26 Oct 2021 Christopher COLLINSON · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure of the patient allocation system to identify patients who have not been seen View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Christopher COLLINSON · 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
Christopher Collinson was admitted to Birmingham Heartlands Hospital with suspected deep vein thrombosis and pulmonary embolism, but was not seen by a doctor for several hours. He was prescribed a prophylactic rather than therapeutic dose of Enoxaparin, later suffered a cardiac arrest, and died on 15 June 2021. Concerns related to the patient-allocation system not making it clear when an allocated patient had not been seen, and the electronic prescribing system not requiring a secondary medication check.
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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 the patient allocation system to identify patients who have not been seen
Wider context from the report “1. The current system for allocating patients requires a manual check to see whether a patient has actually been seen once they have been allocated . If they are not seen, there is currently no way of other clinicians being aware of that , and therefore patients could be left for long periods of time without having been assessed .
” Source location Christopher COLLINSON · 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 Roll out the paper-free PICS electronic patient record system across Birmingham Heartlands Hospital AMU, including waiting-time markers for patients awaiting assessment.
Verbatim wording from the response “Following Mr Collinson’s admission, the above process has been updated and we have rolled out our in-house electronic system, PICS to BHH. PICS has been in use in AMU at BHH since July 2021. PICS provides a paper-free electronic patient record system that allows for simultaneous access and entries to the record of a single patient by multiple clinicians. With PICS, it is easy to access and review patient records at any time. To ensure patients are seen without delay, there are time markers on the system which indicate when patients have been waiting to be seen for a period of time without progression. This allows” Source location 2021-0361-Response-from-Queen-Elizabeth-Hospital_Published
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22 Oct 2021 Serena Naomi Roberts · Prevention of Future Deaths report Manchester South
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Concerns raised 3
Lack of GP referral follow-up systems to identify increased patient risk View source Failure of GP referral follow-up systems to escalate referrals when required View source Lack of GP referral follow-up systems to identify referrals that have not taken place View source
This report raised 3 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
Serena Naomi Roberts · 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
Serena Naomi Roberts experienced recurrent very heavy vaginal bleeding and delays in referral, triage and follow-up for specialist gynaecological assessment. She was later found to have ovarian cancer with extensive peritonitis and died from complications including septic shock and intra-abdominal sepsis. The principal concerns included delays in secondary care, poor recognition and application of guidance on heavy bleeding and risk factors, inadequate referral information, and a lack of clear systems to follow up referrals.
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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 GP referral follow-up systems to identify increased patient risk
Wider context from the report “4. There was no evidence available that GP practices had clear systems of follow up in relation to referrals to identify where they had not taken place or identify if the risk had increased and to escalate the referral.
” Source location Serena Naomi Roberts · 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 Failure of GP referral follow-up systems to escalate referrals when required
Wider context from the report “4. There was no evidence available that GP practices had clear systems of follow up in relation to referrals to identify where they had not taken place or identify if the risk had increased and to escalate the referral .
” Source location Serena Naomi Roberts · 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 GP referral follow-up systems to identify referrals that have not taken place
Wider context from the report “4. There was no evidence available that GP practices had clear systems of follow up in relation to referrals to identify where they had not taken place or identify if the risk had increased and to escalate the referral.
” Source location Serena Naomi Roberts · Prevention of Future Deaths report
Open source report
4 Oct 2021 Caden Stewart · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Failure to check whether a person awaiting healthcare has been seen View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Caden Stewart · 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
Caden Stewart, aged 16, became unwell after weightlifting in custody and was later found collapsed and unresponsive in his cell. He was diagnosed with a brain haemorrhage, underwent surgery, and died at King’s College Hospital. The principal concerns were inadequate reporting and recording procedures and insufficient communication between prison officers and healthcare staff, resulting in healthcare failing to attend his requests to be seen.
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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 check whether a person awaiting healthcare has been seen
Wider context from the report “3. The wing officer in charge did not check whether Caden had been seen by healthcare at any stage over the following hours nor did he inform his successor on handover that Caden was waiting to see healthcare and had not been seen
” Source location Caden Stewart · Prevention of Future Deaths report
Open source 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 Use daily residential roll books, guidance prompts and NOMIS records to capture healthcare requests, follow-up actions and relevant wellbeing information for staff sharing.
