2024

PFD Reports
Reports: 689 Areas: 67

98% response rate (above 63% average).

689 results
Nigel Hammond
All Responded
2024-0537 9 Oct 2024 Suffolk
Department of Health and Social Care Norfolk and Suffolk NHS Foundation Trust Suffolk County Council
Concerns summary (AI summary) An Authorised Mental Health Professional was unable to directly refer a high-risk patient needing immediate mental health support to the Crisis Resolution and Home Treatment Team, leading to critical delays over a weekend.
Action Taken (AI summary) Norfolk and Suffolk NHS has produced a guidance document jointly with Suffolk County Council to foster better communication between crisis teams and AMHP staff prior to Mental Health Act Assessments, clarifying referral processes. Suffolk County Council and NSFT have jointly developed an information guide for AMHPs on referral criteria and processes for Crisis Resolution and Home Treatment Teams, which has been shared with all AMHPs in Suffolk. Norfolk and Suffolk NHS Trust has worked jointly with Suffolk County Council to confirm a guidance protocol to foster better communications and understanding between the AMHP staff and crisis team, emphasising the need for discussion and communication prior to Mental Health Act assessments.
David Martin
All Responded
2024-0536 8 Oct 2024 Cornwall and the Isles of Scilly
Royal Cornwall Hospital
Concerns summary (AI summary) A locum doctor lacked cardiology induction and policy awareness, and there were multiple failures to identify incorrect medication, even after a senior nurse recognised the oversight.
Action Taken (AI summary) The Trust has reviewed and amended the wording in the PCI pack to clarify Dual Anti-Platelet Therapy provision, with changes approved by the Safer Surgery Group and Forms Review Group. The Trust is also developing a training package for nursing teams and amending induction programs to include catheter lab pack and preparation, expected by 31 December 2024.
James Agius
All Responded
2024-0535 7 Oct 2024 Essex
North East London NHS Foundation Trust
Concerns summary (AI summary) The Trust's mental health care had significant medical record omissions, conflicting assessments of the patient's mental state, and failed to implement new national risk assessment training.
Action Taken (AI summary) NELFT has implemented several changes, including mandatory training on risk assessments for all qualified clinical staff, requiring reference to speech and observation of psychotic symptoms in mental state examinations, and transitioning to risk formulation assessments.
John Eyre
All Responded
2024-0534 7 Oct 2024 Mid Kent and Medway
Department of Health and Social Care
Concerns summary (AI summary) There's no clear escalation route for prison healthcare staff to challenge inappropriate prisoner discharges from acute care, nor national guidance for returning prisoners when healthcare concerns are unaddressed by consultants.
Action Taken (AI summary) Medway Maritime Hospital is working with system partners to co-create a written document setting out the process for effective and safe discharges of prisoners and has implemented twice-daily board rounds to discuss patient status. NHS England will share learnings with regional leads.
Helen Davey
Partially Responded
2024-0533 7 Oct 2024 Durham and Darlington
Department for Business and Trade Office for Product Safety and Standards
Concerns summary (AI summary) Concerns exist regarding the design and use of gas piston bed mechanisms, whose failure presents a direct risk to life.
Action Planned (AI summary) OPSS has contacted BSI to request a review of furniture standards for Ottoman-style beds and is writing to trade bodies to raise awareness of potential risks.
Maeve Boothby O’Neill
Partially Responded
2024-0530 7 Oct 2024 Devon, Plymouth and Torbay
Department of Health and Social Care Medical Research Council Medical Schools Council +3 more
Concerns summary (AI summary) There is a critical lack of specialist healthcare provision and funding for research into severe Myalgic Encephalomyelitis (ME). Limited doctor training and inadequate NICE guideline details on managing severe ME are also significant concerns.
