2024

PFD Reports
Reports: 689 Areas: 67

98% response rate (above 63% average).

689 results
Kial Thurman
All Responded
2024-0454 13 Aug 2024 Staffordshire and Stoke-on-Trent
Staffordshire County Council
Concerns summary (AI summary) A rural, unlit road with a 60 mph limit narrows at a blind bend and bridge, causing frequent collisions. The national speed limit is too high, posing a risk of future deaths.
Noted (AI summary) Staffordshire County Council reviewed the road layout and collision history, consulted colleagues, and assessed traffic speed. They believe the existing safety features are sufficient and note a future bridge replacement proposal depends on funding.
Joanita Nalubowa
All Responded
2024-0453 13 Aug 2024 Inner North London
Ministry of Housing, Communities and Lo…
Concerns summary (AI summary) Rigid Mental Health Act aftercare criteria lack flexibility, preventing suitable accommodation for patients whose historical residences are inappropriate, risking future harm by limiting discretion in placement decisions.
Action Planned (AI summary) The MHCLG will write to the local authorities concerned to remind them of their statutory duties, and the government will bring forward changes to social housing allocations regulations to apply exemptions to victims of domestic abuse from local authority residency and local connection tests.
Margaret Huntley
All Responded CC
2024-0452 13 Aug 2024 Teesside and Hartlepool
Association of Ambulance Chief Executiv… NHS England North East Ambulance Service NHS Founda… +1 more
Concerns summary (AI summary) Ambulance staff lack understanding of steroid medication importance and Addison's Crisis, with no NHS Pathways guidance for triaging. Awareness and GP use of Steroid Emergency Cards and system alerts are inadequate.
Noted (AI summary) NHS England is working with the Association of Ambulance Chief Executives (AACE) to ensure patients inform 999 call handlers or healthcare professionals if they are steroid dependent; NHS England's National Primary Care Team will consider GP awareness of alerting ambulance services to specific conditions; the ICB will take the circumstances surrounding Margaret’s death to their GP learning sessions and consider a system-wide safety alert. AACE expresses condolences and explains its role in supporting ambulance services with national policy and guidelines. They highlight existing JRCALC guidance and raise concerns about the validity of flagging patient addresses. NEAS has taken several actions including reviewing and updating clinical practice guidelines to highlight steroid dependency and adrenal insufficiency, updating the NHS Pathways system to improve recognition of steroid dependency, and accepting care plans and flags from providers until an automated solution is available. They have also established an ICB-wide group to improve flagging challenges.
Elizabeth Van Der Drift
All Responded
2024-0451 13 Aug 2024 Inner North London
Department of Health and Social Care Office for Product Safety and Standards Sainsburys +1 more
Concerns summary (AI summary) Brightly coloured laundry pods and their sweet-like packaging are confused for food by people with dementia, and easy-to-open packaging increases the risk of accidental ingestion of toxic products.
Noted (AI summary) UKCPI expresses condolences and confirms that the laundry pouch packaging complies with GB CLP Regulation and industry PSP. They suggest that the packaging may have been left open or damaged. OPSS has spoken to the UKCPI, who are exploring a new awareness campaign for those with caring or safeguarding responsibilities, which OPSS will promote to local regulators. Sainsbury's states that their capsules already included a bittering agent and that the packaging adhered to A.I.S.E. guidelines. They have since changed their packaging to a cardboard box with a child-impeding closure, tested in line with AISE protocol. The HSE acknowledges the concerns regarding laundry tablet packaging and refers to existing regulations about the classification, labelling and packaging of hazardous substances, detailing specific requirements around outer and inner packaging.
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) 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. 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.
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) 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. 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. 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.
Craig Steadman
Partially Responded
2024-0442 12 Aug 2024 Hampshire, Portsmouth and Southampton
Chief Coroners Office HMP Winchester Practice Plus Group
Concerns summary (AI summary) Investigations into a death in custody were not effectively disseminated to directly involved staff, hindering learning and preventing recommendations from being fully acted upon.
Action Taken (AI summary) HMP Winchester shared and discussed the investigation report with relevant staff, and the Head of Safety will now routinely share reports and learning points. Recommendations are also used to produce national learning bulletins across the prison estate.
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.
Sean Davies
No Identified Response CC
2024-0460 8 Aug 2024 Mid Kent and Medway
HMP Swaleside Ministry of Justice
Concerns summary (AI summary) Inadequate risk formulation for IPP prisoners and failures by prison officers to conduct welfare checks according to guidance. Furthermore, some operational support staff lacked proper training or adhered to it.
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 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. 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.
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.
Janet Harrison
Partially Responded CC
2024-0562 5 Aug 2024 Hampshire, Southampton and Portsmouth
Eastleigh Borough Council Southampton City Council
Concerns summary (AI summary) Multiple properties in the area have walls with the same unsafe dimensions as a collapsed wall, posing a risk of further collapses during severe storms and endangering lives.
Action Planned (AI summary) Eastleigh Borough Council will send letters to residents of houses with similar garden walls, advising them of potential stability issues and to seek professional advice within 21 days. They will revisit the site in 6 months to determine if any walls show signs of instability.
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 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. 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.
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) 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. 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 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.