28 Apr 2023 Winbourne Gregory Charles · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to incorporate available clinical information into self-harm risk assessments View source
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
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Winbourne Gregory Charles · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Winbourne Gregory Charles was found unresponsive on 10 April 2021, suspended on a mental health ward, after being admitted under the Mental Health Act following an attempt to take his own life. The principal concerns included failures in risk assessment, observation practices, emergency response, record keeping, and governance processes.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to incorporate available clinical information into self-harm risk assessments
Wider context from the report “1. A failure to adequately assess risk of harm - Poor record keeping and a failure to read electronic records meant that important information was not considered at a Multi-Disciplinary Team (“MDT”) ward round on 6ᵗʰ April 2021. The MDT arrived at a conclusion that Mr Charles’ risk of self-harm was “no risk”. A psychologist’s assessment on the clinical record that assessed Mr Charles risk of self-harm as high on 31/3/21 was neither read nor incorporated into the MDT discussion.
” Source location Winbourne Gregory Charles · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use live RiO records for handovers, daily run-throughs and MDT ward rounds.
Verbatim wording from the response “1. Risk assessment (lack of appropriate consideration of risks) – the Coroner found that poor | 1. | Handovers and daily run through to take place using live RiO | 1. Matrons, Ward Managers and Consultant Psychiatrists to be made aware that this needs to be in place” Source location NELFT NHS Foundation Trust Action Plan
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit compliance with live-record use and risk-assessment processes.
Verbatim wording from the response “2. To be audited to ensure compliance | DON/AMD | June 2023” Source location NELFT NHS Foundation Trust Action Plan
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Concerns about care provision and coordination are mainly for the NHS Trust to address.
Verbatim wording from the response “Your report raises concerns over the provision and coordination of care that Winbourne received at North East London NHS Foundation Trust, which are mainly for the Trust to address. I understand that the Trust has already carefully considered the matters of concern in your report and has provided you with a comprehensive response as well as a copy of its action plan setting out the actions to be taken to improve care quality and patient safety.” Source location Response from Department of Health and Social Care
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27 Feb 2023 Sophie Gwen Williams · Prevention of Future Deaths report North London
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Concerns raised 1
Failure of assessment protocols to require consideration of previous diagnoses, treatment and available care information View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
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Sophie Gwen Williams · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sophie Gwen Williams died at home in the early hours of 20 May 2021 after taking a fatal overdose of prescription medications while in a psychotic or dissociative state. The report identifies concerns about the lack of assessment and management of her overdose and self-harm risk, continuity of care and crisis support, staff training and gender-affirming care, and coordination between mental health and gender-identity services.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of assessment protocols to require consideration of previous diagnoses, treatment and available care information
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance.
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving treatment
” Source location Sophie Gwen Williams · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require initial assessments to examine previous diagnoses and treatments in consultation with the service user.
Verbatim wording from the response “4. The absence from the assessment protocol of a provision to ensure that a full account is taken of:” Source location Response from Barnet, Enfield and Haringey Mental Health Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Seek internal and external records of previous engagements and treatments, and incorporate relevant information from service users and permitted supporters into assessment and treatment planning.
Verbatim wording from the response “b. all other information (including information from those who have previously provided care and treatment to the patient) available to the member of the team” Source location Response from Barnet, Enfield and Haringey Mental Health Trust
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Concerns raised 1
Inadequate review of evolving diagnoses and relevant diagnostic information View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Chelsea Blue Louise Mooney · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Chelsea Blue Louise Mooney died two days after tying two non-fixed ligatures while in hospital, following inadequate observations and delays in the emergency response. Principal concerns included insufficient review of her diagnosis, inadequate exploration of allegations and information-sharing decisions, a failure to learn from previous ligature incidents, uncertainty among staff about responding to her, and delays and poor coordination during the final emergency response.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate review of evolving diagnoses and relevant diagnostic information
Wider context from the report “1. The diagnosis whilst described as not being fixed, was not adequately reviewed. The primary witness for Cygnет in relation to diagnosis lacked professional curiosity even when asked questions in evidence. For example dismissing the potential that Chelsea may be hyperbolic in some of her descriptions of incidents and could that be relevant to diagnosis or treatment; evidence from the family about another member of the family with an autism diagnosis was not followed up (the evidence from Cygnет being that they had not been aware the family wished to explore this); nonetheless in evidence it was dismissed as a possibility.
