10 Jun 2021 Clive Edward Rivers · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to provide Covid-19 vaccination to eligible inpatients View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Department of Health and Social Care
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Clive Edward Rivers · 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
Clive Edward Rivers was admitted to hospital after a fall, contracted Covid-19 while awaiting discharge, and died at home after being discharged to sheltered accommodation with a care package and a requirement to isolate. Concerns included his not being vaccinated while an inpatient, delays in discharge planning during which he contracted Covid-19, and an assessment framework that did not appear to account for his vulnerability to rapid deterioration while isolating at home.
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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 provide Covid-19 vaccination to eligible inpatients
Wider context from the report “1. Clive Rivers was vulnerable to Covid-19 by reason of his age but had to go into hospital as a result of a fall. He had a longstanding skin condition that caused him a great deal of distress and discomfort. Whilst an inpatient he was prescribed immunomodulatory therapy and the consultant dermatologist wanted him to be vaccinated due to the increased risk Covid-19 presented to him both in terms of catching it and being able to recover from it. The inquest was told that whilst vaccines were available on the hospital site, they were at that time due to NHS policy only for staff not inpatients . Therefore, Mr Rivers was not vaccinated .
” Source location Clive Edward Rivers · Prevention of Future Deaths report
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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 Local organisations decide whether and where to offer hospital inpatients Covid-19 vaccination, within the JCVI’s prioritisation advice.
Verbatim wording from the response “Anyone in hospital and falling within the JCVI’s recommended groupings being invited for vaccination, would be eligible for the vaccine, subject to a clinical assessment of suitability on a case by case basis and local operational policies. While there is no national guidance preventing hospitals from vaccinating hospital inpatients, operational decisions on who to offer a vaccine to, and in what settings, are made locally, and in the context of the JCVI’s advice.” Source location 2021-0199-Response-from-Department-of-Health-Social-Care_Published.pdf
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26 Oct 2018 Timothy Alastair Mason · Prevention of Future Deaths report Kent (North-West)
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Concerns raised 2
Failure to provide Men ACWY vaccination to eligible patients View source Inadequate systems for providing and monitoring Men ACWY vaccination View source
This report raised 4 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. 3
NHS England
Write to local practices asking them to verify Men ACWY alert activation and invite eligible patients.
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NHS England
Continue offering opportunistic Men ACWY vaccination to eligible people up to age 25 during 2019/20.
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NHS England
Undertake a national review of vaccination and immunisation arrangements, including call-and-recall expectations.
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AI-generated summary
Timothy Alastair Mason · 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
Timothy Alastair Mason became unwell over several days, attended Tunbridge Wells Hospital twice on 16 March 2018, and died later that day after treatment. The inquest recorded the medical cause of death as meningococcal septicaemia and identified concerns about failure to diagnose and treat him, his discharge while seriously unwell, and his not receiving the Men ACWY vaccination. Further concerns related to staff instructions and training and the systems for offering, recording and monitoring vaccination.
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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 provide Men ACWY vaccination to eligible patients
Wider context from the report “(5) How it happened that Timothy did not receive the Men ACWY vaccination and what systems are in place to ensure patients do receive the vaccination, how this is provided and monitored by NHS England and whether this is adequate or should be improved to avoid patients failing to receive the vaccine.
” Source location Timothy Alastair Mason · Prevention of Future Deaths report
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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 systems for providing and monitoring Men ACWY vaccination
Wider context from the report “(5) How it happened that Timothy did not receive the Men ACWY vaccination and what systems are in place to ensure patients do receive the vaccination , how this is provided and monitored by NHS England and whether this is adequate or should be improved to avoid patients failing to receive the vaccine .
” Source location Timothy Alastair Mason · 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 Write to local practices asking them to verify Men ACWY alert activation and invite eligible patients.
Verbatim wording from the response “As a result of this incident, the practice has acted to ensure that the vaccination has been offered to all eligible patients. I can also confirm that the practice has now switched on the necessary alerts prompting the offer for patients who have not received the Men ACWY vaccination. The practice has also written to EMIS requesting that Men ACWY is added to the list of vaccines flagged up in the alert box as a routine. All local practices have been written to and asked to check that the Men ACWY vaccination alert is activated and patients invited from the relevant cohort.” Source location 2018-0351-Response-by-NHS-England-1
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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 Continue offering opportunistic Men ACWY vaccination to eligible people up to age 25 during 2019/20.
