Concerns raised 1
Failure to record the full extent of significant critical incidents in hospital notes View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
University Hospitals Plymouth NHS Trust
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AI-generated summary
Ian Jacka · 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
Ian Jacka suffered serious injuries after a fall from height on 3 June 2022 and later developed hypoxic brain injury following airway complications during spinal surgery. He died in intensive care on 15 June 2022. The principal concerns were omissions in record keeping and handover about a serious medical episode before surgery, and the absence of a formal written handover process for significant events involving complex patients.
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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 record the full extent of significant critical incidents in hospital notes
Wider context from the report “(1) There was an error of omission in record keeping and in handover from critical care to surgery, and that this error likely contributed to Ian’s death.
(2) There was no entry in Ian’s hospital notes to indicate the full extent of the critical incident of 5 June 2022 .
” Source location Ian Jacka · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The clinical record comprehensively documented the critical incident, and there was no omission in record keeping or handover.
Verbatim wording from the response “The documentation in relation to the critical incident is both comprehensive and appropriate. Mr Jacka deteriorated, requiring intubation and ventilation as a result of type 2 respiratory failure caused by his significant chest and spinal injuries. His blood oxygen saturations and blood pressure fell significantly but were rapidly restored to normal upon the arrival of the ICU registrar with simple interventions after a relatively short period of time. The lowest oxygen saturations and blood pressure values were recorded in the notes by the ICU nurse at the time. Mr Jacka was anaesthetised and intubated – this was technically challenging and represented a difficult airway, but Mr Jacka remained stable throughout this process with no further drop in oxygen levels.” Source location Response from University Hospitals Plymouth NHS Trust
Open published response
Concerns raised 1
Failure to complete observation charts adequately 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
Paul Perrott · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul Perrott, an inpatient detained under the Mental Health Act, died on 31 July 2020 after attempting to hang himself on Ashcombe Ward. Concerns included inadequate recording of his 15-minute observations, unclear responsibility for checking observation charts, insufficient staff awareness of his recent and historical suicide risk, and a focus on immediate rather than historical and contextual risks.
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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 complete observation charts adequately
Wider context from the report “(1) Paul Perrott’s observations charts were not filled out adequately or at all on the date of his death
” Source location Paul Perrott · 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 Amend the observation policy to require shift-by-shift completion checks by the nurse in charge and immediate action on omissions.
Verbatim wording from the response “An amendment to the Trust therapeutic engagement and observation policy has been requested to state that the nurse in charge of each shift is responsible for ensuring completion of observations on a shift by shift basis and taking immediate action where these are not completed. This will go through ratification in January 2024 and has been discussed with the Director and Deputy Director of Nursing.” Source location Response from Devon Partnership NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct monthly senior nurse manager audits of observation completion, submit results to governance, provide feedback, and review performance with ward managers.
Verbatim wording from the response “Policy states that observation audits to check completion of observations are completed monthly by senior nurse managers. This process is in place through the quality review of clinical records and the results of those audits are submitted to the governance manager, feedback to staff and ward governance meetings. The audit performance is then reviewed monthly with ward managers at inpatient governance meetings. Engagement and observation competency checklists are completed for all new staff and these are reviewed and stored by ward managers with the senior nurse manager’s administrator monitoring compliance for wards.” Source location Response from Devon Partnership NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review inpatient wards' shift-by-shift observation-record initials to check that nurses in charge evidence completion.
Verbatim wording from the response “In addition, the patient observation record has a tick box on each observation sheet where the nurse in charge adds their initials to evidences completion on a shift by shift basis. This has been reviewed on each inpatient ward by the senior nurse manager to check it is being completed by the nurse in charge.” Source location Response from Devon Partnership NHS Trust
Open published response
Concerns raised 1
Failure to keep accurate and complete records of interactions View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Sheffield Health Partnership University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 10
Sheffield Health Partnership University NHS Foundation Trust
Incorporate discharge-quality compliance into biannual record-keeping audits and address results through ward governance.
View source
Sheffield Health Partnership University NHS Foundation Trust
Request regular clinical record-keeping audit reports and monitor progress through Directorate Leadership Teams and the Clinical Quality and Safety Group.