” Source location Chelsea Blue Louise Mooney · Prevention of Future Deaths report
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3 Apr 2022 Edward Arthur AKROYD · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 1
Failure to obtain available laboratory results for treatment planning View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
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Edward Arthur AKROYD · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Edward Arthur Akroyd was delivered by forceps on 13 January 2018 at Calderdale Royal Hospital after concerns arose during his mother’s labour, including pre-eclampsia and abnormal CTG tracing. He was transferred to Leeds General Infirmary for intensive treatment and died there on 17 January 2018. The principal concerns included inadequate monitoring and treatment of his mother’s elevated blood pressure, incomplete handover and medical records, failure to communicate laboratory results, and delayed recognition and interpretation of non-reassuring CTG findings.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to obtain available laboratory results for treatment planning
Wider context from the report “9. The same registrar stated in evidence that he was aware that samples had been taken at Huddersfield Birthing Centre but didn’t think there was a need to obtain the results to assist in determining an appropriate treatment plan. I am concerned that if similar circumstances were to reoccur it may pose a risk to the wellbeing of the expectant mother and their unborn child.
” Source location Edward Arthur AKROYD · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement automatic transfer of laboratory results into the primary patient record and display them on the Trust-wide system home screen.
Verbatim wording from the response “The computer system for reporting results has changed since 2018. As soon as results are put onto the laboratory computer system those results are pulled through to the primary patient record and can then be seen on the “home” screen of the Trust wide system. Any doctor or midwife can therefore check on the blood test results, including remote access, for example, on an on call consultant accessing the system from home. This means there is no need for the results to be phoned through or passed on verbally.” Source location Response from Calderdale and Huddersfield NHS Foundation Trust (1)
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19 Nov 2021 Sarah McGarrigle · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Failure to incorporate relevant collateral information and community history in mental disorder assessments View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Pennine Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Pennine Care NHS Foundation Trust
Introduce an inpatient–community interface meeting to improve discharge-planning information sharing and communication.
View source
Pennine Care NHS Foundation Trust
Introduce a process for arranging and facilitating discharge-planning and ward-round meetings.
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Pennine Care NHS Foundation Trust
Share the Regulation 28 response with the Aspen Ward consultant psychiatrists’ responsible officer.
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Pennine Care NHS Foundation Trust
Provide Oldham mental health services with a referral route to the multi-agency Adults with Multiple Complex Needs Meeting.
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Pennine Care NHS Foundation Trust
Recommend that the Oldham Safeguarding Adult Partnership Board develop a multi-agency mental-capacity protocol.
View source See 2 more actions
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Sarah McGarrigle · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sarah McGarrigle, aged 23, was found deceased at home on 1 March 2020. She died from catastrophic internal haemorrhage caused by spontaneous rupture of oesophageal varices associated with chronic alcohol use, in the context of trauma, mental disorder and self-neglect. The principal concerns were that relevant information about her history and community behaviours was not properly considered on Aspen Ward, and that a requested assessment of her mental disorder and capacity did not take place.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to incorporate relevant collateral information and community history in mental disorder assessments
Wider context from the report “(1) That the clinicians on Aspen Ward did not consider relevant information provided to the ward by the allocated social worker and the AMHP in the assessment of the Deceased’s mental disorder . The was an over-reliance on Sarah’s presentation on the ward and insufficient consideration given to the concerns that had been raised by community agencies, her psychiatric history and behaviours in the community setting .
” Source location Sarah McGarrigle · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce an inpatient–community interface meeting to improve discharge-planning information sharing and communication.
