Recurring concern

Failure to ensure essential clinical equipment and supplies are available and serviceable

Pin Get email alerts Request correction

First reported 30 Aug 2013•Latest report 8 May 2026

Definition

What this concern includes

Includes availability, stock, checking, maintenance or servicing failures that leave essential clinical equipment or supplies unavailable or unfit for use.

Not included

  • Excludes non-clinical equipment and vehicle, environmental, or recreational-equipment checks.
  • Excludes failures concerning the operation or use of equipment during care when no equipment-readiness or serviceability check is implicated.
  • Excludes generic staffing, training, documentation, audit, or supervision deficiencies unless they are specifically tied to the reliability of daily clinical-equipment serviceability checks.
  • Excludes checks of patient condition, care processes, messages, or other non-equipment objects.
Reports
41

Distinct published reports

Individual concerns
46

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
43

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England6
Department of Health and Social Care4
Care Quality Commission3
East Kent Hospitals University NHS Foundation Trust2
General Pharmaceutical Council2
Greater Manchester Health and Social Care Partnership2
Royal College of Physicians2
Association Of Anaesthetists (Great Britain & Ireland)1
Avenue House Nursing and Care Home1
Ayuntamiento de La Oliva1
Barking, Havering and Redbridge University Hospitals NHS Trust1
Barts Health NHS Trust1
Blackpool Teaching Hospitals NHS Foundation Trust1
Brunswick Ward at Lindridge1
Care UK1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. West London

    AI-generated summary

    Jake Daniel Taylor · 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

    Jake Daniel Taylor, aged 19, suffered a cardiac arrest at his care home on 16 January 2025 and died in Kingston hospital on 20 January 2025. The report identified delays in first aid and concerns about the lack of individual emergency planning, staff training, immediately available equipment, and airway training and equipment.

    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

    Lack of airway equipment

    Wider context from the report

    “No planning for this foreseeable emergency. Inadequate staff training (to always conduct CPR if no decision to the contrary) No defibrillator on site and staff misunderstanding of the function of a defibrillator. No airway training and equipment although Registered Nursing staff have this within their competencies. I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do. This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate. ”

    Source location

    Jake Daniel Taylor · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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

    Obtain provider assurance on emergency preparedness, equipment availability and staff training.

    Verbatim wording from the response

    “Following Jake’s tragic death and receipt of your report, the ICB took immediate action, including obtaining comprehensive assurance from the provider regarding emergency preparedness arrangements, the availability of emergency equipment, and staff training. A summary of the assurance received from the provider is set out in Section A of Appendix 1.”

    Source location

    Response from NHS South West London ICB
    Page 1 · response
    Published 2 July 2026

    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

    Require providers to review airway needs, maintain appropriate nursing competencies, and provide airway equipment and training where clinically indicated.

    Verbatim wording from the response

    “d. Airway Management Training and Equipment All commissioned providers to:”

    Source location

    Response from NHS South West London ICB
    Page 3 · response
    Published 2 July 2026

    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 and finalise individualised first aid support plans for people supported at Roy Kinnear House, including emergency interventions, equipment and staff training.

    Verbatim wording from the response

    “All people currently supported at (5 people) Roy Kinnear House will now have a clearly documented first aid support plan. The steps to fulfil this are as follows: - Draft plans to be developed through multidisciplinary team involvement and best interests decision-making. As the support provider we will liaise with medical professionals who are best placed to make decisions around the type of support and equipment people will need in emergency interventions. - Detail the level of support and interventions required during medical emergencies - Detail the type of equipment needed, which may include airway equipment - Staff will have relevant training on the first aid support plan and on the necessary equipment. - Final plans to be uploaded onto each person’s profile”

    Source location

    Response from Choice Support
    Page 2 · response
    Published 2 July 2026

    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

    Airway equipment is provided only where clinically indicated, prescribed and documented in an individual's care plan.

