8 May 2026 Jake Daniel Taylor · Prevention of Future Deaths report West London
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Concerns raised 1
Lack of airway equipment View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation 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
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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 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
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require 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
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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 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
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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 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
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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 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
Open published response
17 Nov 2025 Paolino AMICO · Prevention of Future Deaths report Essex
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Concerns raised 1
Out-of-date PAT testing for oxygen equipment View source
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England the Princess Alexandra Hospital NHS Trust
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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.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation 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
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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 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
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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 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
Open published response
13 Oct 2025 Jamie Stuart Funnell · Prevention of Future Deaths report East Sussex
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Concerns raised 1
Failure to monitor life support equipment for faults View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Practice Plus Group
Implement fortnightly emergency-bag checks, daily seal checks, monthly audits and bimonthly dip tests to verify equipment readiness and drug validity.
View source
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to 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
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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 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
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16 Jun 2025 Mrs Norma Faye Campbell · Prevention of Future Deaths report East London
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Concerns raised 1
Lack of monitoring equipment in the majors area of A&E View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Barts Health NHS Trust
Implement electronic observations and Early Warning Score visibility across Emergency Department clinical areas using the upgraded patient record and observation machines.
View source
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of 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
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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 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
Open published response
24 Feb 2025 Pamela Anne Marking · Prevention of Future Deaths report Surrey
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Concerns raised 1
Unavailability of promptly accessible suction for aspiration during rapid sequence induction View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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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 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
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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 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
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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 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
Open published response
15 Jan 2025 Sheila Josephine WEXLER · Prevention of Future Deaths report Inner North London
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Concerns raised 2
Failure to provide and replace medical equipment with correct, functional equipment View source Delays in delivering required medical equipment View source
Linked responses
NHS England Nottingham Rehab Limited (trading as NRS Healthcare
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
Nottingham Rehab Limited (trading as NRS Healthcare
Improve the product ordering system to clarify which equipment is in place.
View source
Nottingham Rehab Limited (trading as NRS Healthcare
Improve communications with hospital discharge teams.
View source
NHS England
Conduct weekly oversight meetings with commissioners and key partners to identify equipment-access concerns, review performance indicators, and monitor improvement.
View source
NHS England
Continue regional meetings with equipment commissioners and key partners to oversee performance indicators and support consortium members and associated providers.
View source See 1 more action
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide 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
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
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 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
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 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
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 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
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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 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
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 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
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 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
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 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
Open published response
Concerns raised 1
Maintenance failing to identify ERC wear and tear View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
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.
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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 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
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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 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
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 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
Open published response
Concerns raised 1
Lack of availability of required equipment 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. 1
Care Quality Commission
Require and assess additional supporting information and policies during registration, including applicants’ commitment to providing equipment meeting intended service users’ needs.
View source
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of 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
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 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
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 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
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 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
Open published response
20 Aug 2024 Hannah Enola Ayamo Jacobs · Prevention of Future Deaths report East London
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Concerns raised 1
Unavailability of AAI stock in chemists for emergencies View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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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 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
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 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
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 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
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 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
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 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
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 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
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 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
Open published response
7 Nov 2023 Irene Joy White · Prevention of Future Deaths report Somerset
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Concerns raised 1
Failure to provide TED stockings or similar thromboprophylactic equipment 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
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.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to 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
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.