Verbatim wording from the response “████████o reduce the likelihood of similar incidents occurring in the future, the PCFT Oldham Triumvirate Leadership Team have held several meetings to renew the discharge process on its inpatient adult acute mental health wards. A number of ████████tions to improve the quality of discharges have been taken, which include:” Source location Response from NHS Pennine Care Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a process for arranging and facilitating discharge-planning and ward-round meetings.
Verbatim wording from the response “████████o reduce the likelihood of similar incidents occurring in the future, the PCFT Oldham Triumvirate Leadership Team have held several meetings to renew the discharge process on its inpatient adult acute mental health wards. A number of ████████tions to improve the quality of discharges have been taken, which include:” Source location Response from NHS Pennine Care Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the Regulation 28 response with the Aspen Ward consultant psychiatrists’ responsible officer.
Verbatim wording from the response “• The concerns identified during the inquest have been reviewed by Professor Nihal Fernando, PCFT’s Executive Medical Director. Professor Fernando will share a copy of PCFT’s Regulation 28 response with the Aspen ward consultant Psychiatrists Responsible Officer, in his new Trust.” Source location Response from NHS Pennine Care Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Oldham mental health services with a referral route to the multi-agency Adults with Multiple Complex Needs Meeting.
Verbatim wording from the response “• Oldham's mental health services now have a route to refer patients to the Oldham multi-agency Adults with Multiple Complex Needs Meeting. This ████████to support professionals to work with complex patients who present with high levels of risk but are assessed as having the mental capacity to make unwise decisions or do not engage with their care and treatment.” Source location Response from NHS Pennine Care Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recommend that the Oldham Safeguarding Adult Partnership Board develop a multi-agency mental-capacity protocol.
Verbatim wording from the response “• PCFT’s Head of Safeguarding and the Named Professional for Safeguarding Adults will make a recommendation to the Oldham Safeguarding Adult Partnership Board that a multi-agency protocol be developed. The recommended protocol would outline the roles and responsibilities of each agency when assessing mental capacity for complex patients with a mixture of health and social care needs. The guidance would also outline how multi-agency partners can request specialist mental health input for a mental capacity assessment.” Source location Response from NHS Pennine Care Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The MDT found no acute mental illness or immediate risk and considered an inpatient mental health ward inappropriate for ongoing alcohol-dependence support.
Verbatim wording from the response “physical symptoms of withdrawal. On admission to Aspen Ward, she was not experiencing any alcohol-related behavioural issues. It is widely accepted that alcohol use can cause or increase symptoms of behavioural and/or mental illness. For some patients, when they stop alcohol, their symptoms can significantly improve or stop all together. Sarah’s overall presentation from the time she was assessed and detained under the MHA in the Royal Oldham Acute Hospital, compared to while an inpatient on Aspen was significantly better. Sarah appeared to improve in the time between being detained under Section 2 and being transferred to Aspen Ward (which was a period of several days). Sarah had been safely using leave off the medical wards for a cigarette break. While on Aspen Ward, she also used leave off the ward for cigarettes.” Source location Response from NHS Pennine Care Foundation Trust
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18 Jun 2021 Leslie Horsfield · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Lack of prompts in admissions assessment tools to ask about previous choking episodes View source
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AI-generated summary
Leslie Horsfield · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Leslie Horsfield, aged 84, was admitted to hospital with a cough and worsening breathlessness and died on 3 October 2020 after vomiting and becoming unresponsive. A post-mortem found food material blocking his left bronchus, and the reported cause of death was asphyxiation from vomited stomach contents. The principal concern was that the admissions assessment tool did not prompt assessors to ask about previous choking episodes, creating a risk that relevant information would be missed.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of prompts in admissions assessment tools to ask about previous choking episodes
Wider context from the report “The absence of any prompt in the admissions assessment tool which reminds assessors to ask patients about previous choking episodes creates a risk that relevant information is missed from the assessment and places the onus on the patient to volunteer information which they may not appreciate is relevant to the assessment
” Source location Leslie Horsfield · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the nursing admission proforma to ask whether patients have previously experienced choking episodes during the EPR rollout.
