Concerns raised 1
Maternity Helpline triage by unregistered, inadequately trained and unqualified staff View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Charlie Mark Jermyn · 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
Charlie Jermyn was born at home on 9 May 2015 and developed sleepiness, feeding difficulty and possible respiratory distress. He stopped breathing during a routine visit the following day and died in hospital despite resuscitation attempts. The principal concerns were delayed recognition and referral for suspected sepsis, inadequate telephone triage and recording, insufficient observations, and wider shortcomings in midwifery guidance, equipment and training.
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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 Maternity Helpline triage by unregistered, inadequately trained and unqualified staff
Wider context from the report “7. The telephone Maternity Helpline was inappropriately triaged by unregistered inappropriately trained and qualified staff , who were unable to identify obvious and significant sepsis markers indicating the seriousness of the deterioration in Charlie’s health. No structured note taking or recording of the call was made for future referral. Nor was the call/caller recorded. Helpline triage is a complex task and should only be undertaken after specialist training by an appropriately qualified person and the outcome of the conversations should be recorded formally in line with best practice.
” Source location Charlie Mark Jermyn · Prevention of Future Deaths report
Open source report
16 May 2016 Mr Critall · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Insufficient nursing competence in resuscitation and chest drain management View source
This report raised 22 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Mr Critall · 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
Mr Critall, an 80-year-old man, developed a haemothorax after insertion of a chest drain while being treated for pneumonia and died on 6 July 2014 after further deterioration and emergency treatment. The report raised concerns about the necessity and technique of the drain insertion, the failure to confirm its position, inadequate monitoring and resuscitation, and the hospital’s lack of appropriate emergency facilities and protocols. It also recorded that his family were not contacted after he became unwell or died.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient nursing competence in resuscitation and chest drain management
Wider context from the report “1. The admission of an acutely unwell patient with pneumonia to a private hospital dealing primarily with elective surgical procedures with no HDU/ITU facilities in case of deterioration. The most senior doctor in the hospital, other than visiting clinicians was an RMO of unclear experience who usually has the care of more than 50 patients at any one time but can be as many as 72. This is alongside nursing staff who have no significant grounding in resuscitation and an unclear understanding of chest drain insertion for pneumonic pleural effusions , usually having to deal with malignant pleural effusions.
” Source location Mr Critall · 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 Run regular unannounced resuscitation scenarios for staff and RMOs, identifying learning requirements for follow-up.
Verbatim wording from the response “2. All staff and RMO’s are involved with regular unannounced resuscitation scenarios run at the hospital by an externally appointed resuscitation training company engaged to teach resuscitation skills to all staff. Any learning requirements are identified to staff and to the RMOs and their agency.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
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 Train nursing staff and healthcare assistants in acute illness management and assess competencies for caring for deteriorating patients.
Verbatim wording from the response “3. All nursing staff and Health Care Assistants have attended AIMS (Acute Illness Management training) and completed competencies in the care of the deteriorating patient.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
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 Review and incorporate chest-drain insertion training and competencies for radiology and nursing staff into Acute Care Competencies.
Verbatim wording from the response “4. The protocol for the care of patients with a chest drain has been updated to align with British Thoracic Society (BTS) guidelines. Training and competencies for all radiology and nursing staff on the understanding of chest drain insertion is currently under review by BMI to be incorporated in the Acute Care Competencies.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
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 Nursing staff had required resuscitation training, with senior nurses generally holding advanced life-support certification.
Verbatim wording from the response “Nursing staff - All hospital staff receive either advanced life support (ALS); basic life support (BLS) or immediate life support (ILS) resuscitation council accredited training. All nursing staff are ILS trained as a minimum requirement and the current senior nursing team are ALS trained with the exception of 1 member of the team. The requirement is for renewal every 4 years. In the intervening years between formal ALS training all ALS qualified staff attend an ALS refresher (previously this was an ILS refresher).” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
Open published response
8 Dec 2015 Madhumita Mandal · Prevention of Future Deaths report South London
View report summary
Concerns raised 1
Insufficient qualification for assessment of urgent care patients View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Croydon Health Services NHS Trust NHS South West London Integrated Care Board Virgin Care Wandle LLP
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
NHS South West London Integrated Care Board
Implement the current streaming model and joint standard operating policy to direct patients to UCC or ED according to presenting complaints.