    Verbatim wording from the response

    “We note the concern regarding airway management and equipment. In this service model, clinical equipment such as oxygen therapy and suctioning is provided where clinically indicated, prescribed and documented within an individual’s care plan. The nursing team is supported to undertake clinical observations, including monitoring of blood pressure, oxygen saturation and temperature, to identify deterioration and escalate appropriately. Where a person requires additional medical equipment as part of a planned emergency response, this will be agreed through multidisciplinary team discussion and appropriate equipment and training will be put in place to ensure staff have the skills and confidence to deliver care safely and effectively.”

    Source location

    Response from Choice Support
    Page 3 · response
    Published 2 July 2026

    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

    Health professionals determine appropriate emergency interventions and the training required to deliver them for each individual.

    Verbatim wording from the response

    “the training, staff are introduced to possible equipment, including airway supports. The use of such equipment will then be based on the needs of the person supported, their health needs and in best interests discussions with the family and health professionals. The health professionals will guide on the most appropriate interventions for each individual and training requirements to support their use.”

    Source location

    Response from Choice Support
    Page 3 · response
    Published 2 July 2026

    Open published response
  2. Essex

    AI-generated summary

    Paolino AMICO · 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

    Paolino Amico, who had metastatic bladder cancer and advanced clinical frailty, was admitted with severe bilateral pneumonia and died in hospital on 12 June 2024. He received multiple overdoses of slow-release morphine following a prescription error, with concerns also raised about medication administration, delayed emergency escalation, oxygen provision after discharge, and the management of morphine reversal and pain relief.

    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

    Out-of-date PAT testing for oxygen equipment

    Wider context from the report

    “(1) The consultant required a discharge plan for oxygen therapy to be in place before Mr Amico could go home. The hospital discharge plan and medications were confusing and the referral for oxygen therapy requirement was unclear, and the PAT testing for the machine was out of date. Paramedics advised the family that the oxygen provided on Mr Amico’s discharge was low flow and was not meeting his oxygen requirements with his oxygen saturations at 68% and this immediately improved on ambulance crew equipment. ”

    Source location

    Paolino AMICO · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.

    Verbatim wording from the response

    “The Princess Alexandra Hospital NHS Trust will be providing their own response to this Report, however, the Hertfordshire & West Essex ICB have advised NHS England of the Trust’s governance arrangements and actions being taken to address the concerns raised. It is understood that the Trust’s Patient Safety Group (PSG) has active oversight of several of the areas highlighted in the Report, particularly medicines safety, recognition of deterioration, and incident learning.”

    Source location

    Response from NHS England
    Page 4 · response
    Published 19 November 2025

    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

    The oxygen concentrators did not require portable appliance testing because there was no legal requirement for supplier testing.

    Verbatim wording from the response

    “Portable Appliance Testing (PAT) is a process used to ensure the safety of electrical appliances and equipment. The head of patient services at BOC has informed our operations team that they do not PAT test concentrators as there is no legal requirement for them to be PAT tested.”

    Source location

    Response from Princess Alexandra Hospital
    Page 2 · response
    Published 19 November 2025

    Open published response
  3. East Sussex

    AI-generated summary

    Jamie Stuart Funnell · 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

    Jamie Stuart Funnell died at HMP Lewes on 16 December 2023 while withdrawing from alcohol and drugs. The inquest concluded that his death was due to the effects of drug and alcohol withdrawal, exacerbated by omissions by healthcare and prison staff. Concerns included failures in withdrawal assessment and monitoring, communication, CPR response, staff training, equipment maintenance, and updating relevant procedures.

    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

    Failure to monitor life support equipment for faults

    Wider context from the report

    “2. I heard evidence describing the care given to Jamie Funnell after his collapse as chaotic, with faulty equipment and incorrect CPR technique. The Ambulance crews witnessed the healthcare members carrying out CPR before taking over. After Jamie’s death was confirmed, a crew member raised concerns with the Duty Governor about the CPR attempts she had witnessed. I have heard evidence that although 32 eligible healthcare staff have now completed life support training, I have not heard any evidence regarding the level of this training and remain concerned, especially in light of the unsatisfactory response by PPG in its Action Plan for the PFO Report dated September 2024 that adequate training of staff and monitoring of equipment to prevent faults in its operation have been undertaken to prevent a fatality occurring in similar circumstances. ”

    Source location

    Jamie Stuart Funnell · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 fortnightly emergency-bag checks, daily seal checks, monthly audits and bimonthly dip tests to verify equipment readiness and drug validity.

