9 Jul 2018 Robert Andrew Power · Prevention of Future Deaths report Gloucestershire
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Concerns raised 1
Failure to ensure that outpatients are not lost to follow-up care View source
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Robert Andrew Power · 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
Robert Andrew Power, a 49-year-old man living in a neurological care home, had a chronic brain condition and experienced recurrent aspiration pneumonia and seizure activity. He died on 17 May 2017 after being discharged for palliative care following admission with aspiration pneumonia. The principal concern was that, while treated by the trust, he was lost to outpatient follow-up between 2007 and 2015, creating a risk that future deaths may occur unless patients are not lost to follow-up care.
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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 ensure that outpatients are not lost to follow-up care
Wider context from the report “Robert whilst being treated as a patient by the trust was essentially lost to follow up between 2007 – 2015. No explanation was given as to why this happened.
For the reasons given in my summary of evidence I determined that there was no evidence that this area of concern had any direct causative impact on Robert’s death. However in my opinion there is a risk that future deaths may occur unless action is taken to ensure that outpatients are not lost to follow up care . It is acknowledged that significant steps have already been made.
” Source location Robert Andrew Power · 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 Introduce processes to arrange patient follow-up appointments.
Verbatim wording from the response “The information provided confirms the Trust is now working under different systems than in 2008 and that processes have been introduced to arrange follow-up appointments and monitor and manage a patient on an allocated pathway.” Source location 2018-0221-Response-by-North-Bristol-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 Introduce processes to monitor and manage patients on allocated pathways.
Verbatim wording from the response “The information provided confirms the Trust is now working under different systems than in 2008 and that processes have been introduced to arrange follow-up appointments and monitor and manage a patient on an allocated pathway.” Source location 2018-0221-Response-by-North-Bristol-NHS-Trust
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28 Jun 2018 Stephen Whitehead · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Absence of a national safety-netting system for biliary stents 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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Stephen Whitehead · Prevention of Future Deaths report
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Report summary
Stephen Whitehead was admitted with abdominal symptoms on 6 February 2018 and deteriorated despite intensive treatment, dying in hospital on 8 February 2018. The report identified concerns about the absence of a national registry or safety-netting system for biliary stents and the lack of a clear definition of “short-term” use in clinical guidance.
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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 Absence of a national safety-netting system for biliary stents
Wider context from the report “1. The absence of a national ‘safety-netting’ system (stent registry) , akin to that already established for ureteric stents (a web-based registry). There is no equivalent for biliary stents . Without a safety netting system, I am concerned that there is a real risk that patients will remain susceptible to what is medically recognised as the ‘phenomenon of the forgotten biliary stent’, resulting in future deaths.
” Source location Stephen Whitehead · 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 Discuss adding stent planning and recall databases to national endoscopy standards key performance indicators and incorporating them into the ISREE programme.
Verbatim wording from the response “The BSG and JAG are however in discussion concerning adding the use of a stent planning/recall database to the key performance indicators (KPI) within its national standards framework, and incorporating it into the ISREE (Improving Safety and reducing Errors in Endoscopy) programme. This topic will be formally discussed at the BSG Endoscopy Committee in October.” Source location 2018-0293-Response-by-BSG
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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 A national stent registry is not required because existing guidance, communication, management-plan recording and proposed safety-net arrangements are considered sufficient.
Verbatim wording from the response “Your report was issued to the British Society of Gastroenterology (BSG) and I understand the Society has provided a response. You will therefore be aware that after careful consideration, the Society is of the opinion that a national stent registry is not required, instead pointing to the existing guidance available and the need for clear communication between medical professionals and with the patient, as well as the clear recording of next steps in management plans.” Source location 2018-0293-Response-by-Department-of-Health-and-Social-Care
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PFD Monitor interpretation A national stent registry would not necessarily have prevented the outcome because the apparent shortcomings concerned local care arrangements.
Verbatim wording from the response “This view is supported by the National Institute for Health and Clinical Excellence (NICE) which points out that in this case there appeared to be an intention to remove the stent but this did not happen due to an administrative” Source location 2018-0293-Response-by-Department-of-Health-and-Social-Care
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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 A national biliary stent database is not needed because local endoscopy-unit arrangements and communication address the identified shortcomings.