View source
Sheffield Health Partnership University NHS Foundation Trust
Implement the new electronic record system to deliver automated record-keeping improvements.
View source
Sheffield Health Partnership University NHS Foundation Trust
Complete and roll out a Trustwide clinical record-keeping policy and associated staff training.
View source
Sheffield Health Partnership University NHS Foundation Trust
Establish Trustwide, team-level supervision and spot-check audits within the clinical record-keeping quality-assurance programme.
View source
Sheffield Health Partnership University NHS Foundation Trust
Issue a Blue Light Learning Notice and cascade the requirement for timely, accurate recording of patient-facing interactions to clinical teams.
View source
Sheffield Health Partnership University NHS Foundation Trust
Audit clinical record keeping, including risk assessments and discharge summaries.
View source
Sheffield Health Partnership University NHS Foundation Trust
Implement a clinical record keeping standards policy guiding clinicians to prepare for appointments using current issues, risks and concerns.
View source
Sheffield Health Partnership University NHS Foundation Trust
Disseminate and publish a staff alert reminding all staff about good-quality record keeping.
View source
Sheffield Health Partnership University NHS Foundation Trust
Roll out the clinical record keeping training package across the Trust following its development and pilot session.
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AI-generated summary
Gareth Michael Etchells-Heights · 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
Gareth Michael Etchells-Heights experienced deteriorating mental health and psychosis before being admitted to hospital and later moved to a step-down bed at Wainwright Crescent. He died there in the early hours of 24 April 2022 after tying a ligature, with the inquest recording asphyxiation by ligature. Substantive concerns included inadequate discharge information, inconsistent review of medical notes, failure to update risk assessments, and inadequate record keeping.
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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 keep accurate and complete records of interactions
Wider context from the report “4. Record Keeping
There was a failure generally to keep proper records. It became clear as the evidence progressed that many of the record entries did not accurately or fully reflect the interactions with Gareth . There is no audit system in place to check the records.
” Source location Gareth Michael Etchells-Heights · 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 Incorporate discharge-quality compliance into biannual record-keeping audits and address results through ward governance.
Verbatim wording from the response “The new discharge template will be completed by the end of June 2024 and the launch of this will be supported by local best practice training by the Directorate Leadership Team. An audit of quality compliance will be incorporated into the existing cycle of biannual record keeping audits. Results from the audits will be reflected and acted through our local ward governance processes.” Source location Response from Sheffield Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request regular clinical record-keeping audit reports and monitor progress through Directorate Leadership Teams and the Clinical Quality and Safety Group.
Verbatim wording from the response “We will request regular reporting on clinical record keeping audits and monitor progress via our Directorate Leadership Teams into the Clinical Quality and Safety Group.” Source location Response from Sheffield Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the new electronic record system to deliver automated record-keeping improvements.
Verbatim wording from the response “I will refer back to my letter dated 3 November 2023 where we outlined the move to our new record system (RIO). The implementation of the system has been delayed for some services in the Trust, however, the functionality of RIO will bring about significant automated improvements in record keeping.” Source location Response from Sheffield Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete and roll out a Trustwide clinical record-keeping policy and associated staff training.
Verbatim wording from the response “In addition to the positive impact of the electronic record implementation this year, we have also commissioned a new clinical record keeping policy and training, which aligned to the quality improvement programme we noted in our letter (3 November), will be rolled out to all staff teams. Built alongside this will be a robust audit programme which will include Trustwide clinical audit and team level audits through supervision and spot check audits as part of our Quality Assurance programme. We anticipate the policy will be completed by May 2024 and the training will commence roll out, alongside a clear communication plan from June 2024.” Source location Response from Sheffield Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish Trustwide, team-level supervision and spot-check audits within the clinical record-keeping quality-assurance programme.
Verbatim wording from the response “In addition to the positive impact of the electronic record implementation this year, we have also commissioned a new clinical record keeping policy and training, which aligned to the quality improvement programme we noted in our letter (3 November), will be rolled out to all staff teams. Built alongside this will be a robust audit programme which will include Trustwide clinical audit and team level audits through supervision and spot check audits as part of our Quality Assurance programme. We anticipate the policy will be completed by May 2024 and the training will commence roll out, alongside a clear communication plan from June 2024.” Source location Response from Sheffield Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a Blue Light Learning Notice and cascade the requirement for timely, accurate recording of patient-facing interactions to clinical teams.
