Concerns raised 1
Insufficient medical practitioner cover for assessing patients' care needs View source
Linked responses
NHS England University Hospitals of Leicester NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
NHS England
Publish the 7-Day Hospital Services Programme introducing clinical standards for consistent seven-day acute care.
View source
NHS England
Continue encouraging local health systems to develop workforce plans providing sufficient qualified staff for population care needs.
View source
NHS England
Develop future training-post distribution to align the supply of doctors with population need.
View source
NHS England
Publish the NHS Long Term Workforce Plan setting out workforce training, retention and reform over fifteen years.
View source
University Hospitals of Leicester NHS Trust
Increase site medical staffing, including weekend and bank-holiday consultant, registrar and junior-doctor coverage.
View source
University Hospitals of Leicester NHS Trust
Review the potential for increasing medical staffing across all sites during weekends and bank holidays.
View source See 3 more actions
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AI-generated summary
Patricia Ann WALTON · 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
Patricia Ann Walton fell while visiting her granddaughter on Christmas Day 2022 and was later admitted to hospital with a fractured right ankle and shoulder injury. She subsequently received warfarin and dalteparin without a clear review or stopping plan; the dalteparin was not stopped when her INR rose above 2, and she later developed a haemorrhage, pneumonia and deteriorating health before dying on 9 January 2023. The principal concern was insufficient medical cover to assess patients’ ongoing care needs over the New Year Bank Holiday period.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient medical practitioner cover for assessing patients' care needs
Wider context from the report “The evidence at the inquest that no medical practitioner saw this lady from the 30 December 2022 to the 03 January 2023, over the New Year Bank Holiday period. My concerns are that whilst there might be a doctor available on call to treat emergencies that occur, there is insufficient cover to assess the subtleties of care required by patients , the absence of which may be as detrimental to the patient as not having emergency cover.
” Source location Patricia Ann WALTON · 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 Publish the 7-Day Hospital Services Programme introducing clinical standards for consistent seven-day acute care.
Verbatim wording from the response “In 2016, NHS England published its 7-Day Hospital Services (7DS) Programme which introduced clinical standards regarding the provision of a “truly seven-day NHS” and requiring acute trusts to provide board assurance compliance. The Programme focuses on the provision of acute medical care in such a way that there is no difference in quality for patients, whichever day they attend at hospital.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue encouraging local health systems to develop workforce plans providing sufficient qualified staff for population care needs.
Verbatim wording from the response “The NHS continues to encourage local health systems to develop effective workforce planning to ensure that they have the sufficient qualified staff working across their Trusts and wider system that are required for their population care needs. The NHS People Promise helps NHS providers to consider ways to recruit and retain staff. Work is in progress to ensure that future distribution of training posts to help ensure the supply of doctors is matched to population need.” Source location Response from NHS England
Open published response
×
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 Develop future training-post distribution to align the supply of doctors with population need.
Verbatim wording from the response “The NHS continues to encourage local health systems to develop effective workforce planning to ensure that they have the sufficient qualified staff working across their Trusts and wider system that are required for their population care needs. The NHS People Promise helps NHS providers to consider ways to recruit and retain staff. Work is in progress to ensure that future distribution of training posts to help ensure the supply of doctors is matched to population need.” Source location Response from NHS England
Open published response
×
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 Publish the NHS Long Term Workforce Plan setting out workforce training, retention and reform over fifteen years.
Verbatim wording from the response “Workforce and staffing levels continue to be a challenge across the NHS and we know that this can present issues to Trusts. In June 2023, NHS England published the NHS Long Term Workforce Plan, setting out how it will train, retain and reform its workforce across the next fifteen years to ensure that we are improving access, providing safe and timely urgent and emergency care and continuing to reduce elective care backlogs. The Plan is underpinned by the biggest recruitment drive in NHS history.” Source location Response from NHS England
Open published response
×
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 Increase site medical staffing, including weekend and bank-holiday consultant, registrar and junior-doctor coverage.