Verbatim wording from the response “After careful consideration, we do not feel that the answer is a national database of biliary stents. This would be unwieldy and require significant additional manpower and infrastructure to police. The vast majority of patients will have their care in one locality and, as suggested in the report, shortcomings in local arrangements of care, including communication between local teams, GP and patient, were the fundamental issues highlighted here. Although the National Endoscopy Database (NED) has now been introduced nationally, it is important to record that this does not allow individual patient tracking, and could not act as a proxy database of biliary stents.” Source location 2018-0293-Response-by-BSG
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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 A national biliary stent database is not pursued because it would be unwieldy and require significant additional manpower and infrastructure.
Verbatim wording from the response “After careful consideration, we do not feel that the answer is a national database of biliary stents. This would be unwieldy and require significant additional manpower and infrastructure to police. The vast majority of patients will have their care in one locality and, as suggested in the report, shortcomings in local arrangements of care, including communication between local teams, GP and patient, were the fundamental issues highlighted here. Although the National Endoscopy Database (NED) has now been introduced nationally, it is important to record that this does not allow individual patient tracking, and could not act as a proxy database of biliary stents.” Source location 2018-0293-Response-by-BSG
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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 Recording and monitoring biliary stents should be owned by the endoscopy unit that inserted the stent.
Verbatim wording from the response “3. Database of stents. We completely agree that a clear record of when a stent has been placed, and when this should be removed or changed, is important. We feel this should be within the ownership of the endoscopy unit that has inserted the stent. This may be a formal database or a facility within the electronic endoscopy reporting tool, but should be contemporaneously entered at the time of the ERCP, with a clear plan as to timeframe for patient review/repeat procedure. Crucially the system should allow easy, rapid and demonstrable review of all patients who have undergone stenting within an extended time period.” Source location 2018-0293-Response-by-BSG
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14 May 2018 Gladys Kathleen Rich · Prevention of Future Deaths report Northamptonshire
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Concerns raised 1
Failure of the Falls Prevention Service to proactively follow up required input View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Gladys Kathleen Rich · 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
Gladys Kathleen Rich suffered repeated falls after moving into Avenue House Nursing and Care Home, culminating in a fall on 28 December 2016 that caused traumatic subdural and subarachnoid haemorrhages and a skull fracture. She died on 3 March 2017; the medical cause of death included chest infection, intracranial haemorrhage and a fall, with rectal cancer and liver metastases also recorded. The principal concerns related to failures to identify and manage her falls risk, ineffective referral and follow-up by the care home and Falls Prevention Service, inadequate resources and equipment, and the absence of an effective system to ensure required falls-prevention input was delivered.
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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 Falls Prevention Service to proactively follow up required input
Wider context from the report “2. In relation to the Falls Prevention Service.
a) Despite Mrs Rich having been referred to the Falls Prevention Service by her GP and the service being notified of a fall related hospitalisation in August 2016, the onus was placed on the patient and her family to make a further appointment . In the absence of any further contact, the service assumes that their input is no longer required . As is clear in the case of Mrs Rich, the prevention service was very much still required. Again, when the service was contacted in November 2016 the failure to receive a form or a response to the subsequent letter again led to an automatic assumption that input was no longer required despite the fact that this was the second referral to have been made in relation to Mrs Rich. It was explained in evidence that the reason the service cannot be more proactive is because they are inadequately resourced .
” Source location Gladys Kathleen Rich · 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 Contact the Falls Team after sending referrals and action plans, confirm receipt and intended action, and record each contact in residents’ care plans.
Verbatim wording from the response “Although we believe we followed normal and reasonable procedures in this case, in future to further mitigate against shortcomings of the Falls Team, we will contact them after sending them referrals and action plans. This will be done to ensure that the Falls Team have received them and to find out what action they intend to take. All contact will be recorded in our residents’ Care plans under the visiting professionals’ information section.” Source location 2018-0149_Redacted-Response-by-Avenue-House-Care-Home
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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 After submitting referrals and action plans, the care home must wait for the Falls Team’s input and decisions.