Verbatim wording from the response “In the meantime, we will issue a Blue Light Learning Notice to all clinical teams and flag through our Trustwide cascade with the Executive Team the need to record accurately all patient facing interactions in a timely manner.” Source location Response from Sheffield Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit clinical record keeping, including risk assessments and discharge summaries.
Verbatim wording from the response “The Clinical Director for Acute and Community Services has provided instruction via email to all inpatient Responsible Clinicians that diagnoses must be captured in Insight (our electronic patient record system) to enable them to be pulled through onto the discharge summary. Discussions have taken place regarding the purpose of discharge summaries and the misunderstanding of their use. We commissioned 360 Assurance, our internal auditors, to undertake an audit of our clinical record keeping, including risk assessments and discharge summaries. This audit was completed in May 2024. From the findings of the audit and the new national guidance that was issued in January 2024, we have agreed to review the format and function of our discharge summaries to include early warning signs of deterioration.” Source location 2023-0517 Response from Sheffield Health and Social Care - Update
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 Implement a clinical record keeping standards policy guiding clinicians to prepare for appointments using current issues, risks and concerns.
Verbatim wording from the response “We developed a clinical record keeping standards policy earlier this year to provide clarity on the expected requirements to ensure high quality, person centred clinical documentation across the Trust. Incorporated within this is a section to guide clinicians around preparing for service user appointments, ensuring they are briefed on the current issues, risks and concerns. It is accepted that this will depend upon the relationship between the service user and their worker. This will enable staff to have an up-to-date understanding of the service user’s condition and mental state.” Source location 2023-0517 Response from Sheffield Health and Social Care - Update
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 Disseminate and publish a staff alert reminding all staff about good-quality record keeping.
Verbatim wording from the response “All staff have been reminded about the importance of good quality record keeping through an alert cascade that was produced, disseminated and published on the staff intranet.” Source location 2023-0517 Response from Sheffield Health and Social Care - Update
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 Roll out the clinical record keeping training package across the Trust following its development and pilot session.
Verbatim wording from the response “Following the publication of the new clinical record keeping standards policy, a new training package has been developed to support the implementation of the policy and a pilot training session has already taken place with preceptee nurses. The feedback from this pilot session has been extremely positive. The training is now being rolled out across the Trust by the Clinical Risk and Patient Safety Advisor.” Source location 2023-0517 Response from Sheffield Health and Social Care - Update
Open published response
10 Nov 2023 Christopher Richard ALLUM · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 1
Unavailability of NHS notes to private healthcare providers at admission View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Christopher Richard ALLUM · 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
Christopher Richard Allum had escalating mental health issues and a history of deliberate self-harm before being admitted to the Langford Centre on 14 May 2022. He was found unresponsive in his room on the evening of 15 May 2022, and death was confirmed at 23:01; the inquest concluded that he died as a result of suicide. The concerns identified included gaps in obtaining and recording previous methods of self-harm and relevant family information at referral and admission, and difficulties accessing NHS notes in private healthcare settings.
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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 NHS notes to private healthcare providers at admission
Wider context from the report “Initial referral - there seems to be a gap at the initial referral and admission stage in obtaining information about and recording previous methods of self-harm and suicide. There also appears to be a gap in the seeking and recording of relevant information from an individual's family at the point of referral and admission. An individual's family is often able to provide detailed and useful information about events that may not have been previously reported and/or be able to bridge the gap in communications between various health agencies involved in someone's care.
Access to notes - the other concerning issue is the difficulty prevalent within the private sector in accessing of NHS notes . It appears to be the position across the private sector that access to an individual's notes is not provided as standard . This means that there may be a significant gap in the information available when someone is admitted to a premises run by a private healthcare provider, even within an NHS allocated bed . This gap in information can have an impact on an individual's risk assessment and their subsequent care plan.
” Source location Christopher Richard ALLUM · 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 Provide qualified medical staff with read-only access to referred patients’ NHS medical records.