Verbatim wording from the response “In relation to the preventing future deaths action regarding medical staffing. We have already increased medical staffing at the site where the incident occurred. During bank holiday and weekend periods, we are rostering for a medical consultant to be present 9am to 5pm onsite, the consultant is supported by a medical registrar onsite 24hr/7days a week and by a junior doctor onsite 24hrs/7days a week.” Source location Response from University Hospital of Leicester
Open published response
×
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 Review the potential for increasing medical staffing across all sites during weekends and bank holidays.
Verbatim wording from the response “We have reviewed the potential for increasing our medical workforce across all our sites during bank holidays and weekends. However, as is the case for other NHS trusts, there are considerable workforce challenges that limit us in our ability to maintain a consistent number of inpatient medical staff 7 days a week, 365 days a year. These challenges become particularly acute during public holidays when our staffing levels reflect the social cultural context of UK society taking holidays, especially during the winter holiday period.” Source location Response from University Hospital of Leicester
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 Bank holiday staffing did not impact the patient’s care, and clinical deterioration did not require earlier escalation.
Verbatim wording from the response “Whilst Patricia was an inpatient over a bank holiday weekend, we are confident this did not impact on her care. Irrespective of the time of year, based on the clinical deterioration triggers there was no cause to raise clinical concerns sooner during her admission. If Patricia’s clinical condition had worsened earlier, our escalation policies” Source location Response from University Hospital of Leicester
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 Existing escalation policies would ensure clinical review regardless of bank holiday staffing levels.
Verbatim wording from the response “Whilst Patricia was an inpatient over a bank holiday weekend, we are confident this did not impact on her care. Irrespective of the time of year, based on the clinical deterioration triggers there was no cause to raise clinical concerns sooner during her admission. If Patricia’s clinical condition had worsened earlier, our escalation policies” Source location Response from University Hospital of Leicester
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 Workforce shortages and disruption to elective services constrain consistently increasing inpatient medical staffing during weekends and bank holidays.
Verbatim wording from the response “We have reviewed the potential for increasing our medical workforce across all our sites during bank holidays and weekends. However, as is the case for other NHS trusts, there are considerable workforce challenges that limit us in our ability to maintain a consistent number of inpatient medical staff 7 days a week, 365 days a year. These challenges become particularly acute during public holidays when our staffing levels reflect the social cultural context of UK society taking holidays, especially during the winter holiday period.” Source location Response from University Hospital of Leicester
Open published response
Concerns raised 1
Limited weekend clinical cover for injuries sustained on Fridays View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England University Hospitals of North Midlands NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
NHS England
Implement seven-day clinical standards and require acute trusts to provide board assurance of compliance.
View source
NHS England
Grow the urgent and emergency care workforce, including introducing more flexible ways of working.
View source
NHS England
Develop local workforce planning and distribute future training posts to match doctors’ supply with population need.
View source
University Hospitals of North Midlands NHS Trust
Review weekend demand and prepare a business case for extending dedicated fragility-fracture theatre capacity to Saturdays.
View source See 1 more action
×
AI-generated summary
Mrs Kathleen Booth · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Kathleen Booth was admitted to hospital after a fall in her garden on 9 June 2023, sustaining a fractured neck of femur. Surgery was delayed for four days and, after the operation, she deteriorated suddenly and died. The concerns included staffing and funding pressures, limited weekend cover, and the potential disadvantage to patients injured on a Friday.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Limited weekend clinical cover for injuries sustained on Fridays
Wider context from the report “3. Patients can be disadvantaged by not receiving treatment if an injury is sustained on a Friday as cover over the weekend is limited .
” Source location Mrs Kathleen Booth · 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 seven-day clinical standards and require acute trusts to provide board assurance of compliance.
Verbatim wording from the response “In 2013, NHS England published its 7-Day Hospital Services (7DS) Programme which introduced clinical standards regarding the provision of a “truly seven-day NHS” and requiring acute trusts to provide board assurance of compliance. The Programme focuses on the provision of acute medical care in such a way that there is no difference in quality for patients, whether it is a weekday or a weekend. There is a good level of compliance with these standards across acute trusts and many services and surgical and diagnostic lists are operating at weekends and evenings.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Grow the urgent and emergency care workforce, including introducing more flexible ways of working.