    Verbatim wording from the response

    “Emergency bag equipment is checked every 2 weeks by the team to ensure that they contain the correct equipment, that the equipment works and that emergency drugs are in date. After each check, the bags are resealed and the seals are checked daily on site to ensure they remain intact. The emergency bag check process is audited monthly as per the Practice Plus Group annual audit schedule and in line with the Emergency Response Policy for Healthcare Professionals within Health in Justice sites (ratified January 2024 and due for review March 2026). In addition to the regular bag checks, we have also implemented bimonthly dip tests of the emergency response bags to provide further reassurance.”

    Source location

    Response from Practice Plus Group
    Page 5 · response
    Published 14 October 2025

    Open published response
  4. East London

    AI-generated summary

    Mrs Norma Faye Campbell · 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 Norma Faye Campbell attended Whipps Cross Hospital emergency department on 13 January 2024 with clear signs of sepsis and died there in the early hours of 14 January 2024 after suffering a cardiac arrest. The report identifies delays and omissions in sepsis treatment, monitoring, fluid resuscitation and escalation of care. It also raises concerns about overcrowding, inadequate staffing and facilities, insufficient resuscitation beds, lack of electronic observations and the absence of Critical Care Outreach Team support in the emergency department.

    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

    Lack of monitoring equipment in the majors area of A&E

    Wider context from the report

    “3. There are often insufficient numbers of resuscitation beds. Patients who require a resuscitation area level of care are often directed to the majors area of A&E. The majors area lacks the levels of staffing and lacks the monitoring equipment required to treat this cohort of patients. In the absence of increased numbers of resuscitation beds, a system for continuous monitoring of observations in majors would significantly improve patient care. ”

    Source location

    Mrs Norma Faye Campbell · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 electronic observations and Early Warning Score visibility across Emergency Department clinical areas using the upgraded patient record and observation machines.

    Verbatim wording from the response

    “In 2024 the Trust upgraded the electronic patient record in the Emergency Department to the “Launchpoint” system provided by Oracle and purchased in May 2024 an additional 49 observations machines that directly relay clinical observations to the electronic patient record.”

    Source location

    Response from Barts Health NHS Foundation Trust
    Page 4 · response
    Published 26 June 2025

    Open published response
  5. Surrey

    AI-generated summary

    Pamela Anne Marking · 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

    Pamela Anne Marking was admitted with abdominal symptoms, was diagnosed with a nosebleed by a Physician Associate and discharged without medical review or direct medical supervision. She later returned with small bowel obstruction caused by an incarcerated femoral hernia and aspirated feculent fluid during induction of anaesthesia for emergency surgery, subsequently dying from respiratory failure and sepsis. The concerns included the Physician Associate’s role, supervision and scope of practice, and the absence of updated guidance for rapid sequence induction, TIVA and airway protection.

    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

    Unavailability of promptly accessible suction for aspiration during rapid sequence induction

    Wider context from the report

    “8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic Evidence was heard that cricoid pressure was ineffective it was not routinely applied for a RSI intubation. After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved. ”

    Source location

    Pamela Anne Marking · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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

    Communicate and reinforce the use of cricoid pressure for rapid sequence induction in bowel obstruction through meetings, induction training, and simulation training.

    Verbatim wording from the response

    “The use of cricoid pressure during RSI is not universal in all situations as it can make intubation more difficult and is listed as an optional measure by the Difficult Airway Society. However, the Trust accepts that in the setting of bowel obstruction, with the increased risk of aspiration, cricoid pressure should have been used. This has been communicated across the whole anaesthetic team at a departmental meeting and in the Mortality & Morbidity meeting. All anaesthetic trainees at their departmental induction are instructed to use cricoid pressure and this is reiterated in regular simulation training.”

    Source location

    Response from Surrey and Sussex NHS
    Page 4 · response
    Published 26 February 2025

    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

    The College will not comment on the provision of general anaesthesia in operating theatres.