Verbatim wording from the response “I note that in relation to your further concern relating to difficulties in accessing a patient’s NHS notes, you made reference during your conclusions to the unprecedented steps The Langford” Source location Response from Bramley Health
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 Publish guidance on information sharing and holistic assessment during admission, including key actions within 72 hours.
Verbatim wording from the response “Christopher’s case does highlight the importance of effective information sharing to support providing the best care possible where individuals are transferred between different care settings. That is why joined up partnership working is one of the four key principles underpinning NHS England’s guidance on Acute inpatient mental health care for adults and older adults that was published in July 2023. This document provides specific advice on good practice on information sharing as well as guidance on the holistic assessment that should take place when someone enters a new facility, including identifying any safeguarding or risk issues, including risk to self and others. This includes guidance on the key actions that should take place within 72 hours of admission which include:” 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 Enhance sharing of patient information with commissioned voluntary, charitable, social enterprise and independent-sector providers.
Verbatim wording from the response “NHS England is working to enhance the sharing of patient information to and from Voluntary, Charity and Social Enterprise (VCSE) and other independent sector providers who are commissioned by NHS organisations.” 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 Integrated Care Boards are responsible for determining which independent providers connect to local Shared Care Records and supporting their connection.
Verbatim wording from the response “NHS England is working to enhance the sharing of patient information to and from Voluntary, Charity and Social Enterprise (VCSE) and other independent sector providers who are commissioned by NHS organisations.” Source location Response from NHS England
Open published response
27 Oct 2023 Francis Osborne Barnes · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 1
Failure to record vascular surgery consultations View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Francis Osborne Barnes · 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
Francis Osborne Barnes suffered an external iliac artery injury and major haemorrhage during elective hernia repair on 12 March 2022. He underwent amputation at Royal Berkshire Hospital on 14 March and died there on 16 March 2022. The concerns included whether he should have been transferred to a vascular centre sooner, and the Oxford Trust’s failure to investigate, cooperate with other organisations, maintain records, and demonstrate learning from the death.
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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 record vascular surgery consultations
Wider context from the report “The focus of my concerns relates to the approach of your Trust to learning from deaths. Although Mr Barnes was not treated at the John Radcliffe Hospital, I concluded that he should have been transferred there, and that the delay in carrying out vascular surgery there contributed to his death. The Oxford Trust has been involved in this investigation almost from the start, and other Interested Persons involved in the investigation have attempted to work with your Trust to investigate the circumstances of Mr Barnes’ death.
I have been assisted by investigation reports and statements from the Spire Dunedin Hospital, and Royal Berkshire Hospital. This, I am afraid, sits in stark contrast to the response and approach by the Oxford Trust.
The Oxford Trust has carried out no investigation. They did not co-operate with the offer to conduct a joint investigation with Royal Berkshire Hospital.
There is no recorded morbidity and mortality meeting minute, although we were told at inquest that the case was discussed.
There is no recorded MDT meeting minute, although we were told at inquest that the case was discussed.
There is no evidence of proposed changes beyond evidence in court during the inquest that “we are looking into this”. Whilst I accept entirely that a knee-jerk response, even following a tragic death, is not appropriate, it is now some 18 months since Mr Barnes’ death.
Evidence from RBH and Spire Dunedin was consistent, namely that attempts to liaise with your trust and learn from this event jointly have been universally ignored.
It was also difficult for my office to obtain evidence for the inquest. We were provided with a joint statement, from three consultant vascular surgeons (only two of whom were clinically involved). It transpired that this statement was written by a clinical governance manager, and each of the witnesses who gave evidence was careful to tell the court that they did not agree with the wording of that statement. We subsequently received a statement from the consultant vascular surgeon in this case on the 29th of September, and from the clinical lead of vascular surgery some 5 days before the inquest started. We were also informed 11 days before the inquest started that the key vascular surgery witness would be on holiday abroad. This witness was summoned in May 2023. He ultimately gave evidence by video link, but this was difficult technically, and arrangements would have been made for him to attend in person, had we been made aware of this holiday arrangement, even aside from the fact that he had been formally summoned.
Multiple attempts have been made by the other Interested Persons in this case (notably Royal Berkshire Hospital and Spire Dunedin Hospital) to discuss the issues arising, but each of these offers has been ignored. The key clinical issues in this respect have been clarification of vascular surgery pathways, and use of an OARS system (or similar).