Verbatim wording from the response “In January 2023, NHS England published the Delivery plan for recovering urgent and emergency care services. This is a two-year delivery plan which sets the NHS commitment to the public to improve waiting times and patient experience within urgent and emergency care (UEC). This includes commitments to:” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop local workforce planning and distribute future training posts to match doctors’ supply with population need.
Verbatim wording from the response “The NHS continues to encourage local health systems to develop effective workforce planning to ensure that they have the sufficient qualified staff working across their Trusts and wider system that are required for their population care needs. The NHS People Promise also helps NHS providers to consider ways to recruit and retain staff. Work is in progress to ensure that future distribution of training posts to help ensure the supply of doctors is matched to population need. You will need to refer to Staffordshire and Stoke-on-Trent Integrated Care System on what system arrangements they have in place for their UEC provision and workforce.” Source location Response from NHS England
Open published response
×
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 Review weekend demand and prepare a business case for extending dedicated fragility-fracture theatre capacity to Saturdays.
Verbatim wording from the response “However, the trust does annually review capacity and demand for all its services and based on one of these reviews and subsequent business case, on the 6 November 2023, the Trauma Directorate introduced a dedicated fragility fracture list, 5 days per week. This has seen a reduction in time to theatre for this cohort of patients since its inception. Capacity and demand also include the weekend provision and the division are preparing a business case to see if the demand over the weekend period requires the same on a Saturday also.” Source location Response from University Hospitals of North Midlands NHS Trust
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 Staffordshire and Stoke-on-Trent Integrated Care System is responsible for local urgent and emergency care workforce arrangements.
Verbatim wording from the response “The NHS continues to encourage local health systems to develop effective workforce planning to ensure that they have the sufficient qualified staff working across their Trusts and wider system that are required for their population care needs. The NHS People Promise also helps NHS providers to consider ways to recruit and retain staff. Work is in progress to ensure that future distribution of training posts to help ensure the supply of doctors is matched to population need. You will need to refer to Staffordshire and Stoke-on-Trent Integrated Care System on what system arrangements they have in place for their UEC provision and workforce.” Source location Response from NHS England
Open published response
×
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 A dedicated weekend fragility-fracture theatre depends on available clinical and financial resources.
Verbatim wording from the response “The trust is also reviewing whether there is a need for a dedicated fragility fracture theatre over the weekend. As referenced in the response to question 2, this is a matter which is being reviewed and will be dependent on available clinical and financial resources.” Source location Response from University Hospitals of North Midlands NHS Trust
Open published response
27 Oct 2023 Gerald Roy Cruse · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1
Insufficient specialist medical capacity for timely and proactive care of older hospital patients View source
This report raised 6 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
Gerald Roy Cruse · 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
Gerald Cruse fell from a bed while being assisted to use the toilet in an ambulance cohort area after admission following a fall at home. He sustained multiple rib fractures, a haemopneumothorax and surgical emphysema, later developed pneumonia, and died in hospital. Concerns included inadequate falls-risk assessment and recognition by ambulance staff, a lack of identified learning after investigation, and wider concerns about the organisation of care for older patients requiring both surgical and geriatric medical input.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient specialist medical capacity for timely and proactive care of older hospital patients
Wider context from the report “(1) That over 75% of patients receiving hospital care are 65 and over. There is a conflict and tension between where within the hospital those patients should be receiving their care. A proportion of these patients require admission to a surgical ward due to the elements of their care which require surgical oversight and management, for example, analgesia through an epidural, insertion of a chest drain. However, this group of patients have multiple co-morbidities and complexities due to their age, which would be better managed by a medical team specialising in care of the elderly. Whilst medical teams can review patients, their limited resources mean it may not be as quickly as it needs to be, and they cannot be proactive in following up on the care of these patients. This results in an increasing risk that these patients will not receive the care they need in a timely manner. There is an increasing need for more doctors specialising in the care of older persons and this is a national issue.