Verbatim wording from the response “To ensure improved and effective information sharing regarding a prisoner’s well-being, in September 2021 the Young People Services Team introduced daily roll books onto the residential areas which record the amount of time each young person spends in various activities. The logs provide for comments to be added and ‘guidance prompts’ are now in place which outline the importance of providing this information so that it is available to all staff. The guidance prompts also explain the type of information staff should record, including where a young person has made a request to see healthcare. A Notice to Staff detailing the use of the roll books was issued to ensure all staff are aware of the need to record information about a young person in custody.” Source location 2021-0328-Response-from-HMPPS_Published
Open published response
17 Jun 2021 Daniel David Rennoldson · Prevention of Future Deaths report Sunderland
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Concerns raised 1
Failure to identify cases that have not been progressed 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
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
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AI-generated summary
Daniel David Rennoldson · 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
Daniel died at home on 11 November 2020 after expressing suicidal intentions and contacting mental health services and the police. Concerns included there being no contingency for more than one face-to-face response at a time and no mechanism to identify cases that had not progressed, with almost 12 hours elapsing before someone visited his 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 identify cases that have not been progressed
Wider context from the report “2) almost 12 hours had elapsed from Daniel’s call to someone visiting his home address with no mechanism to identify cases, which had not been progressed .
” Source location Daniel David Rennoldson · Prevention of Future Deaths report
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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 referral tracking, handover, electronic board and multidisciplinary review mechanisms are sufficient to identify outstanding Crisis Team assessments.
Verbatim wording from the response “The Trust can confirm that there are already robust mechanisms in place to track referrals active to the Crisis Team, including those still awaiting an assessment.” Source location 2021-0206-Response-from-Cumbria-Northumberland-Tyne-and-Wear-NHS-Foundation-Trust-Redacted
Open published response
24 Sep 2020 June Mavis Winterbottom · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Failure to identify urgent cases that drift outside normal hours 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. 7
Wakefield City Council
Implement a dedicated out-of-hours workforce system for handling referrals.
View source
Wakefield City Council
Give Social Care Direct access to extended-hours rotas, staff mobile numbers and a manager escalation contact for urgent referrals.
View source
Wakefield City Council
Embed a referral-transfer process requiring dashboard entry and direct confirmation with the worker on shift.
View source
Wakefield City Council
Distribute weekly rota emails with working arrangements and out-of-hours shift guidance, including instructions to check both Urgent Response Dashboards.
View source
Wakefield City Council
Enable all Adult Triage workers to view both East and West Urgent Response Dashboards and monitor submitted referrals.
View source
Wakefield City Council
Instruct out-of-hours Approved Mental Health Professionals to check the Urgent Response Dashboard when starting evening duty.
View source
Wakefield City Council
Require core-hours Urgent Response workers to communicate follow-up requirements directly to extended-hours workers.
View source See 4 more actions
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AI-generated summary
June Mavis Winterbottom · 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
June Mavis Winterbottom, aged 90, lived alone in sheltered accommodation and was found semi-conscious in her own faeces and vomit, covered in pressure sores, after an urgent Adult Social Care referral received no contact. She was taken to hospital and treated for urosepsis, but died later that day. The report identified ineffective urgent-referral handling, unclear accountability, and no safety net for calling an ambulance when Adult Social Care could not respond promptly.
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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 identify urgent cases that drift outside normal hours
Wider context from the report “(1) The system for handling urgent referrals within Adult Social Care in Wakefield on 02/06/20 was ineffective. Despite being graded as ‘urgent’, no contact was made with an elderly, isolated, vulnerable lady, who was evidently in dire need of assistance
(2) In consequence, Mrs Winterbottom was left alone without the medical assistance which would probably have been called in, had she been seen. It is, however, not possible to say whether her life would have been saved, had she been admitted to hospital on 02/06/20.
(3) Even the following day, 03/06/20, no visit took place, despite the urgency of the situation. The urgent referral system was exposed as deficient.
(4) Evidence taken at the Inquest indicated that the team in Adult Social Care were not aware of the need to watch out for such cases which had drifted outside of normal hours . Such a generalised instruction serves to diffuse responsibility, rather than establish accountability on the part of an identified manager.
(5) There was no safety net in place, whereby an ambulance would have been called in the event the Adult Social Care team were unable to respond in a timely manner for any reason.
” Source location June Mavis Winterbottom · Prevention of Future Deaths report
Open source 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 Implement a dedicated out-of-hours workforce system for handling referrals.