No records were made by the vascular surgery consultant involved , despite being consulted several times about the same patient in a short space of time , and the fact that there was a clinical difference of opinion about where the patient should best be managed .
We heard no evidence of a reason for the failure to engage with processes specifically aimed at learning from deaths – whether resourcing or any other reason.
The matters of concern can be summarised as follows:
1. Clarification of vascular surgery pathways - i.e. working with others in the Thames Valley network to consider how patients should be efficiently referred to the vascular team, wherever that patient is physically based (including in the private sector).
2. Consideration of an electronic referral system (such as OARS). I note that OARS was set up by the Oxford Trust itself, and is already in operation in a neurosurgery context, and indeed even for some vascular surgery patients.
3. Consideration of how the Oxford Trust responds to and learns from deaths.
” Source location Francis Osborne Barnes · 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 Appraise options for documenting TVVN vascular referrals and consultant advice.
Verbatim wording from the response “2. Consideration of an electronic referral system” Source location Response from Oxford University Hospitals NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a Microsoft 365 Form to document emergency vascular referrals from across the TVVN.
Verbatim wording from the response “2.3.1 The use of a Microsoft 365 Form which will enable all referrals to be documented in real time including a record of the patient’s name and NHS number. This does not require the patient to have an existing OUH medical record number (MRN) and so allows documentation of referrals of patients who are not currently under the care of OUH. This Form is currently used by the vascular surgical team to track patients from around the region who are awaiting discussion at the Multidisciplinary Team meetings. The data is stored within the OUH server on Sharepoint.” Source location Response from Oxford University Hospitals NHS Foundation Trust
Open published response
27 Oct 2023 Geoffrey Alan WHATLING · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1
Failure to record observations in Care Records View source
This report raised 7 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
Geoffrey Alan WHATLING · 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
Geoffrey Alan Whatling entered Amberley Hall Care Home for rehabilitation and later became unwell, with deteriorating NEWS2 scores leading to hospital admission on 10 April 2023. He died on 26 April 2023, with the medical cause of death recorded as infective exacerbation of chronic obstructive pulmonary disease, with frailty and old age. Concerns included incomplete food and fluid records, failures to call emergency services when required, inadequate observation frequency, and gaps in care-record documentation and follow-up.
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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 record observations in Care Records
Wider context from the report “5. Some of Mr Whatling’s observations were recorded on a piece of paper and were not logged in his Care Records
” Source location Geoffrey Alan WHATLING · Prevention of Future Deaths report
Open source report
26 Oct 2023 Jacqueline Anne CARREY · Prevention of Future Deaths report Milton Keynes
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Concerns raised 1
Lack of clear recording of potential medication-abuse risks in patient medical records 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
Jacqueline Anne CARREY · 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
Jacqueline Anne CARREY was admitted to Milton Keynes University Hospital with severe pancreatitis pain, discharged with an excess of medication, and found deceased at home on 25 May 2023; the inquest conclusion was drug related. The principal concern was that risks of medication abuse may not have been clearly recorded or flagged before discharge, raising concerns about medication distribution and patient-record procedures.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clear recording of potential medication-abuse risks in patient medical records
Wider context from the report “There may not have been a clear indication on the patients medical record about the potential risk of ████████ abuse , or for the risk to be flagged up to members of staff before discharge. This oversight raises serious questions about the hospital's processes and procedures for managing ████████ medication and patient records. I strongly urge the hospital to undertake a comprehensive review of the procedures concerning the distribution of ████████ medication. It is imperative that the hospital ensures that the potential risks and warnings are clearly marked on the patient's medical record and that all staff are made aware of any potential concerns regarding ████████ use. I believe that a thorough review of your procedures and the implementation of more robust protocols can protect the well being of patients and prevent future similar deaths.
” Source location Jacqueline Anne CARREY · 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 electronic health record for proportionate additional safety measures affecting discharge medication processes.
Verbatim wording from the response “In addition to using Mrs Carrey’s case for awareness raising and education within the broad pharmacy team, we have reviewed our EHR to determine whether additional safety steps can be incorporated in such a way as they do not negatively impact the timeliness of high-volume processes in a disproportionate way.” Source location Response from Milton Keynes University 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 Introduce a coded limited-supply question that triggers prominent alerts and directs doctors and pharmacists to review the medication history before discharge prescribing or dispensing.