Noted (AI summary) NHS England is awaiting DHSC's final ME/CFS Delivery Plan and is developing e-learning modules for healthcare professionals. They have engaged with NICE regarding guidance on ME/CFS and nutrition support, and regional colleagues are working with Royal Devon University Healthcare NHS Foundation Trust to develop formal pathways for acute admission and emergency admission for patients with ME/CFS. NICE will review evidence on dietary management for severe ME/CFS published since the 2021 guidelines and consider amendments to emphasize the need for appropriate nutritional support. It will also work with the Royal Devon University Healthcare NHS Foundation Trust to identify examples of good practice and determine if any updates to the section on fatigue are possible in NICE Clinical Knowledge Summaries. The MSC highlights that it is not a regulator but shares information about how ME/CFS is taught and assessed in medical schools, noting the GMC's new national licensing exam and examples of curriculum content. It has also shared the NHS England e-learning package on ME with medical schools. DHSC will reconvene the ME/CFS Task and Finish Group to develop a final delivery plan by the end of March 2025, focusing on research, attitudes, and education. NHS England is establishing a working group to determine additional support for commissioners, and NICE will review evidence on dietary management and strategies for severe ME/CFS and amend guidance. The MRC has invested £3.6m since 2019 in ME/CFS research in partnership with the NIHR, including co-funding the DecodeME study, and continues to engage with researchers and patient representatives to catalyse biomedical research in this area.
Bryan and Mary Andrews
All Responded
2024-0532 4 Oct 2024 South Yorkshire West
Sheffield Health and Social Care NHS Fo…
Concerns summary (AI summary) A severe lack of communication and coordination between multiple health services resulted in significant delays, repeated referral rejections, and missed opportunities for treatment for a patient with complex epilepsy and psychotic symptoms.
Action Planned (AI summary) Sheffield Health and Social Care will provide electronic copies of crisis assessments to the Neurology Department for service users known to them, include discharge summaries in annual record keeping audits, and establish a six-monthly shared learning forum with the Neurology Department.
James Southern
All Responded
2024-0529 4 Oct 2024 Nottingham
Nottinghamshire Healthcare NHS Foundati…
Concerns summary (AI summary) Concerns were raised about persistent poor record keeping and inadequate communication between professionals within the Trust and with patients.
Action Taken (AI summary) The Trust has taken actions to address concerns about poor record keeping and communication. This includes investigating individual practice, developing clinical quality standards for record keeping, and reviewing the pathway between Crisis and LMHT services, adding standards to the Crisis Team Internal Working Instructions.
Marina Young
All Responded
2024-0527 4 Oct 2024 Lancashire and Blackburn with Darwen
Lancashire Teaching Hospitals NHS Trust
Concerns summary (AI summary) In A&E, prolonged patient stays lacked timely alerts to management, care needs were inadequately assessed for complex patients, and nurses lacked essential asthma assessment knowledge without senior escalation.
Action Planned (AI summary) Lancashire Teaching Hospitals NHS Trust has formulated an action plan to address the coroner's concerns and will share updates on its progress. The Trust met with the deceased's sister to offer apologies and involve her in overseeing improvements.
Kevin Woods
All Responded
2024-0531 3 Oct 2024 Cornwall and Isles of Scilly
Department of Health and Social Care
Concerns summary (AI summary) Persistent ambulance handover delays are linked to inadequate social and community care, with no single organisation responsible for ensuring sufficient provision or overall patient safety from these systemic failures.
Action Planned (AI summary) Royal Cornwall Hospitals NHS Trust is implementing changes to improve patient flow, including a Clinical Decision Unit model, converting the Same Day Medical Assessment Unit (SDMA) to a Same Day Emergency Care (SDEC), and supporting the move of acute medical resource from the emergency department to Acute Medical Unit.
Gabrielle Steel
All Responded
2024-0526 3 Oct 2024 East London
London Borough of Newham London Fire Brigade
Concerns summary (AI summary) Critical fire safety assessment findings were not communicated by the London Fire Brigade to carers or family, preventing the implementation of a vital risk management plan for a vulnerable individual.