Verbatim wording from the response “At this time, WMDC Adult Social Care had realigned its workforce in order to support the Covid response as directed by the Department for Health and Social Care. In particular, the national guidance required Adult Social Care to facilitate urgent hospital discharges between 8am and 8pm, to ease the mounting pressure on overburdened hospitals. WMDC Adult Social Care had implemented a new system of workers covering referrals outside of usual working hours in the weeks prior to this referral being received. There were also further changes to usual working practices in that significant numbers of staff were working remotely from home due to the Covid situation. Nevertheless, action should have resulted from the referral during the evening of 2nd June 2020 and I offer my sincere apologies to Mrs Winterbottom’s family.” Source location 2020-0183-Response-from-Wakefield-Council_Redacted.pdf
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 Give Social Care Direct access to extended-hours rotas, staff mobile numbers and a manager escalation contact for urgent referrals.
Verbatim wording from the response “On the 3rd June 2020, senior managers worked immediately to improve the system.” Source location 2020-0183-Response-from-Wakefield-Council_Redacted.pdf
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 Embed a referral-transfer process requiring dashboard entry and direct confirmation with the worker on shift.
Verbatim wording from the response “Further work was then undertaken over the next four weeks to ensure that the referral transfer process was robust, with the following specific actions being implemented:” Source location 2020-0183-Response-from-Wakefield-Council_Redacted.pdf
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 Distribute weekly rota emails with working arrangements and out-of-hours shift guidance, including instructions to check both Urgent Response Dashboards.
Verbatim wording from the response “• A weekly email is distributed across the Adult Social Care service, containing the rota which in turn contains clear working arrangement guidance. It makes it clear who is working and when, and in what role.” Source location 2020-0183-Response-from-Wakefield-Council_Redacted.pdf
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 Enable all Adult Triage workers to view both East and West Urgent Response Dashboards and monitor submitted referrals.
Verbatim wording from the response “• We have ensured that all Adult Triage workers in Social Care Direct can view the Urgent Response Dashboards for both East and West to check the progress of any referrals they sent through.” Source location 2020-0183-Response-from-Wakefield-Council_Redacted.pdf
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 Instruct out-of-hours Approved Mental Health Professionals to check the Urgent Response Dashboard when starting evening duty.
Verbatim wording from the response “• Additionally, the Social Care Direct Manager has instructed the Out of Hours Approved Mental Health Professionals (“AMHP”) to check the Urgent Response dashboard when they come on duty in the evening (although it is recognised that they will always have to prioritise Mental Health Act assessments over other work).” Source location 2020-0183-Response-from-Wakefield-Council_Redacted.pdf
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 Require core-hours Urgent Response workers to communicate follow-up requirements directly to extended-hours workers.
Verbatim wording from the response “• The Urgent Response workers covering core hours will directly communicate with the extended hours workers regarding anything which needs following up from the day.” Source location 2020-0183-Response-from-Wakefield-Council_Redacted.pdf
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 Adult Social Care considers its reviewed and strengthened systems sufficiently robust, so no additional actions are required following the report.
Verbatim wording from the response “I trust that the above information addresses the matters of concern you raise, and provides sufficient reassurance that Adult Social Care in Wakefield have already appropriately reviewed our systems following the death of Mrs Winterbottom, and taken action to ensure the robustness of our systems. As a consequence, Adult Social Care do not feel that there are any additional actions which need to be taken resulting from your issuance of the Regulation 28 Report.” Source location 2020-0183-Response-from-Wakefield-Council_Redacted.pdf
Open published response
16 Dec 2019 Arnold Fletcher Ward · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Lack of a system to follow up unanswered specialist referrals View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission NHS Greater Manchester Integrated Care Board Olea Care Ltd
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
Olea Care Ltd
Route tissue-viability referrals by email or telephone, confirm them by summary email and next-day calls, and track follow-up using diary and audit-sheet prompts.
View source
NHS Greater Manchester Integrated Care Board
Change Tissue Viability referrals from fax to email and add prompts to follow up referrals not actioned within two working days.
View source
NHS Greater Manchester Integrated Care Board
Require Fernlea staff to obtain email read receipts, telephone the service the following day, and record confirmed visit dates.
View source
Care Quality Commission
Complete the extended comprehensive inspection of Fernlea Care Home, examining pressure-ulcer management and management oversight.