    Verbatim wording from the response

    “RCEM does not feel it would be appropriate to comment on matters related to the provision of general anaesthesia in the operating theatre.”

    Source location

    Response from RCEM
    Page 2 · response
    Published 26 February 2025

    Open published response
  6. Inner North London

    AI-generated summary

    Sheila Josephine WEXLER · 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

    Sheila Wexler lived with dementia and other significant comorbidities and died at home on 17 February 2024 from bilateral pulmonary embolism. Delays in supplying equipment and the provision of defective turning equipment significantly increased her immobility, contributing to her death. The report identified ongoing concerns about delays and defective equipment supplied by NRS Healthcare, including wider risks affecting other patients.

    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

    Failure to provide and replace medical equipment with correct, functional equipment

    Wider context from the report

    “NRS Healthcare related matters: I heard evidence of a delay in delivering some of the required equipment, which in turn meant a delay in the patient being able to make use of the equipment. The delay meant that the patient’s family, carers, and the district nursing team underwent a period of time in which they were unable to provide the patient with the optimal care required in relation to the pressure ulcer. When the TOTO turning system arrived it was defective. An urgent repair/replace request was made to NRS Healthcare, which resulted in an engineer attending the patient’s home to replace the pump on 23 January 2024. However, despite advising that they had replaced the pump with a like-for-like pump, it transpired that the replacement pump was a ‘Tri-Pos Bariatric Alternating Air Cushion’ pump. This replacement pump had none of the settings that would allow the proper and effective use of the TOTO system. In this instance, the TOTO system was required to turn the patient from one side to the other every 60 minutes. I was told in evidence that equipment issues would have added to the patients ‘pain and distress’ and the fitting of the incorrect pump meant that the patient was not being turned every 60 minutes, as required. Again, this creates the risk that those caring for the patient were precluded from providing an optimal level of care. While the presence of a pressure ulcer, in itself, did not add to the underlying risk of the patient developing a pulmonary embolism, the delayed and defective equipment provided significantly increased the patient’s immobility in the weeks prior to her death. There was evidence that immobility is a major risk factor in the development of pulmonary emboli. I heard evidence that issues with delays and defective equipment from NRS Healthcare persist to date. NRS Healthcare and NHS England related matters: I heard evidence that since being awarded the contract to provide such equipment, there had been numerous and ongoing delays and ‘problems’ in the service provided by NRS Healthcare. The evidence was such that the repeated issues and concerns had actually been placed on the Trust/Integrated Care Board’s (ICBs) risk register. While I heard that there had been some improvement, I was told that the service provided was still ‘not great’. While this particular case is the first in which I have formed the opinion that delayed and defective equipment has created a risk of future deaths, I have heard similar evidence of delayed and defective equipment issues relating to NRS Healthcare in other inquests concerning different NHS Trusts and ICBs. On that basis, I am also of the opinion, given NRS Healthcare’s operations are not confined to organisations within this coroner area, that the risks posed are likely to be more widespread and that action should be taken more widely. ”

    Source location

    Sheila Josephine WEXLER · Prevention of Future Deaths report
    Page 3 · concerns

    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 delivering required medical equipment