Action Planned (AI summary) The London Borough of Newham will hold a reflective case discussion at the Fire Safety Group, improve training for social care staff on fire safety risk assessment, produce a '7 minute briefing' on fire safety risk management plans, and enhance monitoring where there is an established risk of fire. The London Fire Brigade is reviewing its processes for sharing home fire safety visit findings with third parties, consulting the Information Commissioner regarding data protection issues, and reviewing questions asked at booking to identify care provision.
John Turner
All Responded
2024-0525 3 Oct 2024 Manchester South
Department of Health and Social Care
Concerns summary (AI summary) Overwhelming demand on the Emergency Department led to deviations from triage protocols, delayed medical record keeping, and a reduced ability to identify serious conditions presenting atypically.
Action Taken (AI summary) Tameside and Glossop Integrated Care NHS Foundation Trust has opened a rebuilt emergency department with a larger footprint and increased patient capacity.
Alix Knowles
All Responded
2024-0528 2 Oct 2024 Staffordshire
Derby and Burton Hospital NHS England Royal Stoke University Hospital
Concerns summary (AI summary) Incompatible computer systems prevent bank staff and different NHS Trusts from accessing critical patient notes before assessments, hindering coordinated care.
Action Planned (AI summary) NHS England has set up the Frontline Digitisation Programme (FLD) in 2021 to support NHS Trusts in acquiring modern Electronic Patient Records (EPR) systems and has been supporting NHS and Foundation Trusts in acquiring modern EPR systems and helping them develop their system’s effectiveness. UHDB is working with MPFT to arrange access to Meditech V6 for current short-term bank staff in the Liaison Psychiatry team who do not already have access and is developing a written standard operating procedure for both organisations. MPFT has provided a list of bank staff to UHDB to allow access to patient notes and has developed a joint Standard Operating Procedure for referrals to Liaison Psychiatry and Crisis Resolution teams.
Sean Heath
All Responded
2024-0524 2 Oct 2024 Manchester South
Care Quality Commission Department of Health and Social Care Greater Manchester Mental Health NHS Fo… +6 more
Concerns summary (AI summary) Concerns include inadequate police training for mental health calls, poor coordination between international and UK mental health services, and a lack of integrated information sharing between mental health agencies.
Noted (AI summary) NHS England acknowledges the coroner's concerns regarding connectivity between mental health services abroad and in the UK, but notes that information sharing cannot be mandated for overseas healthcare providers. They highlight the work of the Regulation 28 Working Group in sharing learnings from PFD reports. The Home Office outlines the Right Care, Right Person (RCRP) approach, which GMP is rolling out, to ensure the right agencies respond to people in need of support, but defers to the College of Policing and GMP for specific issues. NWAS has provided feedback and reflection to the Mental Health Practitioner involved in the incident. They continue to deploy mental health Trust practitioners in NWAS control rooms and directly employ mental health practitioners for triaging calls. The DHSC acknowledges concerns about training for police officers, notification of carers for Mental Health Act admissions, connectivity between international and UK mental health services, GP practice list removals, and communication between mental health agencies, deferring to other bodies on some points and explaining existing policy on others. GMMH has emphasized the notification of carers following admission under the Mental Health Act through daily staff huddles and implemented a process to ensure written information is provided to carers within 72 hours of admission. GMMH will also carry out an audit to ensure staff are following guidance on safe transfers between teams by the end of March 2025. The College of Policing highlights the national 'Right Care Right Person' (RCRP) framework, supported by Authorised Professional Practice (APP) and a toolkit, along with a bespoke e-learning training package. They are in contact with Greater Manchester Police, who are implementing RCRP. The CQC acknowledges the concerns but states that they fall outside of its regulatory remit, particularly regarding GP practices and information sharing between agencies. It outlines its inspection methodology but takes no direct action. Trafford Council has reinforced expectations within Adult Social Care that staff must verify if the Police are responding to a call, reviewed and strengthened safeguarding processes, and invested in mental health management and practitioner capacity. Single agency recommendations from the Safeguarding Adults Review have been actioned. Response contains only blank pages.