Verbatim wording from the response “C) The management of the home completed the falls risk assessment and action plan and sent this by post, and not by the fax facility. There was a copy of this in the resident’s file for reference. There was no information in the resident’s file to say that the falls team hadn’t received this information. Mrs Rich had also been referred to the Falls Team prior to admission to Avenue House and again this was not followed up by the Falls Team. Once falls risk action plans are received by the falls team, they do not typically give the home even a rough estimate of how long it will be before it is followed up and the resident is seen. Therefore the care home simply has to wait for the Falls’ Team’s input.” Source location 2018-0149_Redacted-Response-by-Avenue-House-Care-Home
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12 May 2017 Nasar AHMED · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Lack of follow-up review tracking after replacement medication is requested View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Nasar AHMED · 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
Nasar died following an anaphylactic reaction contributed to by asthma while he was in the internal exclusion room at school. The concerns included delayed or inappropriate advice about using his adrenaline auto-injector, discrepancies and gaps in asthma and allergy care planning, unsuitable emergency inhaler equipment, inadequate medication review systems, and shortcomings in staff awareness, training and emergency procedures.
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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 review tracking after replacement medication is requested
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided .
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” Source location Nasar AHMED · 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 Deliver tailored biannual school-nursing training covering record keeping, communication, action follow-up, electronic diaries and diary management.
Verbatim wording from the response “In addition to the above training, the bi-annual training received by the school nursing service was delivered in June 2017. During bi-annual training, the service is suspended and training takes place across all staff groups. The training has been tailored to support the key learning points from the tragic death of Nasar Ahmed and the requirements and expectations of a school nurse. It covered a range of key areas including how to improve record keeping and the importance of this, the increased function of school nurse administrators in communication and following up of actions with key staff in school and the parents, the use of electronic diary systems and diary management. A copy of the training schedule undertaken in June 2017 is attached.” Source location Response from Compass Wellbeing
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement measures requiring school nurses to follow up and update IHCP meeting actions routinely.
Verbatim wording from the response “CWB have implemented additional measures to ensure that the checking and updating of actions from IHCP meetings are routinely followed up by all school nurses and to prevent this event from happening again.” Source location Response from Compass Wellbeing
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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 Train clinical staff to use electronic diaries, reminders, shared calendars and mobile devices for appointment and action follow-up.
Verbatim wording from the response “All clinical staff have received guidance on how to manage an electronic diary in order to assist staff in diarising appointment, reminders and sharing calendar appointments. All clinical staff have access to mobile working devices, for example laptops, and the service is moving to a fully electronic diarising system in order to support sharing of appointment calendars and the effective use of an electronic diary and reminder system. Specific training on electronic diarising and the use of this took place on 21 June” Source location Response from Compass Wellbeing
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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 Roll out the electronic diarising system fully across the service in the new academic year.
Verbatim wording from the response “All clinical staff have received guidance on how to manage an electronic diary in order to assist staff in diarising appointment, reminders and sharing calendar appointments. All clinical staff have access to mobile working devices, for example laptops, and the service is moving to a fully electronic diarising system in order to support sharing of appointment calendars and the effective use of an electronic diary and reminder system. Specific training on electronic diarising and the use of this took place on 21 June” Source location Response from Compass Wellbeing
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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 Reinforce contemporaneous record keeping, action-point ownership and follow-up dates through medico-legal training and competency-framework training.
Verbatim wording from the response “CWB have re-enforced to all staff the requirement and expectation across the service to ensure that accurate and contemporaneous records are kept, including recording and documenting action points and dates for follow up, as well as documenting who is responsible for each action point. This has been re-enforced through medico-legal training which was arranged for all staff in order to address the implications of poor documentation keeping and the effect this has on the delivery of healthcare. This training took place on 19 June 2017.” Source location Response from Compass Wellbeing
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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 monitored procedures for arranging and following up Individual Health Care Plan and medication reviews, including senior oversight and deadline reminders.
Verbatim wording from the response “The Executive Headteacher, along with Headteacher representatives from across the area, has been invited by the Local authority to meet to discuss the school nursing service as part of a scheduled contract renewal process. This meeting is due to take place later this year, but it is understood that the concerns identified during the Inquest will inform that process. In the interim the school has been working with Compass Wellbeing to clarify the procedure for setting up IHP meetings and medication reviews. The school has had additional processes to ensure this procedure is robustly monitored at senior level. The procedure requires that, in all cases an update of the pupil’s medical need is required at each review.” Source location Response from Bow School
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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 Checking that in-date medication is provided is a shared responsibility between the school and school nurse.