” Source location Gerald Roy Cruse · Prevention of Future Deaths report
Open source report
Concerns raised 1
Delays in Radiologist review of emergency chest x-rays View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
NHS England
Publish national image-report turnaround-time guidance, including a four-hour maximum for acutely unwell A&E patients during routine hours.
View source
NHS England
Support Trusts to increase radiology reporting capacity through additional reporting radiographers, radiologist trainees, international recruitment and workforce planning tools.
View source
NHS England
Implement the NHS Long Term Workforce Plan to train, retain and reform healthcare staff across the NHS over fifteen years.
View source
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AI-generated summary
Chantelle Reed · 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
Chantelle Reed, who was 33 and had no significant medical history, attended hospital with back, neck and chest symptoms before returning with worsening breathlessness, chest pain, vomiting and fever. She was managed for suspected pulmonary embolism but died after becoming unconscious in the emergency department; the inquest recorded an undiagnosed Type A aortic dissection. Concerns included limited recognition of aortic dissection symptoms in emergency guidance and delays in radiological review that can leave abnormal findings unidentified until after death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in Radiologist review of emergency chest x-rays
Wider context from the report “2. The evidence also indicated that the timescale for a Radiologist to review the chest x-ray (2 days) was not unusual and that often the timescale is longer and this is due to a national shortage of Radiologists . The concern is that, to a trained Radiologist, the possibility of an aortic dissection was immediately recognised, but the review did not take place until after Chantelle had died . In an emergency situation such as this one, this delay represents on ongoing risk of future deaths .
” Source location Chantelle Reed · 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 Publish national image-report turnaround-time guidance, including a four-hour maximum for acutely unwell A&E patients during routine hours.
Verbatim wording from the response “NHS England published the Image report turnaround time guidance in August 2023, available here: NHS England » Diagnostic imaging reporting turnaround times. The guidance sets out the maximum turnaround times from acquisition to image reports, with a 4-hour maximum for acutely unwell patients in Accident & Emergency (A&E) during routine hours of working.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support Trusts to increase radiology reporting capacity through additional reporting radiographers, radiologist trainees, international recruitment and workforce planning tools.
Verbatim wording from the response “The guidance includes caveats for sufficient availability of workforce as the numbers of reporting staff (radiologists and reporting radiographers) are not increasing in line with demand. We are supporting Trusts to increase reporting capacity by increasing the number of reporting radiographers and radiologist trainees per financial year, international recruitment initiatives and workforce demand and capacity planning tools.” Source location Response from NHS England
Open published response
×
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 the NHS Long Term Workforce Plan to train, retain and reform healthcare staff across the NHS over fifteen years.
Verbatim wording from the response “In June 2023, NHS England also published the NHS Long Term Workforce Plan, in response to the current lack of sufficient workforce. The plan sets out how we will train, retain and reform healthcare staff across the NHS over the next fifteen years, and is underpinned by the biggest recruitment drive in NHS history.” Source location Response from NHS England
Open published response
19 Jul 2023 Michael Kevin Amesbury · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Delays in cardiology clinic assessment due to insufficient clinician or appointment-slot availability 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
Michael Kevin Amesbury · 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
Michael Kevin Amesbury had extensive cardiac disease and became increasingly unwell while awaiting assessment for severe mitral regurgitation. He died in hospital after becoming unresponsive and undergoing cardiopulmonary resuscitation; post-mortem examination identified bilateral bronchopneumonia and aspiration of gastric contents, with heart failure contributing to reduced physiological reserves. The concerns included delays and problems in referrals between secondary and tertiary services, information-sharing and transfer of clinical records and images, and delays in cardiology assessment and trans-oesophageal echocardiography due to resource and appointment constraints.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in cardiology clinic assessment due to insufficient clinician or appointment-slot availability
Wider context from the report “2. The evidence also indicated that there were delays in patients who had been identified as requiring cardiology input being seen in cardiology clinics due to availability of clinicians/appointment slots inquest . This was exacerbated where there was a need for trans-oesophageal echocardiogram due to resource issues. The inquest heard that this type of echocardiogram could be key in understanding the cardiac issues of a patient.