    Wider context from the report

    “NRS Healthcare related matters: I heard evidence of a delay in delivering some of the required equipment, which in turn meant a delay in the patient being able to make use of the equipment. The delay meant that the patient’s family, carers, and the district nursing team underwent a period of time in which they were unable to provide the patient with the optimal care required in relation to the pressure ulcer. When the TOTO turning system arrived it was defective. An urgent repair/replace request was made to NRS Healthcare, which resulted in an engineer attending the patient’s home to replace the pump on 23 January 2024. However, despite advising that they had replaced the pump with a like-for-like pump, it transpired that the replacement pump was a ‘Tri-Pos Bariatric Alternating Air Cushion’ pump. This replacement pump had none of the settings that would allow the proper and effective use of the TOTO system. In this instance, the TOTO system was required to turn the patient from one side to the other every 60 minutes. I was told in evidence that equipment issues would have added to the patients ‘pain and distress’ and the fitting of the incorrect pump meant that the patient was not being turned every 60 minutes, as required. Again, this creates the risk that those caring for the patient were precluded from providing an optimal level of care. While the presence of a pressure ulcer, in itself, did not add to the underlying risk of the patient developing a pulmonary embolism, the delayed and defective equipment provided significantly increased the patient’s immobility in the weeks prior to her death. There was evidence that immobility is a major risk factor in the development of pulmonary emboli. I heard evidence that issues with delays and defective equipment from NRS Healthcare persist to date. NRS Healthcare and NHS England related matters: I heard evidence that since being awarded the contract to provide such equipment, there had been numerous and ongoing delays and ‘problems’ in the service provided by NRS Healthcare. The evidence was such that the repeated issues and concerns had actually been placed on the Trust/Integrated Care Board’s (ICBs) risk register. While I heard that there had been some improvement, I was told that the service provided was still ‘not great’. While this particular case is the first in which I have formed the opinion that delayed and defective equipment has created a risk of future deaths, I have heard similar evidence of delayed and defective equipment issues relating to NRS Healthcare in other inquests concerning different NHS Trusts and ICBs. On that basis, I am also of the opinion, given NRS Healthcare’s operations are not confined to organisations within this coroner area, that the risks posed are likely to be more widespread and that action should be taken more widely. ”

    Source location

    Sheila Josephine WEXLER · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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

    Improve the product ordering system to clarify which equipment is in place.

    Verbatim wording from the response

    “NRS took over the contract to supply 21 London Boroughs with healthcare equipment in April 2023. Since taking over the contract NRS has taken significant steps to evolve and improve the quality of customer services and equipment provided to service users.”

    Source location

    Response from NRS Healthcare
    Page 4 · response
    Published 16 January 2025

    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

    Improve communications with hospital discharge teams.

    Verbatim wording from the response

    “NRS took over the contract to supply 21 London Boroughs with healthcare equipment in April 2023. Since taking over the contract NRS has taken significant steps to evolve and improve the quality of customer services and equipment provided to service users.”

    Source location

    Response from NRS Healthcare
    Page 4 · response
    Published 16 January 2025

    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

    Conduct weekly oversight meetings with commissioners and key partners to identify equipment-access concerns, review performance indicators, and monitor improvement.

    Verbatim wording from the response

    “To review, address and monitor these issues, weekly oversight meetings were initiated with members of the London regional team, the commissioners of the equipment contract (Royal Borough of Kensington and Chelsea/Westminster City Council) and key partners, to identify areas of concern, review core key performance indicators and monitor improvement trajectories.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 16 January 2025

    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

    Continue regional meetings with equipment commissioners and key partners to oversee performance indicators and support consortium members and associated providers.

    Verbatim wording from the response

    “• NHS England’s London regional team continue to meet with the equipment commissioners and key partners to oversee and monitor key performance indicators, to support consortium members and associated providers.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 16 January 2025

    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

    Responsibility for installing the Tri-Pos pump is not accepted because it was unavailable through the approved catalogue and technician access.

    Verbatim wording from the response

    “This pump is not one which is supplied by NRS. It is not available on the equipment catalogue and therefore not possible for it to either be ordered by a prescriber or supplied to a service user by a Community Equipment Technician. An online search shows that this pump is publicly available as a rental product.”

    Source location

    Response from NRS Healthcare
    Page 3 · response
    Published 16 January 2025

    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

    Responsibility for the equipment contract and its oversight rests with the London Community Equipment Consortium and local authorities, not NHS England.

    Verbatim wording from the response

    “NRS Healthcare are listed on the NHS Supply Chain Framework for Aids for Daily Living, for the supply of basic living aids with no service or maintenance provision included in the Framework. The Framework does not include the provision of the lateral turning system. The contract for services described in your Report has not been contracted through NHS England’s NHS Supply Chain team and our national Framework, but through the London Community Equipment Consortium, a consortium of 21 London boroughs/local authorities (LAs), in a contract awarded by the Cabinet Member for Adult Social Care, Public Health and the Voluntary Sector running from 1 April 2023 to 31 March 2028. The Coroner may therefore wish to refer your concerns to the Department of Health and Social Care (DHSC) or the London Consortium.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 16 January 2025

    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

    The alleged initial equipment-delivery delay is not accepted because the equipment was delivered within the applicable service-agreement timescale.