View source
NHS South West London Integrated Care Board
Use healthcare assistant observations scored with the VIEWS early warning system to identify patients requiring ED transfer or specialist referral after UCC streaming.
View source
NHS South West London Integrated Care Board
Introduce clinical streaming at the front end of A&E following the changed layout and redevelopment of the ED department.
View source
Croydon Health Services NHS Trust
Deliver UCC streaming through senior emergency department nurses.
View source
Croydon Health Services NHS Trust
Hold fortnightly governance meetings between the UCC and emergency department to review and refine governance, streaming, and handover processes.
View source
Virgin Care Wandle LLP
Use interim clinical streaming by an ED nurse to assess patients entering the department while the UCC and ED redevelopment proceeds.
View source
Virgin Care Wandle LLP
Train receptionists to apply the streaming process and escalate uncertain or concerning patient presentations to a clinician.
View source
Virgin Care Wandle LLP
Strengthen the triage process by assigning General Practitioners rather than nurses to carry out Manchester Triage System assessments.
View source See 5 more actions
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AI-generated summary
Madhumita Mandal · 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
Madhumita Mandal became unwell and attended Croydon University Hospital on 7 September 2013, where the inquest recorded multiple organ failure due to sepsis associated with a ruptured endometriotic ovarian cyst. The principal concerns were delays in assessment and treatment, including initial streaming by a receptionist without medical training, and failures in clinical supervision. The report also raised concerns about differing assessment based on whether patients arrived by ambulance.
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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 Insufficient qualification for assessment of urgent care patients
Wider context from the report “Mrs Mandal was taken to Croydon University Hospital by her husband. Virgin Care was contracted by the Croydon Clinical Commissioning Group to provide urgent care services, and to stream adult patients arriving at the emergency department. A streaming model was followed by a receptionist who had no medical training and who performed no medical observations. This led to a delay of about an hour before Mrs Mandal was seen by any qualified healthcare professional, by which time her condition was critical.
The streaming model had been approved and commissioned in the contract as recommended by an NHS body called the Emergency Care Intensive Support Team. The system at Croydon has changed since Mrs Mandal’s death but concerns remain about the level of qualification for assessment of patients , and there may be lessons for other Trusts who contract out the provision of urgent care.
” Source location Madhumita Mandal · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the current streaming model and joint standard operating policy to direct patients to UCC or ED according to presenting complaints.
Verbatim wording from the response “By way of back ground the service was initially implemented using the Manchester Triaging model, which required the triaging of all patients (primary care and otherwise). As a consequence there was a significant impact on performance due to the delays this introduced into patient flows. The national Emergency Intensive Support Team (ECIST) supported a local review of the model, which led to a joint agreement by ED consultants, urgent care and CCG GP clinicians and implementation of the current streaming model and a joint standard operating policy agreed and implemented on the 9th October 2012. The model was based on trained appropriately experienced streaming patients to either the UCC or ED depending on their presenting complaint, with the aid of the streaming protocol.” Source location MMandal-Response3
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 Use healthcare assistant observations scored with the VIEWS early warning system to identify patients requiring ED transfer or specialist referral after UCC streaming.
Verbatim wording from the response “This issue was reviewed in a workshop with CHS, UCC and commissioner clinicians and executives where it was agreed that a modification would be made to the streaming model on a pilot basis, which has continued, whereby patients streamed to UCC would be given basic observations by a HCA. All observations would be scored using the Vital – Pac Early Warning System (VIEWS). Any patient scoring 4 and below would be asked to remain in the UCC; a score of 5 and above would indicate that the patient was inappropriately streamed and would be sent to ED or referred directly to a specialist. The VIEWS assessment not only gives assurance to the Trust about when patients are handed over but it is also compliant with guidance from the London Standards. The model has evidenced that less than 1% of patients initially streamed to the UCC are transferred to ED following the observations review.” Source location MMandal-Response3
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 Introduce clinical streaming at the front end of A&E following the changed layout and redevelopment of the ED department.
Verbatim wording from the response “from the ED Department, clinical streaming has now been introduced at the front end of A&E. We are currently commencing re-procurement of urgent care services in Croydon and the specification for the new service will continue to require that effective streaming process are in place. The VIEWS process however continues to be used in the UCC.” Source location MMandal-Response3
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 Deliver UCC streaming through senior emergency department nurses.