” Source location Michael Kevin Amesbury · Prevention of Future Deaths report
Open source report
10 Feb 2023 Celia Sanderson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2
Delays in Emergency Department senior clinician review due to insufficient senior medical staffing View source Delays in Emergency Department clinician review due to patient volume and insufficient staff availability View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS England
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AI-generated summary
Celia Sanderson · 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
Celia Sanderson was involved in a road traffic collision and died at Wythenshawe Hospital after developing severe injuries, neurological damage and an acute myocardial infarction while awaiting transfer to a major trauma centre. The concerns included delays in triage and clinician review, shortages of senior emergency department and radiology staff, delays in CT scanning and reporting, and insufficient recognition of potential “silver trauma” cases in district general hospitals.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in Emergency Department senior clinician review due to insufficient senior medical staffing
Wider context from the report “2. The inquest heard that amongst the challenges faced was a shortage of ED consultants and ED middle grade doctors . Mrs Sanderson’s time at the hospital included late evening and the early hours of the morning. The inquest heard that across the NHS during these hours the number of staff at these grades in an ED is significantly reduced . Historically that had been a quieter period however demands on ED meant that was no longer the case . As a consequence senior reviews of patients were further delayed . An earlier review by a senior clinician was likely to have identified her as a potential silver trauma case and ensured she was moved to a trauma centre for appropriate treatment before she began to deteriorate;
” Source location Celia Sanderson · 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 Delays in Emergency Department clinician review due to patient volume and insufficient staff availability
Wider context from the report “1. Demands on the Emergency Department due to the volume of people waiting to be seen meant that Mrs Sanderson had a long wait for a clinician review far outside the expected target time . The inquest heard evidence that delays such as hers were common throughout that period and were due to the volume of people attending and staff available to deal with them ;
” Source location Celia Sanderson · Prevention of Future Deaths report
Open source 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 NHSE and local integrated care bodies are responsible for addressing the concerns about treatment at Wythenshawe Hospital.
Verbatim wording from the response “Your report raises concerns about the treatment provided at Wythenshawe Hospital, Manchester University NHS Foundation Trust. I understand that NHS England (NHSE) have written to you to address these concerns, including information from Greater Manchester Integrated Care and the Integrated Care Board on the action taken locally. This includes NHS Greater Manchester’s action plan to respond to urgent and emergency care demand pressures, as well as their Major Trauma Network. This network provides care to patients who have sustained major trauma injuries; partners work collaboratively to ensure trauma is recognised and treated appropriately. Learning from the investigation into Ms Sanderson’s death has been used to improve practice across the network.” Source location Response from DHSC
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 Greater Manchester Integrated Care provides the relevant services, while its Integrated Care Board decides commissioned health services.
Verbatim wording from the response “In order to be able to respond to your Report, NHS England has engaged with Greater Manchester Integrated Care (NHS GM) who is the provider of the healthcare services in question, and the Integrated Care Board (ICB) who is responsible for making decisions about commissioned health services across Greater Manchester NHS England’s response to your Report is based on our informed discussions with these two organisations.” Source location Response from NHS England
Open published response
6 Aug 2022 Ernest Bacon · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Insufficient availability of doctors for ward clinical reviews View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care Tameside and Glossop Integrated Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Department of Health and Social Care
Commission NHS England to develop a 15-year NHS workforce plan addressing staffing numbers, skills, supply gaps and retention.
View source
Department of Health and Social Care
Fund 1,500 additional annual medical school places for domestic students in England, completing the expansion in September 2020.
View source
Department of Health and Social Care
Temporarily lift the cap on English medical school places for eligible students with 2020 or 2021 A-Level offers.
View source
Department of Health and Social Care
Publish a workforce plan containing independently verified 10- and 15-year forecasts for doctors, nurses and other professionals.
View source
Tameside and Glossop Integrated Care NHS Foundation Trust
Progress a business case to increase junior-doctor provision and reduce reliance on locum and agency doctors.