View source See 1 more action
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AI-generated summary
Arnold Fletcher Ward · 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
Arnold Fletcher Ward was a resident at Fernlea Nursing Home who developed a deteriorating grade 4 sacral pressure ulcer, later associated with osteomyelitis, and died in hospital on 21 January 2019 from a myocardial infarction. Concerns included inadequate monitoring and escalation of the pressure ulcer, failure to follow up a referral to the Tissue Viability Nursing Team, and the resulting lack of appropriate wound dressing.
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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 a system to follow up unanswered specialist referrals
Wider context from the report “The inquest heard that within the home the forms used did not capture the deterioration of the pressure ulcer or require detailed monitoring/use of photographs to track its progress. This meant that the significant and steep deterioration was not recognised and escalated at an early opportunity to the Tissue Viability Nursing team for expert wound management input. As a result the type of wound dressing he required were not utilised/available.
It had been captured in the notes that there had been a referral to the Tissue Viability Nursing team in October. There was no system in the home to chase up the team after a number of weeks had elapsed and there had been no response . The inquest heard that even in non-urgent cases the Tissue Viability Nursing team would contact a home requesting support in at least 10 days and more quickly in an urgent case.
” Source location Arnold Fletcher Ward · Prevention of Future Deaths report
Open source 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 Route tissue-viability referrals by email or telephone, confirm them by summary email and next-day calls, and track follow-up using diary and audit-sheet prompts.
Verbatim wording from the response “During the time of the incident with AFW, the TVNs were in the process of transferring referrals from fax to email. They have acknowledged that there was a number of issues around that time with referrals and follow ups. We have since changed our processes to ensure all referrals to the TVNs are via e-mail or telephone followed up by a summary e-mail. All referrals are followed up by a phone call the day after irrespective of urgency status and prompts are placed in the diary and on a referral audit sheet for the care management team to follow up.” Source location 2019-0433-Response-from-Fernlea-Care-Home-Redacted.pdf
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 Change Tissue Viability referrals from fax to email and add prompts to follow up referrals not actioned within two working days.
Verbatim wording from the response “• Refresh of the requirements of the referral to Tissue Viability service process in response to the issues of the delay in escalation to the specialist Tissue Viability Nursing Team despite clear signs of deterioration, and No evidence of a robust system to track the status of a referral to the Tissue Viability Nursing Team” Source location 2019-0433-Response-from-Stockport-NHS-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 Require Fernlea staff to obtain email read receipts, telephone the service the following day, and record confirmed visit dates.
Verbatim wording from the response “It is now standard practice for Fernlea nursing home to ensure a read receipt is requested so that the referring home can check to ensure that the email has been accessed / read by the Tissue Viability Team. In addition a follow up telephone call is made to the service the following day, irrespective of the pressure ulcer urgency status; during this call the date for a visit from the team is confirmed and added to the nursing home diary.” Source location 2019-0433-Response-from-Stockport-NHS-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 Complete the extended comprehensive inspection of Fernlea Care Home, examining pressure-ulcer management and management oversight.
Verbatim wording from the response “The matters of concerns which arose from the preventing future deaths report were reviewed by CQC and a decision was made to undertake an unannounced, focused inspection of the Fernlea Care Home. This was because the concerns indicated that the registered provider may have been/may still be in breach of the following fundamental standards:” Source location 2019-0433-Response-from-the-Care-Quality-Commission-Redacted
Open published response
18 Nov 2019 Alex Grady · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Failure to extend detoxification follow-up beyond the medication course to explore continued substance use View source
This report raised 2 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
Alex Grady · 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
Alex Grady was found deceased in his bed on 26 February 2019 and died from combined toxicity involving prescribed and non-prescribed medication and illicit drugs. Concerns included the adequacy of support and follow-up when alcohol detoxification is managed solely by a GP, and the accessibility of complete prescription information to healthcare practitioners.
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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 extend detoxification follow-up beyond the medication course to explore continued substance use
Wider context from the report “I heard that Mr Grady’s alcohol detoxification programme in January 2018 involved two appointments with his GP during which prescriptions for a seven day course of Chlordiazepoxide were issued. The GP was unaware that Alex was using any type of drugs. Given Mr Grady’s history of dependency on alcohol and benzodiazepines, a referral into the Drug and Alcohol service would have allowed for specialised support at that time of increased vulnerability. My concern is that if detoxification programmes are provided solely by the GP, adequate support is put in place. If a decision is made to manage the detoxification process within the GP practice, follow up appointments should extend beyond the date of the 7 day medication course so that questions around continued use of substances can be explored .