Verbatim wording from the response “1. Medical observation reviews in UCC
The streaming model currently in place between the UCC and the Trust’s emergency department is now delivered by band 6/7 (senior) emergency department nurses.” Source location MMandal-Response2
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 Hold fortnightly governance meetings between the UCC and emergency department to review and refine governance, streaming, and handover processes.
Verbatim wording from the response “3. Fortnightly governance review meeting
There is now a fortnightly review of governance and process issues between the UCC and the emergency department; this has allowed us to work more closely with our UCC colleagues and recognise and deal with potential problems more quickly. We have used the forums to refine the streaming and handover processes thus ensuring patients get to the correct clinicians in a safe and timely fashion.” Source location MMandal-Response2
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 Use interim clinical streaming by an ED nurse to assess patients entering the department while the UCC and ED redevelopment proceeds.
Verbatim wording from the response “From November 2015, interim changes have taken place to the way patients are directed to the UCC or ED while the redevelopment of UCC and ED is underway. This means that the ED is now providing ‘clinical streaming’, i.e. one nurse viewing all patients as they enter the department to determine presenting condition. This is not a triage system. This decision was made by the CCG, CUH and Virgin Care as the two departments are no longer co-located. Virgin Care is working closely with both the CCG and CUH to ensure patient safety is maintained during the redevelopment. It is anticipated that the redevelopment will last until March 2017 at the earliest.” Source location MMandal-Response1
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 Train receptionists to apply the streaming process and escalate uncertain or concerning patient presentations to a clinician.
Verbatim wording from the response “Receptionists were instructed to speak to a clinician if they were unsure about a patient's condition or if they had any concerns about a patient. Receptionists were trained to carry out the streaming process and a record of this is attached at Appendix 3 (One to One Training), which has been redacted appropriately to maintain confidentiality. The receptionist who booked in Mrs Mandal had received such training in October 2012.” Source location MMandal-Response1
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 Strengthen the triage process by assigning General Practitioners rather than nurses to carry out Manchester Triage System assessments.
Verbatim wording from the response “When the services commenced in April 2012, the UCC was required, under the contract and conditions of the commission, to assess patients using a process based on the Manchester Triage System (MTS). Due to the nature of patient flows within the services, the MTS process resulted in delays to treatment for both the UCC and the CUH ED. Delays were resulting in four hour breaches in the ED and prolonged waits in patients being seen by a clinician in both services, which was an agreed significant patient safety cause for concern by both services. At busy times clinical staff were taken from treatment duties to assist with the MTS. This meant there were fewer clinicians treating people which in turn added to delays. The UCC had already identified triage as a bottleneck and had strengthened the process by replacing nurses with General Practitioners (GP) to carry out the MTS.” Source location MMandal-Response1
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 urgent-care streaming model and related actions rests with Virgin Care Wandle LLP, not the Trust.
Verbatim wording from the response “The Croydon Clinical Commissioning Group (“CCG”) awarded the contract for delivery of urgent care services to Virgin Care Wandle LLP. Virgin Care Wandle LLP controlled the steaming of adult patients who arrived in the Trust’s Emergency Department at the time of the incident. The functionality and review of the streaming model at the time of the incident is accordingly the responsibility of Virgin Care Wandle LLP.” Source location MMandal-Response2
Open published response
11 Sep 2015 Thomas Nicholls · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1
Lack of care-staff training and competence in PEG feeding, including resident mobility, handling and feed controls View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Thomas Nicholls · 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
Thomas Nicholls died in hospital on 14 April 2015 after recurrent vomiting, aspiration pneumonia and deterioration following PEG feeding, in the context of prior strokes and other illness. The substantive concerns included inadequate staff training in the mobility, handling and care of residents receiving PEG feeds, an unreported vomiting incident, inadequate recording of incidents, and malfunctioning bed 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 care-staff training and competence in PEG feeding, including resident mobility, handling and feed controls
Wider context from the report “1. During the Inquest evidence was heard that
i. On the 16th March 2015 Mr Nicholls’ daughter, ████████, visited Mr Nicholls at Arden Court to accompany Mr Nicholls to a hospital appointment. Mrs Mellor gave evidence that when she attended at 09.15hrs on that day her father was lay flat on the bed and it looked as if someone had been getting him ready for the hospital appointment but had been interrupted.
Mrs Mellor knew that her father should not be laid flat whilst PEG feeding was in progress and she tried to find the remote control to adjust the angle of the bed without success.
