retardant materials.
Action Planned (AI summary) RoSPA will review and update fire safety information for sheltered premises on their website in Q4 2024, explore collaborations with professionals in the sector in Q1 2025, and develop a policy position on fire safety in sheltered accommodation in Q1 2025.
Kieran Lavin
All Responded
2024-0422 1 Aug 2024 Birmingham and Solihull
Birmingham and Solihull Mental Health N…
Concerns summary (AI summary) Critical suicide risk information was not recorded or shared effectively due to busy shifts. Post-death guidance for informal patient transport risk assessment remains inadequate, lacking specific questions for comprehensive evaluation.
Action Taken (AI summary) The Trust is setting up regular Risk Huddles, providing further Risk Assessment training, sharing investigation findings with staff, appointing an Urgent Care Team Manager, and updating the Transport Policy to improve communication and handover processes.
Stephen Lindsay
All Responded
2024-0420 1 Aug 2024 Cumbria
North East and North Cumbria Integrated…
Concerns summary (AI summary) Unclear commissioning responsibilities for mental health support caused critical care gaps for a terminally ill patient. This risks future deaths as patients may not receive necessary support, leading to crises.
Action Taken (AI summary) CNTWFT is raising awareness of the Marie Curie helpline and Macmillan services, and NCIC has provided further training to the palliative care team on assessing and supporting patients with risk issues; NCIC is also reviewing its Mental Health Strategy to reflect risks for patients with long-term conditions.
Lee Purkis
All Responded
2024-0418 1 Aug 2024 West Sussex Brighton & Hove
HM Prison and Probation Service
Concerns summary (AI summary) A mental health treatment requirement (MHTR) imposed by the Crown Court was not communicated to the Trust treating Lee Purkis, leading to his discharge without their awareness of it; probation should ensure all involved in administering the requirement are aware of it.
Action Planned (AI summary) The Probation Service acknowledges responsibility for MHTR oversight and is piloting Secondary Care MHTR "Proof of Concept Sites" with NHS England to improve assessment and practice. In Kent, they are collaborating with the Forensic and Specialist Directorate to upskill staff on MHTR processes.
Maria de Ceita
All Responded
2024-0455 31 Jul 2024 North London
North Middlesex University Hospital NHS…
Concerns summary (AI summary) Hospital staff's omission in recording a one-to-one supervision plan for a patient with a known risk of falling led to the plan not being effected; there was a lack of an effective system to document and address the risks of elderly patients while in the hospital.
Action Taken (AI summary) The Trust has implemented several changes including meetings between senior staff to discuss documentation of falls risk assessments, enhanced assessment and care planning tools, a falls risk assessment audit, enhanced care guidelines, and an enhanced care register for better visibility and oversight of patients receiving enhanced care.