Verbatim wording from the response “The Supporting Medical Needs Policy indicates that the responsibility of checking that in-date medication is provided is a shared one between the school itself and the school nurse. It is fully expected that the school nurse and the school would have a conversation to discuss follow-up actions arising from a meeting and appropriately diarise to check that the correct medication has been received and, if not received, to chase this up in a timely manner. As a qualified health professional, the school nurse is able and expected to understand whether a prescription is appropriate and whether the correct medication has been received. Any outstanding actions must be followed up and completed as a matter of course and in accordance with their professional duties.” Source location Response from Compass Wellbeing
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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 Parents or the school nurse are principally responsible for contacting the pupil’s GP or other treating medical professionals before reviews.
Verbatim wording from the response “Principally it remains the responsibility of the child’s parents or school nurse to make contact with the child’s GP or other medical professionals involved in their care prior to the meeting. Where, at the review meeting, this hasn’t been done or there is any uncertainty regarding the pupil’s current need the school nurse is required to follow up with direct contact to the pupil’s GP and confirm the position to the school administrator by email. The deputy head responsible for safeguarding is also copied into those emails. The procedure also differentiates between medication reviews and IHP meetings/reviews to ensure that necessary follow up can be scheduled separately. For example, where actions are required as a result of the medication review, a follow up review is scheduled for the following week.” Source location Response from Bow School
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23 Mar 2017 Grant Lincoln RICHARDS · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to maintain contingency and audit controls for missed follow-up actions View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Grant Lincoln RICHARDS · Prevention of Future Deaths report
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Report summary
Grant Richards died by suicide on 19 October 2016 after ejecting himself from a tenth-floor window and suffering catastrophic injuries. The report identified failures to act on an A&E request for chest-clinic follow-up, failures in contingency and audit systems, omissions in GP reporting, and failures to act on mental-health service fax communications. It noted that anxiety about possible lung cancer may have prolonged or exacerbated his depression leading to his suicide.
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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 maintain contingency and audit controls for missed follow-up actions
Wider context from the report “Mr Richards previous medical history included diagnoses of depression, and anxiety, for which he was treated at various times pharmacologically, by inpatient treatment in a secure hospital, by access to the Home Treatment Team and by community based mental health care. His history included self-harm and suicide attempt. His anxieties included financial worry, debt, unemployment and eviction. He attended A&E at Whipps Cross Hospital on 23rd July 2016 for treatment of pain in his right loin. Whilst there he was x-rayed to the chest, which revealed a “shadow” on the right side. The hospital advised Mr Richards and his sister who attended with him that this matter would be raised with the GP, and he was informed that the hospital recommended follow-up in the chest clinic. The discharge summary recorded “disch for GP F/Up – to check progress” and also specifically noted the clinician’s comments which included “please arrange F/U in the chest clinic”. A letter was given to the patient as well as emailed to the GP surgery. The initial GP evidential witness report to the Coroner, prepared for submission to the Inquest, made no mention of this event. I heard evidence that the usual surgery protocol was that a reviewing doctor would assess all emailed reports received into the surgery, and in a case like this would instruct the surgery receptionist to contact the patient to arrange an appointment for such follow-up to be actioned. The evidence was that this did not happen. There was no follow-up. When Mr Richards was next seen in surgery on 5th October 2016, the x-rays were not discussed and there was no discussion of the requested follow-up with either the doctor, Mr Richards or his sister. The evidence was that Mr Richards was thought to be alarmed at the prospect that he might have lung cancer, from which his mother had died, and it was possible that this anxiety played a part in the prolongation or exacerbation of his depression leading to his suicide.