Brandon Johnson
All Responded
2024-0523 1 Oct 2024 Inner West London
HMP Wandsworth
Concerns summary (AI summary) Inadequate and unreliable procedures for checking prisoners' signs of life, with staff lacking sufficient time and clear training to perform robust, positive-response checks in cells.
Action Taken (AI summary) HMP Wandsworth issued a notice in March 2021 to remind staff to have clear sight of prisoners and obtain signs of life during roll checks and have published further communications since. In 2024, they introduced a quality assurance process for roll checks and the Standards Coaching Team provided support to staff over the summer.
Scott Davies
All Responded
2024-0521 1 Oct 2024 Manchester South
Department for Transport Stockport Metropolitan Borough Council
Concerns summary (AI summary) A hard-to-see, locked, matt black steel barrier on a legitimate road poses a serious collision risk for cyclists and emergency vehicles, especially at dusk or in the dark.
Noted (AI summary) Stockport Council has permanently affixed reflective panels and tape to barriers in parks, including Alexandra Park (completed November 21st, 2024), and will complete remaining work by March 31st, 2025. They also audited lighting and found it compliant with BS5489 standards, and will do remedial work by March 31st, 2025 if needed. The Department of Transport states that the matter of barrier visibility is the responsibility of the local highway authority (Stockport Metropolitan Borough Council). They provided references to relevant guidance and legislation.
Ryan Campbell
All Responded
2024-0519 1 Oct 2024 Manchester South
Department of Health and Social Care NHS England Stepping Hill Hospital
Concerns summary (AI summary) The hospital's lack of a full suite of cardiac diagnostic imaging equipment, specifically CT or MR angiograms, causes diagnostic delays and necessitates risky patient transfers.
Noted (AI summary) NHS England states that Stockport NHS Foundation Trust plans additional weekend lists to reduce Stress Echocardiogram waiting times and hopes to achieve a 6-week standard by 31st January 2025. NHS England is not developing an MR angiogram service at this stage. Stockport NHS Foundation Trust plans an additional 20 weekend lists for Stress Echo to clear the backlog by 31st January 2025, aiming to achieve a 6-week standard for all patients. The Trust is also reviewing CT Coronary Angiogram service provision as part of its service development programme for next year. DHSC acknowledges the concerns but states that the procurement of diagnostic equipment falls under the responsibility of the trust and NHS England, who are better positioned to respond.
Megan Williams
All Responded
2024-0518 30 Sep 2024 Central and South East Kent
East Kent Hospitals University NHS Foun… National Institute for Health and Care … NHS England
Concerns summary (AI summary) Deficiencies included unrecorded critical symptoms, poor clinician knowledge of the Acute Abdominal Pain Pathway, a flawed Serious Incident process, and a lack of clear self-discharge procedures.
Noted (AI summary) NICE acknowledges the concerns raised but does not consider any actions from NICE would address the issues. NHS England states that the concerns are local issues for the Trust to address, but that regional colleagues are engaging with the ICB and NHS England will review the Trust's response; also describes national work on PFD reports. East Kent Hospitals is reinforcing the Acute Abdominal Pain Pathway (AAPP) through monthly teaching sessions and case discussions. The AAPP document includes updated patient risk assessment, and the Hospital Discharge and Criteria to Reside Policy was updated to include a checklist for self-discharge.
Sophie Dean
All Responded
2024-0517 30 Sep 2024 Inner North London
University College London Hospitals NHS…
Concerns summary (AI summary) Incomplete medical record documentation by junior doctors and a surgeon's failure to fully inform parents about treatment options hindered truly informed consent for surgery.
Action Taken (AI summary) UCLH will implement a standard ward round note with minimum information requirements, will audit notes within 12 months, has amended the consent policy to require a second consultant opinion for high-risk emergency surgeries where the patient lacks capacity, and will incorporate PFD learning into Trust induction within three months.