Verbatim wording from the response “Having considered the matter further, I would like to provide you with assurance that as part of our Electronic Patient Record (EPR) Programme roll-out across the North East Sector, the nursing admission proforma will be updated to ask whether the patient has previously experienced any choking episodes. The timeframe for implementation of EPR across Pennine is Spring 2023.” Source location 2021-0215-Response-from-Northern-Care-Alliance_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing swallowing questions are considered adequate to manage choking risk despite lacking a specific question about previous choking episodes.
Verbatim wording from the response “Having discussed this with senior nursing colleagues within the Trust, it is however maintained that the nursing admission proforma provides the assessor with the ability to adequately explore a patient’s swallowing capability. Whilst the nursing assessment does not ask a specific question in relation to previous episodes of choking, the assessment does clearly question patients in relation to any problems with eating and drinking, the need for modified dietary consistency, or anything else to prompt a referral to Speech and Language Therapy.” Source location 2021-0215-Response-from-Northern-Care-Alliance_Published
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3 Feb 2021 Mrs. Monica McCormick · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Failure to consider medical records at hospital discharge View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
Oldham Care Organisation
Share the response at the Divisional Surgery Governance Meeting and discuss the importance of checking medical records during handover completion.
View source
Oldham Care Organisation
Share the PFD response at the divisional surgery governance meeting and discuss the importance of fully checking medical records when completing handover communications.
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Mrs. Monica McCormick · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs. Monica McCormick developed a colonic perforation in October 2019 and underwent emergency surgery, after which pathology identified adenocarcinoma. The diagnosis was not communicated to her or her general practitioner until April 2020, following cancelled outpatient appointments, and the cancer had then spread to the liver and abdominal cavity. She died at home on 24 May 2020; the concerns included failures to follow up the pathology result, review medical records, communicate the diagnosis, and make an earlier referral for adjuvant chemotherapy.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to consider medical records at hospital discharge
Wider context from the report “1. Appropriate consideration was not given to the deceased’s medical records at the time of her discharge from hospital .
” Source location Mrs. Monica McCormick · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the response at the Divisional Surgery Governance Meeting and discuss the importance of checking medical records during handover completion.
Verbatim wording from the response “We apologise that the team did not check whether there had been a histopathology diagnosis at the time of discharge. We will share this PFD response at the Divisional of Surgery Governance Meeting and discuss with team members the importance of checking medical records in full when completing the Handover of Care Communication. It is important to highlight that these documents are completed throughout the patient admission to ensure a timely discharge once the patient is considered medically fit or optimised. We” Source location Response from Northern Care Alliance NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the PFD response at the divisional surgery governance meeting and discuss the importance of fully checking medical records when completing handover communications.
Verbatim wording from the response “We apologise that the team did not check whether there had been a histopathology diagnosis at the time of discharge. We will share this PFD response at the Divisional of Surgery Governance Meeting and discuss with team members the importance of checking medical records in full when completing the Handover of Care Communication. It is important to highlight that these documents are completed throughout the patient admission to ensure a timely discharge once the patient is considered medically fit or optimised. We” Source location Response from Northern Care Alliance NHS Trust
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1 Feb 2021 BETTY ANNIE TADMAN · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Failure to consider the circumstances of a fall during clinical assessment View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Medway NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Medway NHS Foundation Trust
Deliver staff teaching and simulated training on evidence-based trauma care for elderly patients.
View source
Medway NHS Foundation Trust
Resume the suspended staff teaching and simulated training programme on elderly trauma care.
View source
Medway NHS Foundation Trust
Implement ED silver trauma screening for frail patients with low-energy trauma, including senior-clinician assessment where red flags require escalation.
View source
Medway NHS Foundation Trust
Adopt the London Major Trauma System elderly-trauma screening and triage pathway prompting immediate senior-doctor assessment.