Additionally, evidence was given that in the course of a Root Cause Serious Incident Investigation conducted by an independent panel at the behest of the mental health authority (North East London Foundation Trust) that documents were sent electronically by fax from agencies of the Trust, especially the home treatment team and/or the Redbridge Access and Assessment Brief Intervention Team, which the GP surgery did not act upon although the Trust had received successful transmission reports generated by the fax machine. The features of:
a) failure to act upon the request in the A&E discharge summary;
b) failure to have a contingency system or audit in place to ensure that such failures are not missed ;
c) failure to include reference to the attendance at A&E and the discharge summary generated as a result of it, in the GP evidential report;
d) and failure to act on fax documents sent to the surgery,
all indicate a want of management control, lack of suitable procedures in place and a poor attention to documents received.
” Source location Grant Lincoln RICHARDS · Prevention of Future Deaths report
Open source report
16 Dec 2015 William Francis Driscoll · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to follow up a GP’s identification of a relevant consultant View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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William Francis Driscoll · Prevention of Future Deaths report
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Report summary
William Francis Driscoll died at Queen Elizabeth Hospital Birmingham on 30 June 2015 from injuries sustained when a vehicle mounted the pavement and hit him while he was walking. The driver lost control during an epileptic seizure. The report identified serious deficiencies in the DVLA medical assessment process, including limited investigation of health conditions and failure to follow up an identified relevant consultant, which could allow inadequately assessed drivers to continue driving.
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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 follow up a GP’s identification of a relevant consultant
Wider context from the report “████████ gave evidence that if he had been aware of the incident in September 2014 he would have carried out further investigations revealing the epilepsy that was ultimately diagnosed in August 2015 and thus preventing ████████ from driving before the collision with the deceased. It appears that there are serious deficiencies in the medical assessment process as regards the limited investigation into the health conditions on the form POLN3 and/or in not following up the GP’s identification of a ‘Relevant Consultant’ . As a consequence drivers may be permitted to drive who have not been adequately assessed as fit to do so.
” Source location William Francis Driscoll · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure of the referral process to identify and rectify errors View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Jacqueline 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
On 26 January 2015, Jacqueline Williams was taken to Royal Blackburn Hospital and assessed as being at moderate risk of self-harm, but a referral to the Mental Health Liaison Team was not accepted because of a communication breakdown. She subsequently hanged herself in an emergency department cubicle; concerns related to referral errors and systems that did not make missed or unaccepted referrals readily identifiable and rectifiable.
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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 referral process to identify and rectify errors
Wider context from the report “That the process of referral to the Mental Health Liaison Team was subject to human error and that the systems in place failed to provide for such mistakes to be easily identified and rectified . In particular there was no opportunity for staff in the emergency department to see confirmation that a referral had been accepted, the time of that referral and the expected time when a mental health assessment would take place. Likewise the Mental Health Liaison Team did not have a process that whereby they were able to identify those patients that the staff in the emergency department believed had been referred and were awaiting assessment.
” Source location Jacqueline Williams · Prevention of Future Deaths report
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15 Oct 2015 William Gordon Tolen · Prevention of Future Deaths report Manchester South
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Concerns raised 2
Failure of fragmented record systems to support clear follow-up View source Delays in confirming podiatry referral messages View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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
William Gordon Tolen · 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
William Gordon Tolen was living at Shawe Lodge when he developed problems with his legs and left great toenail; a podiatrist removed the toenail, after which he developed cellulitis. The investigation concluded that the death was from natural causes, with septicaemia and cellulitis recorded as the medical cause of death. Concerns included inadequate record-keeping, delays in arranging podiatry care, insufficient staff training, and the inappropriate conditions in which the procedure was carried out.
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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 fragmented record systems to support clear follow-up
Wider context from the report “6. The details kept in the daily “Diary” at the home were grossly inadequate , an example being “chase up podiatry (sic) for William” on the 19th February. He was known as Gordon. No-one appears to have pursued this or noted that the podiatrist did not attend the 24th February , thereby the whole system of notes being kept in a diary, in a separate individual note file, in MDT visits book and in a GP visits book appears inevitably to lead to confusion .(Shawe Lodge)
” Source location William Gordon Tolen · 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 Delays in confirming podiatry referral messages
Wider context from the report “2. The need for the attendance of a podiatrist was, or should have been apparent to the staff at the home, and yet they allowed 5 days to pass without ensuring that their messages had been received , hence there was a delay before Mr Tolen was seen and treated .(Shawe Lodge)
” Source location William Gordon Tolen · Prevention of Future Deaths report
Open source report
5 Dec 2014 Paul Leslie HYDE · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 1
Lack of a referral follow-up system View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Paul Leslie HYDE · 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
Paul Leslie Hyde died after taking an overdose of medication that had been stopped, with the sedatory effect contributing to his death. The report raised concerns that his referral for a psychiatric medication review was not appropriately addressed, that he was not seen within the required period or followed up, and that the re-referral system was not fit for purpose.