Verbatim wording from the response “During 2018/19 GP practices have continued to opportunistically offer the vaccine to anyone up to the age of 25. This includes those who may have missed the opportunity to be immunised as part of the schools-based programme.” Source location 2018-0351-Response-by-NHS-England-1
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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 Undertake a national review of vaccination and immunisation arrangements, including call-and-recall expectations.
Verbatim wording from the response “In 2019/20 NHS England, will continue to offer the opportunistic service and has committed to undertake a national review of the vaccination and immunisations arrangements (https://www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf) which will include a review and clarification of the expectations around call/recall arrangements, reducing the risk of this incident recurring.” Source location 2018-0351-Response-by-NHS-England-1
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25 Jun 2018 Lauren Amelia Rose SANDELL · Prevention of Future Deaths report London (East)
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Concerns raised 3
Unclear responsibility for capturing children unvaccinated through the school programme View source Lack of audit of GP practices’ systems for identifying and protecting children unvaccinated through the school programme View source Lack of systems to identify children not captured by the school vaccination programme 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. 6
NHS England
Share the adolescent vaccination guidance algorithm with relevant services.
View source
NHS England
Work with clinical commissioning groups to embed vaccination call-and-recall systems in GP practice systems.
View source
NHS England
Provide regular CHIS process reports to the national NHS England oversight group.
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NHS England
Work nationally to ensure eligible people are offered Men ACWY vaccination through schools or GP practices.
View source
NHS England
Audit regional vaccination call-and-recall systems and research factors affecting Men ACWY uptake.
View source
NHS England
Launch an electronic record of children’s public health interventions across London, replacing separate local record systems.
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AI-generated summary
Lauren Amelia Rose SANDELL · 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
Lauren Sandell became unwell with headaches, vomiting, aches and pains on 29 September 2016 and became unresponsive at home on 2 October 2016, when her life was pronounced extinct by paramedics. The inquest concluded that she died from meningococcal sepsis (serogroup W135) and fell within the cohort requiring MenACWY vaccination. Concerns included confusion over responsibility for vaccinating children not covered by the school programme, uncertainty about GP responsibilities, and the lack of auditing of systems to identify and protect unvaccinated children before university.
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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 Unclear responsibility for capturing children unvaccinated through the school programme
Wider context from the report “(1) There would appear to be on-going confusion about who is responsible for ensuring that those children who are not (for whatever reason), vaccinated at school, should be vaccinated before attending university. The evidence indicated that 70% to 80% of children receive the vaccination at school. This would leave 20% to 30% of children unvaccinated. The evidence indicated that GPs should primarily provide the safety net for unvaccinated children.
(2)The provision of the vaccination against MenW appears to fall under an enhanced service for GPs. As this is an optional addition to the GMS contract, it is unclear whether all GP surgeries have a responsibility to capture unvaccinated children .
” Source location Lauren Amelia Rose SANDELL · Prevention of Future Deaths report
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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 audit of GP practices’ systems for identifying and protecting children unvaccinated through the school programme
Wider context from the report “(3) It does not appear that there is any form of audit to ensure that GP practices have in place systems to identify those children who are not captured by the school programme and to put in place measures to protect children, particularly before commencing university.
” Source location Lauren Amelia Rose SANDELL · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of systems to identify children not captured by the school vaccination programme
Wider context from the report “(3) It does not appear that there is any form of audit to ensure that GP practices have in place systems to identify those children who are not captured by the school programme and to put in place measures to protect children, particularly before commencing university.
” Source location Lauren Amelia Rose SANDELL · 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 Share the adolescent vaccination guidance algorithm with relevant services.
Verbatim wording from the response “Public Health England (PHE) and NHS England Public Health Commissioning teams have the responsibility to monitor the uptake of Men ACWY, as part of NHS England’s accountabilities as the commissioner of immunisation services. In turn the local commissioning team alert practices to any poor uptake of immunisation programmes. As outlined in our previous correspondence the CHIS service is a key organisation locally that records whether or not a child/young person has received a vaccine or other public health interventions. In London the specific activities to improve services include sharing the guidance algorithm “Pathway for Administration of HPV, Men ACWY and Teenage 3-in-1 Booster (Td/IPV)”. The document outlines when and where adolescent vaccinations are offered and when general practice is to offer the vaccination.” Source location 2018-0205-Response-by-NHS-England
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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 Work with clinical commissioning groups to embed vaccination call-and-recall systems in GP practice systems.