Leighton Dickens
All Responded
2024-0522 29 Sep 2024 South Wales Central
South Wales Police
Concerns summary (AI summary) Police officers face severely limited access to qualified mental health advice and patient records when responding to mental health crises, due to withdrawn triage support and unimplemented alternative services.
Action Planned (AI summary) South Wales Police will continue to work in partnership with NHS Wales and health boards to ensure officers can obtain medically qualified advice for people in crisis at any time.
James Turner
All Responded
2024-0520 29 Sep 2024 Cornwall and Isles of Scilly
Cornwall Council Little Trethew Horningtops
Concerns summary (AI summary) Unaddressed road safety concerns at the collision site, including speed limits and limited visibility for agricultural vehicles, persist due to unimplemented council recommendations.
Action Planned (AI summary) Cornwall Council has instructed its contractor to erect 'Farm Traffic' warning signs and is willing to work with the landowner on potential relocation options for the access. Harpers Farm suggests that signs approaching the entrance would be appropriate.
Maria Kelly
Partially Responded
2024-0515 27 Sep 2024 Inne South London
Gray’s Inn Road Medical Centre North London Mental Health Partnership South Camden Rehabilitation of Recovery…
Concerns summary (AI summary) Significant systemic failure in mental health and physical health follow-up, marked by numerous failed contact attempts for reviews and the absence of a welfare check for a vulnerable patient.
Action Planned (AI summary) The practice will clarify if things have been sorted in future and possibly call Adult Social Care. They have discussed this with practice management and the clinical lead. The Trust has taken or is planning multiple actions including reviewing the policy for patients who repeatedly do not attend appointments, staff wellbeing initiatives, enhancing governance meetings, and ensuring client contact information is accurate and up to date in RiO.
Charne Petit
All Responded
2024-0514 26 Sep 2024 Surrey
NHS England Surrey and Borders Partnership Trust
Concerns summary (AI summary) A severe shortage of mental health beds meant the patient could not receive necessary hospital treatment and led to patients being inappropriately detained in general hospitals.
Noted (AI summary) The Trust acknowledges the concerns about bed shortages and the need for adequate medicalization, and outlines work within the Mind & Body Transformation program to better integrate physical and mental healthcare. They state this issue requires resolution at a national level. NHS England highlights existing funding and initiatives to improve mental health services and reduce pressure on inpatient beds, including investment through the NHS Long Term Plan and Better Care Fund. They are supplementing this with further recurrent investment to recommission inpatient care.
Jyoti Rao
All Responded
2024-0513 25 Sep 2024 Manchester South
Manchester University Hospitals NHS Fou…
Concerns summary (AI summary) The 'Consultant of the Week' model prevented complex transplant patients from having a named consultant, risking discontinuity of care and a comprehensive long-term view of their post-operative recovery.
Action Taken (AI summary) The MRI Transplant team has modified the weekly Wednesday Ward Patient Review meeting to make it an MDT for discussion of complex patients, with the outpatient team now attending to support any issues on discharge. Also, complex renal transplant patients now have dedicated appointments to be seen by a named transplant nephrologist responsible for providing continuity of care for them in the outpatient setting.
Kelly Stevens
All Responded
2024-0512 24 Sep 2024 Worcestershire
Worcestershire Acute Hospitals NHS Trust
Concerns summary (AI summary) A patient on a surgical ward as a medical outlier lacked overall consultant oversight due to absent policy. Doctors failed to monitor electrolytes during IV fluid administration, fluid balance charts were neglected, and outdated care plans were routinely copied and pasted.
Action Taken (AI summary) WAHT has implemented a daily consultant review of medical outlier patients on surgical wards. The copy forward function on EPR was removed from 3 documents on 14th May 2024: Medical Clerking, Ward Round and Specialty Review, and then removed from all documents within the EPR system on 4th September 2024.