View source See 2 more actions
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AI-generated summary
Ernest Bacon · 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
Ernest Thomas Bacon suffered an accidental fall at home, sustained a fractured neck of femur, and was admitted to Tameside General Hospital, where he subsequently had an ischaemic stroke. After triggering for sepsis on 16 January 2022, he was not reviewed face to face, the sepsis pathway was not followed, intravenous antibiotics were delayed, and the failure to escalate was not recognised. He died from sepsis at the hospital on 17 January 2022.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient availability of doctors for ward clinical reviews
Wider context from the report “1. The Inquest heard that when Mr Bacon became unwell on 16th January the Trust was staffed at weekend/OOD doctor numbers . This meant that there were a very limited number of doctors available within the hospital when the ward staff asked for a clinical review when Mr Bacon triggered for sepsis on the NEWS2 system. The Inquest heard that the staffing numbers of doctors and reliance on junior doctors at weekend to cover the wards is part of the national staffing model;
” Source location Ernest Bacon · 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 Commission NHS England to develop a 15-year NHS workforce plan addressing staffing numbers, skills, supply gaps and retention.
Verbatim wording from the response “With regard to concerns regarding the NHS workforce, the Department has commissioned NHS England to develop a long-term plan for the NHS workforce for the next 15 years. This high-level long-term workforce plan will look at the mix and number of staff required across all parts of the country and will set out the actions and reforms that will be needed to reduce supply gaps and improve retention.” Source location Response from Department of Health and Social Care
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 Fund 1,500 additional annual medical school places for domestic students in England, completing the expansion in September 2020.
Verbatim wording from the response “In addition, the Government has funded 1,500 more medical school places each year for domestic students in England, which is a 25% increase over three years. This expansion was completed in September 2020 and has delivered over three new medical schools in England. We have seen the first graduates from this expansion enter foundation training in August 2022. Additionally, the Government temporarily lifted the cap on medical school places for students who completed A-Levels in 2020 and in 2021 and who had an offer from a university in” Source location Response from Department of Health and Social Care
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 Temporarily lift the cap on English medical school places for eligible students with 2020 or 2021 A-Level offers.
Verbatim wording from the response “In addition, the Government has funded 1,500 more medical school places each year for domestic students in England, which is a 25% increase over three years. This expansion was completed in September 2020 and has delivered over three new medical schools in England. We have seen the first graduates from this expansion enter foundation training in August 2022. Additionally, the Government temporarily lifted the cap on medical school places for students who completed A-Levels in 2020 and in 2021 and who had an offer from a university in” Source location Response from Department of Health and Social Care
Open published response
×
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 Publish a workforce plan containing independently verified 10- and 15-year forecasts for doctors, nurses and other professionals.
Verbatim wording from the response “Finally, the Government has committed to publishing the workforce plan next year and this will include independently verified forecasts for the number of doctors, nurses and other professionals that will be needed in future, for 10- and 15-years’ time, taking full account of improvements in retention and productivity. This plan will help ensure that we have the right numbers of staff, with the right skills to transform and deliver high quality services fit for the future.” Source location Response from Department of Health and Social Care
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 Progress a business case to increase junior-doctor provision and reduce reliance on locum and agency doctors.
Verbatim wording from the response “Whilst the Trust does acknowledge that the junior doctor rota meets national guidance it does need to be strengthened further to support increased activity and acuity in the ward areas. The Trust is currently progressing a business case to increase the level of junior doctor provision which also aims to reduce reliance on locum and agency doctors.” Source location Response from Tameside and Glossop Integrated Care
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 Overnight junior doctor cover exceeded Royal College of Physicians national guidance when the deterioration occurred.