    Verbatim wording from the response

    “The PFD report suggests an initial delay in the delivery of equipment. This is not accepted by NRS. Its records show a next day order was received on 10 January 2024 at 17.17. The order was for a Dynamic Mattress, a TOTO turning system (“TOTO”) and side bumpers. The cut off for next day orders is 17:00 and therefore the ‘next day’ for an order placed at 17:17 on 10 January is 12 January. The delivery of the Dynamic Mattress and TOTO was made on 12 January. The bumpers could not be installed as side rails had not been ordered by the prescriber for the bed. The order for bumpers was cancelled. On 12 January a same day order was received from the prescriber for side rails and these were delivered that day.”

    Source location

    Response from NRS Healthcare
    Page 2 · response
    Published 16 January 2025

    Open published response
  7. West Sussex, Brighton and Hove

    AI-generated summary

    June LIDDELL · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    June Liddell underwent cardiac surgery involving a heart-lung bypass machine on 21 March 2023. The machine’s automated electronic remote clamp malfunctioned and unexpectedly stopped the circulation of oxygenated blood, causing a hypoxic brain injury; she died on 1 April 2023. Concerns included an error message and loss of clamp-control icons not being adequately explained in the instructions, and maintenance not identifying wear and tear in the clamp.

    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

    Maintenance failing to identify ERC wear and tear

    Wider context from the report

    “I heard that the error message “Arterial clamp is defective” is not one which is included in the Instructions for Use for the SP5 or ERC machine whilst others are explained. As such this message was not one which the Perfusionist community were aware of prior to this incident. The SP5 and ERC instructions for Use documentation does not specify that the disappearance of the icons for the control of the ERC is indicative of a defect with the ERC. The evidence was that this alarm functions in an entirely different way to other alarms on the SP5 system and this was not within the knowledge of any of the Perfusion witnesses that the Court heard from. The Manufacturers maintenance of the machine does not include a process to identify when an ERC is experiencing wear and tear which may indicate that action should be taken. ”

    Source location

    June LIDDELL · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Investigate the reported heart-lung machine safety concerns and determine appropriate follow-up action.

    Verbatim wording from the response

    “Thank you for notification of the Regulation 28 Report to Prevent Future Deaths concerning the investigation into the death of June Liddell. The coroner’s concerns relating to the LivaNova S5 heart lung machine were noted and an MHRA investigation was commenced to evaluate these concerns.”

    Source location

    Response from MHRA
    Page 1 · response
    Published 16 January 2025

    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

    Standard ERC clamp maintenance is sufficient; its closed design and very low failure rate do not warrant a specific wear-and-tear inspection schedule.

    Verbatim wording from the response

    “The IFU for the ERC is clear that "Liquids must not enter the housing. Therefore, do not use sprays" and further states "Ensure again that no liquids enter the housing".⁷ In this specific case the device functionality was impacted by infiltration of liquids during the 12 years of previous ERC clamp use. Such liquid infiltration is not addressable by standard maintenance because the ERC clamp is a closed unit intended to operate for its expected service lifetime. The observed failure rate of the ERC clamp (being 155 in 6.8 million = 0.0023%) is such that a properly maintained ERC clamp in accordance with the IFU does not warrant a specific maintenance schedule to identify instances of wear and tear caused by a failure to follow the IFU in relation to cleaning and disinfection. Even in the incredibly rare instance of an ERC clamp failure, the device is safe.”

    Source location

    Response from LivaNova
    Page 3 · response
    Published 16 January 2025

    Open published response
  8. Staffordshire and Stoke-on-Trent

    AI-generated summary

    Eleanor Curley-Bennett · 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

    Eleanor Curley-Bennett, aged three weeks, stopped breathing at a family-friendly music festival on 18 August 2023 and died at hospital in the early hours of 19 August 2023. The report identified a lack of correctly sized basic life-support equipment, intubation equipment, and suitable prefilled diluted adrenaline for a baby of her age.