Mrs Mellor saw some feed in Mr Nicholls’ mouth and she gave evidence that he was violently sick with projectile vomiting. She asked a Carer about the angle of the bed and PEG feeding but the Carer informed Mrs Mellor that she had not been trained in PEG feeding .
ii. It was clear from the evidence that care staff had indicated that they had not been trained in relation to PEG feeds, particularly in relation to mobility and handling of residents during PEG feeding and the incident on the 16th March 2015 had not been reported to the Manager of Arden Court, who had not considered either training or re-training in relation to PEG feeds.
The Manager gave evidence at the Inquest that he was not aware of the incident on the 16th March 2015 until he heard the evidence at the Inquest and he had only become aware of the details of the incident during the course of the Inquest. He confirmed that there had been no review of training particularly in relation to mobility, handling and the care of residents on PEG feeding regimes .
iii. Evidence was heard that residents may have to be laid flat at times whilst receiving PEG feed but there were controls to allow the feed to be placed on hold whilst mobilising and handling a resident. The care staff did not appear to be fully conversant with the controls of the PEG feed .
iv. The remote control to operate the bed occupied by Mr Nicholls did not function due to the plug having been detached or the junction box having been smashed.
v. The Manager was not aware of the incident on the 16th March 2015 and the incident did not appear to have been recorded so that any training needs in relation to staff, together with a review of risk assessments did not take place after the incident.
vi. The evidence raised concerns that there is a risk that future deaths could occur unless action is taken to review the above issues.
” Source location Thomas Nicholls · Prevention of Future Deaths report
Open source report
6 Jul 2015 Mr Tommy Faegh Faisali · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 2
Use of staff without appropriate qualifications to provide expert psychiatric referral advice View source Failure to ensure that psychiatric second-opinion referrals are assessed by appropriately qualified psychiatrists View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Mr Tommy Faegh Faisali · 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
Mr Tommy Faegh Faisali, who had hepatitis C causing cirrhosis and was methadone dependent, was found deceased in his accommodation on 30 September 2014. The inquest concluded that the medical causes of death included acute pulmonary oedema, methadone toxicity and liver failure due to cirrhosis, with the jury recording drug-related misadventure. Concerns included the lack of specialist psychiatric assessment despite GP referrals, inadequate risk assessment and documentation, and poor communication and continuity of care within mental health teams.
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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 Use of staff without appropriate qualifications to provide expert psychiatric referral advice
Wider context from the report “(1) That patients referred by their GP for second opinion from psychiatrists are not being seen by the same but rather by psychiatric health care staff with less qualification to diagnose and assess and recommend treatment then the GP who made the referral.
(2) That a shortage of appropriately qualified doctors is being compensated for by staff without the appropriate qualifications to provide the expert advice being requested by GPs when they make psychiatric referrals .
(3) Those patients may be at increased risk because of (1) and (2) above.
” Source location Mr Tommy Faegh Faisali · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure that psychiatric second-opinion referrals are assessed by appropriately qualified psychiatrists
Wider context from the report “(1) That patients referred by their GP for second opinion from psychiatrists are not being seen by the same but rather by psychiatric health care staff with less qualification to diagnose and assess and recommend treatment then the GP who made the referral.
(2) That a shortage of appropriately qualified doctors is being compensated for by staff without the appropriate qualifications to provide the expert advice being requested by GPs when they make psychiatric referrals.
(3) Those patients may be at increased risk because of (1) and (2) above.
” Source location Mr Tommy Faegh Faisali · Prevention of Future Deaths report
Open source report
2 Jul 2014 ALBERT FLYNN · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Insufficient staff training and qualification for assessment and treatment decisions View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
Hc-One Limited
Re-emphasise the need to seek qualified advice during induction training for new staff.
View source
Hc-One Limited
Re-emphasise earlier help-seeking and intervention to the care staff involved through supervision.
View source
Hc-One Limited
Use the case as a reminder to all company care staff to alert senior staff about unexpected or extraordinary resident conditions.
View source
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AI-generated summary
ALBERT FLYNN · 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
Albert Flynn, a resident of Appleton Manor Residential Home, was taken to hospital with a suspected deep vein thrombosis and treated with the blood-thinning drug Enoxaparin. The following night he was left in a chair for approximately 10 hours without food, fluids or prescribed medication, while staff were unable to rouse him. He was suffering from a severe cerebral bleed, which was fatal; concerns included inadequate staff training and failure to recognise the significance of his condition and recent blood-thinning treatment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient staff training and qualification for assessment and treatment decisions
Wider context from the report “1. Whilst the care staff members were apparently concerned as to the condition of Mr Flynn, none of them was sufficiently well trained or qualified to make an informed decision as to how he should be treated .