Verbatim wording from the response “On Sunday night 16th / 17th January 2022, the night when Mr. Bacon’s condition sadly deteriorated, the level of junior doctor cover for the medical wards overnight exceeded that set out in national guidance by the Royal College of Physicians (2018). The actual number of doctors on call at that time were three Tier 1 doctors and one Tier 2 doctor covering non-covid medical beds. At the time that Mr. Bacon died the Trust were experiencing a significant increase in clinical activity as they were responding to the Omicron Covid wave.” Source location Response from Tameside and Glossop Integrated Care
Open published response
4 Aug 2022 Margaret Ena Warwick · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Insufficient cardiology capacity and out-of-hours cover for timely assessment 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
Margaret Ena Warwick · 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
Margaret Ena Warwick, who had significant ischaemic heart disease and left ventricular dysfunction, suffered an accidental fall at home on 23 February 2022 and was taken to hospital with a fractured neck of femur requiring surgery. Her pre-operative cardiac review, surgery and access to a high-dependency unit bed were delayed by shortages of cardiology cover, theatre capacity and HDU beds. She initially recovered after surgery but deteriorated and died in hospital on 7 March 2022.
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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 Insufficient cardiology capacity and out-of-hours cover for timely assessment
Wider context from the report “1. The Inquest heard that under the NICE guidance where a patient needs an operation for a hip fracture such as in Mrs Warwick’s case and needs optimising, that optimisation should be dealt with expeditiously. In Mrs Warwick’s case she needed cardiology assessment. That delay was due in part to a shortage of cardiologists at the trust exacerbated in particular by a lack of cover by cardiologists over weekends and OOH. The Inquest heard that there was no facility for a patient such as Mrs Warwick to be assessed by cardiology over the weekend ;
” Source location Margaret Ena Warwick · Prevention of Future Deaths report
Open source report
1 Jul 2022 Dominic Robert Noble · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Insufficient availability of psychiatric doctor provision for the mentally unwell prison population View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Dominic Robert Noble · 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
Dominic Robert Noble was remanded to HMP Leeds on terrorist charges and died there on 15 August 2020 as a result of suicide. He had been identified as requiring psychiatric assessment, but remained on a waiting list without an appointment. Concerns included the adequacy of psychiatric provision at HMP Leeds, delays in accessing psychiatric assessment, and the possibility that limited resources discouraged 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 Insufficient availability of psychiatric doctor provision for the mentally unwell prison population
Wider context from the report “(1) Evidence was taken at the inquest that:
(i) HMP Leeds has only 3 days per week of a psychiatrist's time available
(ii) HMP Leeds has some 5000 prisoners arriving each year.
(iii) A large proportion of the prisoners arriving have mental health issues
(iv) The mental health team is mainly a nurse-led service
(v) The division of labour between mental health nurses and psychiatrists is that a doctor is responsible for the diagnosis of mental illness, prescribing medication such as anti-psychic drugs and seeing prisoners/patients with severe or complex conditions. Mental health nurses make initial assessments and provide ongoing care.
(vi) Concern was expressed about the adequacy of the psychiatric doctor provision to provide psychiatric treatment for a large population which includes men with significant mental health issues.
(vii) Mr Noble was deemed to require assessment by a psychiatrist on 14 July 2020 as a non-urgent case but at the time of his death on 15 August 2020 no appointment had been given.
(viii) A mental health nurse working on behalf of PPG on 10 July 2020 identified the “possibility of emerging psychotic features” and noted the sentiment that engaging in treatment as soon as possible mitigated in favour of a better outcome. Where such a suspicion was raised it would have been advantageous to obtain a second opinion from a psychiatrist swiftly (particularly after his mother contacted the prison to report his paranoid and bizarre conversation regarding a gun, a secret room in the prison and some unknown person trying to kill him.)
” Source location Dominic Robert Noble · 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 Approach NHS England and discuss seeking additional psychology and psychiatry resource for HMP Leeds.
Verbatim wording from the response “Intended Changes
Following the Learned Coroner’s comments during the inquest into the death of Mr Afzal, ████████, Practice Plus Group’s Regional Director North – Health in Justice, began discussions with Commissioners at NHS England. Whilst Practice Plus Group maintains that the level of psychiatry provision is at least equivalent to that offered in the community, we also recognise that there are significant levels of mental health morbidity in prisons, particularly in a local remand setting such as HMP Leeds. The Learned Coroner’s comments and subsequent report have highlighted a potential need and we have therefore approached our Commissioners for additional resource.” Source location 2022-0204 - Response from Practice Plus Group
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 Submit a business case to Commissioners for increased psychology and psychiatry provision at HMP Leeds.