    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

    Lack of availability of required equipment

    Wider context from the report

    “1. The lack of availability of the equipment and adrenaline described above ”

    Source location

    Eleanor Curley-Bennett · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Require and assess additional supporting information and policies during registration, including applicants’ commitment to providing equipment meeting intended service users’ needs.

    Verbatim wording from the response

    “We can confirm that since Festimed Ltd was registered with CQC in 2014 our registration processes have been reviewed, with more supporting information and policies now assessed at the time of registration. This will assess potential providers commitment to providing equipment to meet the needs of all people they intend to provide a service to.”

    Source location

    Response from CQC regarding Festimed
    Page 3 · response
    Published 27 December 2024

    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

    Care and treatment provided at event sites falls outside regulatory functions until new regulations take effect.

    Verbatim wording from the response

    “We understand that Festimed Ltd provided care and treatment to Eleanor Curley-Bennett both at the festival event site and in their ambulance during conveyance to Telford Hospital. CQC’s regulatory powers do not include care and treatment provided at event work. We do not regulate services, including ambulance providers, who provide a service at events. This meant the care and treatment given by Festimed Ltd to Eleanor at the festival site was not regulated by CQC. CQC can only regulate the service once the ambulance leaves the event (festival site). We are unable to comment on this aspect due to it being outside of our regulatory remit/scope and note that Festimed was the original Respondent who would have been in a better position to respond to the concerns whilst on site.”

    Source location

    Response from CQC regarding Festimed
    Page 2 · response
    Published 27 December 2024

    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

    Festimed Ltd, as the original respondent, was better placed to respond to concerns about care provided at the event site.

    Verbatim wording from the response

    “We understand that Festimed Ltd provided care and treatment to Eleanor Curley-Bennett both at the festival event site and in their ambulance during conveyance to Telford Hospital. CQC’s regulatory powers do not include care and treatment provided at event work. We do not regulate services, including ambulance providers, who provide a service at events. This meant the care and treatment given by Festimed Ltd to Eleanor at the festival site was not regulated by CQC. CQC can only regulate the service once the ambulance leaves the event (festival site). We are unable to comment on this aspect due to it being outside of our regulatory remit/scope and note that Festimed was the original Respondent who would have been in a better position to respond to the concerns whilst on site.”

    Source location

    Response from CQC regarding Festimed
    Page 2 · response
    Published 27 December 2024

    Open published response
  9. East London

    AI-generated summary

    Hannah Enola Ayamo Jacobs · 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

    Hannah Enola Ayamo Jacobs, aged 13, developed anaphylactic symptoms after being served a dairy hot chocolate despite her reported dairy allergy and later died following cardiac arrest. The concerns included dental staff not recognising excessive salivation as inability to swallow and a sign of anaphylaxis, possible misunderstanding of symptoms by her mother, and the availability and use of adrenaline auto-injectors during shortages.

    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

    Unavailability of AAI stock in chemists for emergencies

    Wider context from the report

    “• I was made aware there had been a shortage of AAI at the time but a vial of adrenaline was available at the chemist. However, it takes time to draw up. I am not sure if (assuming no national shortage) all chemists have AAI in stock for emergencies. ”

    Source location

    Hannah Enola Ayamo Jacobs · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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 use and supply of adrenaline auto-injectors.

    Verbatim wording from the response

    “The Pharmacy and Medicines Optimisation Team have been reviewing the use of AAIs and their supply. The detail of this work is still being finalised but my regional colleagues in London have been asked to ensure the national team are provided with updates on this work.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 30 August 2024

    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

    Provide national colleagues with updates on the regional review of adrenaline auto-injector use and supply.

    Verbatim wording from the response

    “The Pharmacy and Medicines Optimisation Team have been reviewing the use of AAIs and their supply. The detail of this work is still being finalised but my regional colleagues in London have been asked to ensure the national team are provided with updates on this work.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 30 August 2024

    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

    The availability of adrenaline auto-injectors in pharmacies for emergencies cannot be commented on.

    Verbatim wording from the response

    “Concern 4 “I was made aware there had been a shortage of AAI at the time, but a vial of adrenaline was available at the chemist. However, it takes time to draw up. I am not sure if (assuming no national shortage) all chemists have AAI in stock for emergencies.””