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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 referral follow-up system
Wider context from the report “(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety.
(2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient.
(3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde.
It should have been obvious from the start that this was not a direction for this referral to take.
There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be.
In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up.
(4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose.
In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death.
” Source location Paul Leslie HYDE · 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 Extend the Breach Tool to record and monitor every referral, pending contact and triage outcome, with updated guidance and staff instruction.
Verbatim wording from the response “The use of the Breach Tool has been extended and the system is now more robust. Medical Personal Assistants now complete this for all referrals, regardless of the triage decision. Team leads have oversight of the tool and it is a ‘live’ record of all pending contacts, whether by telephone or face to face with service users. All actions / outcomes from the clinical triage meetings are now recorded on the Breach Tool and these are closely monitored. The Breach Tool guidance has been reviewed and staff have received clear instruction on how to use the tool.” Source location 2014-0527-Response-by-Sussex-Partnership-NHS
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26 Nov 2014 Amanda Hawkins · Prevention of Future Deaths report Staffordshire South
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Concerns raised 1
Failure to identify missed essential appointments and provide follow-up View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Amanda Hawkins · 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
Amanda Hawkins, aged 44, had schizophrenia and experienced multiple moves to accommodation with reduced levels of care and changes in care co-ordination. She was last seen on 30 May 2014 and reported missing that evening; her naked, decomposed body was found on 22 July 2014, and the cause of death was unascertained. Concerns included increased vulnerability following the moves and inadequate follow-up of essential hospital appointments because care co-ordination workers were not informed of missed appointments.
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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 missed essential appointments and provide follow-up
Wider context from the report “(2) Hospital appointments were sent to Amanda at her home address when she did not have sufficient understanding to deal with correspondence. Care co-ordination workers were not made aware of missed appointments and there was therefore no follow up . Lack of follow up for essential appointments led to her increased vulnerability.
” Source location Amanda Hawkins · 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 Copy North CRS outpatient letters to care coordinators.
Verbatim wording from the response “The Trust utilises the Oasis electronic system which logs and records appointments and instances when patients fail to attend. The Trust does however acknowledge that letters from North Community Recovery Service (CRS) medical teams were not copied to the care coordinator or placement provider for them to be aware of the appointments that Miss Hawkins did not attend and therefore no subsequent follow up was made. This is acknowledged as an area of improvement for the Trust which will be managed through the Trust’s embedding lessons processes. Therefore, going forward within CRS North outpatient letters are now copied to the care coordinator and, in addition to this, the Trust has convened a Working Group to look at long term solutions to this issue; this Working Group is being led by the Trusts Head of Recovery Services.” Source location 2014-0516-Response-by-Dudley-Walsall-NHS-Trust
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 Operate a Working Group led by the Head of Recovery Services to develop long-term solutions for missed-appointment follow-up.
Verbatim wording from the response “The Trust utilises the Oasis electronic system which logs and records appointments and instances when patients fail to attend. The Trust does however acknowledge that letters from North Community Recovery Service (CRS) medical teams were not copied to the care coordinator or placement provider for them to be aware of the appointments that Miss Hawkins did not attend and therefore no subsequent follow up was made. This is acknowledged as an area of improvement for the Trust which will be managed through the Trust’s embedding lessons processes. Therefore, going forward within CRS North outpatient letters are now copied to the care coordinator and, in addition to this, the Trust has convened a Working Group to look at long term solutions to this issue; this Working Group is being led by the Trusts Head of Recovery Services.” Source location 2014-0516-Response-by-Dudley-Walsall-NHS-Trust
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Includes failures of case monitoring, allocation tracking or referral follow-up where the control does not identify that a case has not been seen, assessed or progressed.