2. As a result of the above, he was left sitting in a chair, partially dressed, without food, fluid or medication for a period of approximately 10 hours.
3. None of the staff gave any indication of any, or any proper, training in the assessment of this type of event , nor did they attribute any or any sufficient weight to the fact that he had been administered blood thinning drugs the previous day.
4. The staff did not seem to appreciate the importance of administering prescribed medication.
” Source location ALBERT FLYNN · 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 Re-emphasise the need to seek qualified advice during induction training for new staff.
Verbatim wording from the response “On this particular occasion the care staff members were experienced care assistants, some of whom had undergone NVQ training and had also undertaken mandatory training courses in relation to certain aspects of the delivery of care. As a matter of routine all care staff receive training in essential elements of care and these include Safer people handling; Safeguarding; Emergency procedures; Falls awareness; Promoting healthy skin. It is accepted that in this particular case Mr Flynn was left undisturbed for too long before qualified assistance was sought and during induction training for new staff, the need to call for qualified advice will be re-emphasised.” Source location 2014-0308-Response-by-Lester-Aldridge-LLP
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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 Re-emphasise earlier help-seeking and intervention to the care staff involved through supervision.
Verbatim wording from the response “The circumstances surrounding the care staff’s failure to alert the qualified nurse on duty of Mr Flynn’s condition is regrettable and with the balance of hindsight is accepted by them as having been regrettable. The need to seek earlier help and intervention has been re-emphasised to all the care staff involved in this case during the course of supervision and this case will also serve as a reminder to all care staff working within the company to alert more senior staff should they have any cause for concern about the condition of a resident which is unexpected or extraordinary.” Source location 2014-0308-Response-by-Lester-Aldridge-LLP
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 Use the case as a reminder to all company care staff to alert senior staff about unexpected or extraordinary resident conditions.
Verbatim wording from the response “The circumstances surrounding the care staff’s failure to alert the qualified nurse on duty of Mr Flynn’s condition is regrettable and with the balance of hindsight is accepted by them as having been regrettable. The need to seek earlier help and intervention has been re-emphasised to all the care staff involved in this case during the course of supervision and this case will also serve as a reminder to all care staff working within the company to alert more senior staff should they have any cause for concern about the condition of a resident which is unexpected or extraordinary.” Source location 2014-0308-Response-by-Lester-Aldridge-LLP
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 Qualified nursing input for residential clients would normally be provided by the district nursing service, rather than residential care staff.
Verbatim wording from the response “Mr Flynn’s condition should have been addressed at that stage. The nurse on duty would then have been able to attribute proper weight to the fact that Mr Flynn had received blood thinning drugs the previous day and his state of consciousness was cause for concern. The hospital did not provide any cautionary advice for the care team upon discharge back to the home on the evening of 14th March 2014 following the administration of anti-coagulation therapy, nor did the hospital initiate district nursing input across the weekend. Mr Flynn was accommodated as a residential client and so his day to day care would not have been provided by qualified nurses but by care assistants. The nursing input would normally be provided by the district nursing service.” Source location 2014-0308-Response-by-Lester-Aldridge-LLP
Open published response
3 Dec 2013 Agostino COSTA · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to ensure staff competence in managing patients after falls View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Agostino COSTA · 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
Agostino Costa died after an accidental fall in hospital on 12 May 2013, which hastened death from terminal disease. The principal concerns were staff confusion about falls-risk classification and management, inadequate training for a junior doctor, limited sharing of the hospital root cause analysis, and non-mandatory attendance at falls-prevention seminars.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure staff competence in managing patients after falls
Wider context from the report “4. The junior doctor present did not know how to deal with a patient post fall on the ward , though he had dealt with patients in the emergency unit who had fallen in the community. He had not attended the hospital training seminar on falls.
5. The hospital root cause analysis was not shared with all relevant members of staff, though it was signed off at the beginning of August. Thus learning points from it were completely lost to some.
I heard that a great deal of work is being done in your trust to attempt to prevent falls and appropriately to treat patients when falls have occurred, but attendance at one of the monthly seminars run by the lead doctor for falls is not mandatory for all staff .
” Source location Agostino COSTA · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.