    Source location

    Response from BSACI
    Page 2 · response
    Published 30 August 2024

    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

    Manufacturing medicines and addressing wider adrenaline autoinjector supply and shortage issues fall outside the regulatory role.

    Verbatim wording from the response

    “We are aware of ongoing and intermittent supply issues with adrenaline autoinjectors (AAIs) which have been lasting for several years. While we do not have a direct role in the manufacturing of medicines or wider issues such as supply and shortages, we understand that medicines shortages can cause problems for patients, carers and those supporting people living with life-threatening allergies requiring adrenaline.”

    Source location

    Response from General Pharmaceutical Council
    Page 1 · response
    Published 30 August 2024

    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

    The Department of Health and Social Care, manufacturers and wholesalers are best placed to answer specific medicine availability enquiries.

    Verbatim wording from the response

    “Specific enquiries about the availability of particular medicines, can be directed to the medicines supply team at the Department of Health and Social Care (DHSC) on ████████. Alongside manufacturers and wholesalers, they would be best placed to help answer any questions you may have regarding the availability of medicines.”

    Source location

    Response from General Pharmaceutical Council
    Page 2 · response
    Published 30 August 2024

    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

    Training dentists and dental staff, and supplying adrenaline auto-injectors to pharmacies, fall outside the organisation’s role.

    Verbatim wording from the response

    “As the Royal College of Paediatrics and Child Health, we are primarily responsible for the education and training of paediatricians across the UK. We are not involved in the training of dentists and dental staff and have no role in the supply of epi-pens to pharmacies. As part of our training, we run CPD courses on child health topics that are of interest and relevance to the wider child health workforce. This includes Paediatric Allergy Training study days that focus on the practical clinical management of allergy in children and young people. These courses are suitable for all professionals seeing children with allergic disease. You can read more about these courses on our RCPCH Learning platform. We will ensure these continue to be widely promoted across the child health workforce.”

    Source location

    2024-0464 Response from Royal College of Paediatrics
    Page 1 · response
    Published 30 August 2024

    Open published response
  10. Somerset

    AI-generated summary

    Irene Joy White · 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

    Irene Joy White, who had dementia and became immobile after a fall and hip-fracture surgery, was discharged to a nursing home without further thromboprophylaxis and was not mobilised beyond regular repositioning. She died of a pulmonary embolism, and concerns were raised about the nursing home's failure to identify and manage her DVT risk, including the absence of a DVT policy.

    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

    Failure to provide TED stockings or similar thromboprophylactic equipment

    Wider context from the report

    “I am concerned following the evidence presented to the Inquest that: (i) Frome Nursing Home employs clinically trained staff who would have been well aware (or should have been well aware) of the risk of developing DVT in an immobile patient and yet: (a) Did not make any enquiries with the discharging hospital as to her care needs and lack of thromboprophylaxis. Despite appropriate medical/clinical knowledge the Home did not question this and/or take any active steps whatsoever to ascertain Mrs White’s needs or treatment plan; (b) Did not take any steps to acquire any TED stockings, or similar, to minimise the risk of a DVT; (c) Did not take any steps to mobilise Mrs White, over and above repositioning her in bed every four hours, to minimise the risk of a DVT (ii) Frome Nursing Home did not have a DVT Policy in place at the time of Mrs White’s death, and no such active policy was in place at the time of the Inquest and so I am concerned that there has been no active learning and/or meaningful reflection since Mrs White’s death; meaning that practices have not changed and vulnerable residents remain at risk. I am concerned that the Home did not take appropriate and reasonable steps to identify her risk and then take such steps to minimise it. The overwhelming thrust of the evidence presented indicated a poor attitude to a joined-up and cohesive response from the management and clinical teams and this resulted in a lack of clinical leadership, judgment and action being taken. Mrs White lacked capacity due to her cognitive impairment and so was unable to appreciate the risks that immobility posed to her. She was entirely reliant (because of age, cognitive impairment and general infirmity) on the Home to anticipate her risks and needs in this regard. ”

    Source location

    Irene Joy White · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
Back to top

Data last updated 7 September 2026