Verbatim wording from the response “The NHS England London Immunisations webpage has been amended to include reference to the specific guidance. In addition, the London team, as part of their general drive to improve the quality of services, undertook a region wide audit of call/recall systems for vaccinations in 2016, and a research study looking at factors affecting uptake of Men ACWY in general practice. The outcome of the audit and research project has informed the local action plan to improve services and has informed commissioning. NHS England immunisation commissioners are working with NHS Clinical Commissioning Groups (CCG) to ensure call recall systems are embedded in practice systems. In 2017, the London CHIS services launched a new service providing electronic record of a” Source location 2018-0205-Response-by-NHS-England
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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 regular CHIS process reports to the national NHS England oversight group.
Verbatim wording from the response “The Child Health Information Service (CHIS) service is the key organisation locally that records whether or not a child/ young person has received a vaccine or other public health interventions, and acts to support the process of capturing information, including transferring information it receives from school based services to a GP practice, who then have the responsibility to act on the information received. Each region has an established system in place to ensure that GP providers are made aware of vaccinations administered by school aged vaccination providers, with regular reports on the process within CHIS coming to a national NHS England oversight group on a quarterly basis.” Source location 2018-0205-Response-by-NHS-England
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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 Work nationally to ensure eligible people are offered Men ACWY vaccination through schools or GP practices.
Verbatim wording from the response “NHS England is working to ensure that all those eligible for vaccinations should be offered the vaccine either in school or by a GP practice. Those who may have missed the opportunity to be vaccinated, remain eligible until they are 25 years of age.” Source location 2018-0205-Response-by-NHS-England
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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 Audit regional vaccination call-and-recall systems and research factors affecting Men ACWY uptake.
Verbatim wording from the response “The NHS England London Immunisations webpage has been amended to include reference to the specific guidance. In addition, the London team, as part of their general drive to improve the quality of services, undertook a region wide audit of call/recall systems for vaccinations in 2016, and a research study looking at factors affecting uptake of Men ACWY in general practice. The outcome of the audit and research project has informed the local action plan to improve services and has informed commissioning. NHS England immunisation commissioners are working with NHS Clinical Commissioning Groups (CCG) to ensure call recall systems are embedded in practice systems. In 2017, the London CHIS services launched a new service providing electronic record of a” Source location 2018-0205-Response-by-NHS-England
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 Launch an electronic record of children’s public health interventions across London, replacing separate local record systems.
Verbatim wording from the response “The NHS England London Immunisations webpage has been amended to include reference to the specific guidance. In addition, the London team, as part of their general drive to improve the quality of services, undertook a region wide audit of call/recall systems for vaccinations in 2016, and a research study looking at factors affecting uptake of Men ACWY in general practice. The outcome of the audit and research project has informed the local action plan to improve services and has informed commissioning. NHS England immunisation commissioners are working with NHS Clinical Commissioning Groups (CCG) to ensure call recall systems are embedded in practice systems. In 2017, the London CHIS services launched a new service providing electronic record of a” Source location 2018-0205-Response-by-NHS-England
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing service specifications clearly allocate responsibility for delivering school-based and GP-based vaccination services.
Verbatim wording from the response “1. There would appear to be on-going confusion about who is responsible for ensuring that those children who are not (for whatever reason), vaccinated at school, should be vaccinated before attending university. The evidence indicated that 70% to 80% of children receive the vaccination at school. This would leave 20% to 30% of children unvaccinated. The evidence indicated that GPs should primarily provide the safety net for unvaccinated children.” Source location 2018-0205-Response-by-NHS-England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation GP practices are responsible for administrative systems and acting on vaccination information received from Child Health Information Services.
Verbatim wording from the response “All GP practices have the responsibility to ensure administrative processes are in place for service delivery. The process by which a GP practice offers the vaccine to all eligible children, involves working with the Child Health Information Services (CHIS). CHIS have a role to transfer information about public health interventions, transferring this to and from school based services and GP practice, for those providers to act on and deliver their services to patients. CHIS services and the ‘failsafe’ they provide are being improved as part of the NHS strategy for IT, improving the paperless flow of information across organisations by 2021.” Source location 2018-0205-Response-by-NHS-England
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation GPs must provide eligible registered patients with Men ACWY vaccination or notify NHS England so an alternative primary care provider can do so.
Verbatim wording from the response “2. The provision of the vaccination against Men ACWY appears to fall under an enhanced service for GPs. As this is an optional addition to the GMS contract, it is unclear whether all GP surgeries have a responsibility to capture unvaccinated children.” Source location 2018-0205-Response-by-NHS-England
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.