Verbatim wording from the response “████████ has discussed with NHS England the submission of a business case for greater psychology and psychiatry provision at HMP Leeds. NHS England, are in principle supportive of increasing the commission of psychology and psychiatry provision at HMP Leeds, but have asked for a West Yorkshire wide mental health service review to be undertaken before any additional investment is made. As budget decisions and funding is the remit of the Commissioners, it is within their gift to request such reviews before business cases are submitted. The review will start once the Regional Mental Health Lead has returned from annual leave. It is anticipated that this will take 2 weeks to carry out with the intention being that a business case is submitted to the Commissioners by the end of September.” Source location 2022-0204 - Response from Practice Plus Group
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 Existing stepped-care provision and multidisciplinary referral arrangements are considered sufficient to meet patients’ psychiatric needs at current levels.
Verbatim wording from the response “As in the community, Practice Plus Group delivers a stepped care model, which focuses on providing the most appropriate care for the concerns a patient may have. By adopting this model most people with mental health problems do not need to see a consultant psychiatrist. The stepped care model of mental health focuses on providing people with the right level of support from the right clinician at the right time. For example, people experiencing mild to moderate depression and anxiety would see a primary care mental health clinician in the community, alongside the GP, which is step 2/3.” Source location 2022-0204 - Response from Practice Plus Group
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 NHS England, as commissioner, is responsible for deciding whether additional psychology and psychiatry resources will be funded.
Verbatim wording from the response “████████ has discussed with NHS England the submission of a business case for greater psychology and psychiatry provision at HMP Leeds. NHS England, are in principle supportive of increasing the commission of psychology and psychiatry provision at HMP Leeds, but have asked for a West Yorkshire wide mental health service review to be undertaken before any additional investment is made. As budget decisions and funding is the remit of the Commissioners, it is within their gift to request such reviews before business cases are submitted. The review will start once the Regional Mental Health Lead has returned from annual leave. It is anticipated that this will take 2 weeks to carry out with the intention being that a business case is submitted to the Commissioners by the end of September.” Source location 2022-0204 - Response from Practice Plus Group
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 Even if additional funding is approved, recruitment difficulties may prevent immediate increases in psychiatric provision.
Verbatim wording from the response “HMP Leeds is a high demand remand site and we are seeking additional resource with the aim to improve the number of clinical sessions from 6 to 8 per week. In effect this means that HMP Leeds will need the equivalent of a half-time psychiatrist in addition to what is currently in place in order to achieve the additional clinical sessions. This is due to the non-patient facing time that all directly employed consultant psychiatrists working for Mental Health Trusts have in their contract. These activities include clinical administration tasks (e.g. letters and referrals), service development and training/development.” Source location 2022-0204 - Response from Practice Plus Group
Open published response
16 Jun 2022 James Joseph MANNING · Prevention of Future Deaths report West Sussex
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Concerns raised 1
Delays in reassessment and referral of urgent cases due to inadequate cover View source
This report raised 13 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
James Joseph MANNING · 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
James Joseph Manning, aged two, choked on a piece of sausage at Butlins, Bognor Regis, on 6 June 2018, suffered a cardiac arrest and hypoxic ischaemic brain injury, and died in hospital on 20 June 2018. The concerns included delays and weaknesses in healthcare referral, follow-up and information-sharing systems, and shortcomings in the management of health and safety, incident reporting, first-aid provision and emergency procedures at Bourne Leisure sites.
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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 reassessment and referral of urgent cases due to inadequate cover
Wider context from the report “c) I heard evidence that at some points in James’s medical care there were delays in being reassessed especially following the sleep study . The delay in being reassessed and referred to tertiary care was contributed to by medical staff being off leave. Doctors will inevitably have leave yet I am still concerned that systems in place at that time were not sufficiently robust to ensure suitable cover was in place to progress urgent cases .
” Source location James Joseph MANNING · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.