” Source location Alex Grady · Prevention of Future Deaths report
Open source report
2 Aug 2019 Carol Anne JENNINGS · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Failure to chase up tissue viability referrals View source
This report raised 3 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
Carol Anne JENNINGS · 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
Carol Anne Jennings had multiple comorbidities and was admitted to hospital on 10 January 2019. She developed infected leg ulcers, deteriorated, began end-of-life care on 25 January, and died on 31 January 2019; the inquest recorded septicaemia, infected leg ulcers and hospital-acquired pneumonia as the medical causes of death. Concerns included the handling and follow-up of a Tissue Viability Nurse referral and inadequate wound record keeping.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to chase up tissue viability referrals
Wider context from the report “1. Mrs Jennings was referred to the Tissue Viability Nurse by way of a message being left on a telephone answering machine due to her legs being “red” and “wet” on 12 January 2019. As there was no mention of an “open wound” in the telephone message, no action was taken by the Nurse and the referral was not chased up by the ward . A second referral was made on 21 January 2019 by a different doctor. In evidence the Nurse reported as having too many referrals and not having time to deal with them all. At the resumed inquest evidence was heard that referral by electronic means is being considered which would assist in ensuring consistent and relevant information being provided and an audit trail of referrals and further investigation/patients seen. This is a relatively straightforward system to implement but there is no timescale in place for it to be implemented.
” Source location Carol Anne JENNINGS · Prevention of Future Deaths report
Open source report
28 Jun 2019 Feni Lee · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1
Failure to identify and address hospital loss to follow-up during medication review 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. 1
Bexley Medical Group
Contact mental health patients who miss hospital outpatient appointments to establish reasons and support attendance.
View source
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AI-generated summary
Feni Lee · 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
Feni Lee, who had Behçet’s syndrome, took an excessive quantity of colchicine over a two-week period in September 2017 and died in hospital on 17 September 2017 after developing severe side effects, including liver necrosis. The concerns included the thoroughness of the medication review, the failure to address her loss to hospital follow-up, and delays and ineffective processes for redirecting correspondence between two GP practices.
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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 identify and address hospital loss to follow-up during medication review
Wider context from the report “(1) You informed the inquest that Bexley Medical Group has a system whereby all medication obtained by repeat prescription is reviewed annually. You could not say exactly when the review of Ms Lee’s medication took place (at that time it was not documented) but said it would have been towards the end of 2016. You said the review looked at the need for ongoing medication and the dose. There were a number of features that do not appear to have been taken into account at this review:
a. Colchicine is an unlicensed usage of a drug used to treat a rare disorder. It was being prescribed by the GP under instructions from a specialist hospital clinic.
b. There had been no instructions from Guys as to what should be prescribed since January 2016.
c. The instructions from Guys in January 2016 do not mention colchicine. No inquiry was made with Guys to check whether the intention was for it to be continued as part of the treatment, and yet it continued to be given by the GP as a repeat prescription.
d. The dosage being given on repeat prescription does not match any of the recent instructions from Guys about its use.
e. Ms Lee had mental health problems and was a vulnerable person.
I therefore have concerns about the thoroughness of this medication review.
(2) Towards the end of 2016 it would have been obvious that Ms Lee had been lost to follow up at the hospital, and so the drug review appears to have been a lost opportunity to rectify this.
” Source location Feni Lee · Prevention of Future Deaths report
Open source 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 Contact mental health patients who miss hospital outpatient appointments to establish reasons and support attendance.
Verbatim wording from the response “Our administrators and receptionists will contact patients with mental health problems, who do not attend hospital outpatient appointment to establish the reasons and support them in keeping up with their appointments.” Source location 2019-0224-Response-by-Bexley-Medical-Group
Open published response
10 Jan 2019 Natasha Learline CHIN · Prevention of Future Deaths report Surrey
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Concerns raised 1
Lack of follow-up and recording of prescribed medication non-attendance 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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AI-generated summary
Natasha Learline CHIN · 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
Natasha Learline Chin died in her cell at HMP Bronzefield on 19 July 2016 after profuse vomiting associated with undertreated opiate and alcohol withdrawal. The report identified concerns about delayed medication, inadequate monitoring and escalation, failures in record-keeping and governance, and insufficient auditing and training.
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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 follow-up and recording of prescribed medication non-attendance
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Source location Natasha Learline CHIN · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.