View source
Medway NHS Foundation Trust
Provide a specialist-nurse front-door team to assess frail elderly patients arriving in ED and expedite transfer, escalation or discharge.
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BETTY ANNIE TADMAN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Betty Annie Tadman died after an unwitnessed fall at home caused a pelvic fracture with extensive local haemorrhage. She was treated for suspected urosepsis and deep vein thrombosis, but no imaging was conducted despite signs of possible injury, and the pelvic fracture and internal bleeding were not diagnosed. Concerns were also raised that the Trust did not investigate the death or review it through its morbidity and mortality processes.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to consider the circumstances of a fall during clinical assessment
Wider context from the report “1. Mrs Tadman had dementia and a long-term catheter who was admitted to hospital with a pre-alert for suspicion for urosepsis that was treated appropriately. However, urine dipstick tests were only positive for blood and consideration was not given to the circumstances in which she was found with a history of a fall .
” Source location BETTY ANNIE TADMAN · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver staff teaching and simulated training on evidence-based trauma care for elderly patients.
Verbatim wording from the response “2.2. Prior to the Covid pandemic, extensive staff teaching and training had already been undertaken on improving trauma care of the elderly with a focus on the emerging evidence-based pathway of “silver trauma” care. This training programme, which included simulated exercises, is currently suspended but will be resumed shortly.” Source location 2021-0023-Response-from-Medway-Maritime-Hospital-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Resume the suspended staff teaching and simulated training programme on elderly trauma care.
Verbatim wording from the response “2.2. Prior to the Covid pandemic, extensive staff teaching and training had already been undertaken on improving trauma care of the elderly with a focus on the emerging evidence-based pathway of “silver trauma” care. This training programme, which included simulated exercises, is currently suspended but will be resumed shortly.” Source location 2021-0023-Response-from-Medway-Maritime-Hospital-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement ED silver trauma screening for frail patients with low-energy trauma, including senior-clinician assessment where red flags require escalation.
Verbatim wording from the response “2.3. The Trust is committed to implementing the “silver trauma” screening system in ED for frail patients presenting with ‘low energy’ trauma with an assessment led by a senior clinician (ST 4 +) if there are any red flags signs for escalation.” Source location 2021-0023-Response-from-Medway-Maritime-Hospital-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt the London Major Trauma System elderly-trauma screening and triage pathway prompting immediate senior-doctor assessment.
Verbatim wording from the response “2.5. The Trust plans to adopt the London Major Trauma System; Management of Elderly Major Trauma Patients – Second Edition whereby trauma units use an effective screening triage tool on elderly patients who self-present or arrive by ambulance and this prompts an immediate senior doctor (ST4+ level ) review for assessment. Since November 2018, we have already introduced a “front door” team of specialist nurses to assess elderly frail patients upon arrival in ED to expedite their transfer to the ward or escalate for medical advice or discharge as appropriate.” Source location 2021-0023-Response-from-Medway-Maritime-Hospital-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide a specialist-nurse front-door team to assess frail elderly patients arriving in ED and expedite transfer, escalation or discharge.
Verbatim wording from the response “2.5. The Trust plans to adopt the London Major Trauma System; Management of Elderly Major Trauma Patients – Second Edition whereby trauma units use an effective screening triage tool on elderly patients who self-present or arrive by ambulance and this prompts an immediate senior doctor (ST4+ level ) review for assessment. Since November 2018, we have already introduced a “front door” team of specialist nurses to assess elderly frail patients upon arrival in ED to expedite their transfer to the ward or escalate for medical advice or discharge as appropriate.” Source location 2021-0023-Response-from-Medway-Maritime-Hospital-Redacted
Open published response
11 Jan 2021 Natalie Jane Edgington · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Failure to consider a lower methadone starting dose for patients with liver disease View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Turning Point
Produce and distribute an educational support pack on hepatic dysfunction and methadone metabolism to clinically involved substance-misuse staff.
View source
Turning Point
Develop and roll out a multiple-choice assessment of the educational support pack, with learning monitored through clinical supervision.
View source
Turning Point
Host a clinical session on safe opioid-substitute-treatment prescribing for representatives from every service, supporting subsequent local learning cascades.
View source
Turning Point
Publish a clinical brief reminding all clinical staff about safe opioid-substitute-treatment prescribing.
View source See 1 more action
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Natalie Jane Edgington · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Natalie Jane Edgington, aged 28, died at her mother’s address on 24 February 2020. She died from the effects of an accumulated dose of methadone, which she was unable to properly eliminate because of impaired liver function. Concerns included prescribing methadone without sufficient information about her liver disease or an up-to-date liver function test, and the absence of evidence that a lower starting dose was considered.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to consider a lower methadone starting dose for patients with liver disease
Wider context from the report “2. The BNF recommends that consideration should be given to starting patients with a history of liver disease on a lower dose of methadone than the standard starting dose of 30mls. There was no evidence to suggest that any consideration was given to starting the Deceased on a lower dose.
” Source location Natalie Jane Edgington · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce and distribute an educational support pack on hepatic dysfunction and methadone metabolism to clinically involved substance-misuse staff.
Verbatim wording from the response “1) We have produced an educational support pack on “The effects of hepatic dysfunction on the metabolism of methadone”. I attach a copy of this document for your information. This was distributed on 26 January 2021 to all staff within the organisation who have a clinical role in relation to the treatment of substance misuse. Whilst the document as a whole is relevant to the concerns raised, I highlight particularly the recommendations for staff at page 6 of the document which include the following:” Source location Response from Turning Point
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and roll out a multiple-choice assessment of the educational support pack, with learning monitored through clinical supervision.
Verbatim wording from the response “2) We are producing a Multiple Choice Question (MCQ) assessment of the educational support pack referred to in point 1. This assessment will be rolled out at the end of March 2021 and will be monitored through the clinical supervision structure to ensure that the learning has been cascaded and embedded through all relevant sections of the organisation.” Source location Response from Turning Point
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Host a clinical session on safe opioid-substitute-treatment prescribing for representatives from every service, supporting subsequent local learning cascades.
Verbatim wording from the response “3) ████████ (Clinical Director) and ████████ (Chief Pharmacist) hosted a clinical session on prescribing Opioid Substitute Treatment (OST) (which includes methadone) safely on Thursday 14 January 2021. In attendance at this session was at least one clinician and one operational representative from every service under the Turning Point umbrella with the aim that that clinician then cascaded the learning within their own service (please see point 4 for further support for this process). Key points from this session included:” Source location Response from Turning Point
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a clinical brief reminding all clinical staff about safe opioid-substitute-treatment prescribing.
Verbatim wording from the response “4) The Turning Point Public Health and Substance Misuse Senior Clinical Governance Group published within their January 2021 monthly clinical brief a reminder to all clinical staff on prescribing OST safely. I attach a copy of this document for your information. You will see that the key areas included in this brief are relevant to your concerns reflect those as set out in point 3 above.” Source location Response from Turning Point
Open published response
26 Jun 2020 Gary Etherington · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1
Failure to take and consider relevant patient history before discharge View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Gary Etherington · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Gary Etherington was found dead in his van after taking an overdose of his wife’s Amitriptyline; the inquest concluded that his death was suicide. The coroner identified failures in the mental health assessment and discharge process, including inadequate investigation of psychotic symptoms and suicide risk, insufficient communication with the GP, and an unreliable Root Cause Analysis that failed to identify these care problems.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to take and consider relevant patient history before discharge
Wider context from the report “The coroner found that there were two failures in medical care, namely
1. The failure to contact ████████ at the Mental Health Act assessment in April
2. The failure to take and consider the history of ████████ before discharge and to discharge to GP care, without proper consideration of the voices telling him to commit suicide, delusions of people being present, their cause and relation to drug misuse, or the risks to ████████, about which there was an inadequate plan communicated to the GP.
” Source location Gary Etherington · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.