Verbatim wording from the response “We have been able to incorporate new measures which – at their core – codify information / recommendations around the restriction of medicines supplied at discharge (i.e., exceptions to the contractual 14-day supply expectation). The ‘Pharmacy Medication History Form’ now includes the question ‘Does this patient get a limited supply in community’, requiring a ‘yes’ or ‘no’ answer. The user can still add free text narrative but the fact of selecting ‘yes’ in response to this question fires specific actions downstream when clinicians are looking to progress the patient’s discharge.” Source location Response from Milton Keynes University Hospital
Open published response
20 Oct 2023 Thomas Doyle · Prevention of Future Deaths report East London
View report summary
Concerns raised 1
Poor standard of clinical records 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
Thomas Doyle · 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 Doyle, a 90-year-old man, was admitted to hospital with back and chest pain and subsequently developed sepsis while in hospital, dying on 25 January 2023. The concerns included poor clinical records and failure to commence the diagnostic pathway for sepsis when indicated on admission, contrary to local policy and national guidance.
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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 Poor standard of clinical records
Wider context from the report “1. The trust’s clinical records were of a particularly poor standard which impeded the Trust’s governance investigation and the inquest investigation in determining what, if any considerations was given to the possibility that Mr Doyle was suffering from an infection.
” Source location Thomas Doyle · 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 Disseminate record-keeping standards and safety concerns through staff alerts, intranet video, computer screensavers and clinical governance meetings.
Verbatim wording from the response “• An Internal Alert has been shared with staff via email, Alert reference ████████ Issued Date 9 November 2023 which details good record keeping standards that should be adhered to by all staff.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require medical staff record-keeping e-learning from their first working day and include record keeping in nursing preceptorship and junior-doctor induction.
Verbatim wording from the response “• All medical staff must complete a record keeping module on the Trust BEST learning management system that allows staff to undertake e learning module on their first day working at the Trust. Record keeping for nursing staff is included in the nursing preceptorship programme.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct and report an Emergency Department medical-records audit of Careflow free-text completion, with oversight by the Trust Audit Committee.
Verbatim wording from the response “• ED services have registered a medical records audit which will commence December 2023 and complete 31 January 2024, on the new electronic Careflow record, ensuring the free text sections are being completed to the Trust and professional standards. The audit report will be shared with all teams and action plan agreed for any identified areas of concern; the audit will be overseen by the Trust Audit Committee.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Open published response
20 Oct 2023 Trevor Coy BAILEY · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to record relevant family medical history 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. 5
Church Lane Surgery
Update the NHS health-check template to record negative family history of ischaemic heart disease.
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Church Lane Surgery
Expand family-history updates to annual chronic-disease checks, medication reviews, ECG appointments and standardised templates.
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Church Lane Surgery
Begin updating ischaemic-heart-disease family histories for all patients aged over 25 and inform patients about voluntary updates at registration.
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Church Lane Surgery
Train staff to collect and accurately record family-history information in the clinical system.
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Church Lane Surgery
Audit new family-history entries every 12 months to assess system progress.
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AI-generated summary
Trevor Coy BAILEY · 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
Trevor Bailey attended hospital with chest pain on 19 April 2023 and was discharged after negative test results, without referral to the rapid access chest pain clinic. He subsequently died from a fatal myocardial infarction on 7 May 2023; the concern was that his recent smoking history and family history of ischaemic heart disease were not elicited, which may have prevented an appropriate referral.
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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 record relevant family medical history
Wider context from the report “1. I heard evidence at inquest that Mr Bailey had a family history of ischaemic heart disease – his brother had had two cardiac stents placed in 2006 and two in 2012.
However, this information was not on Mr Bailey’s medical record , it was not elicited at his 2012 or 2018 health checks and it was not elicited when he consulted his general practitioner, ████████
████████, on 19 or 27 April 2023.
The recording of this information is unlikely to have changed the outcome for Mr Bailey, but it was a vital part of the medical history and it might easily for another patient.
” Source location Trevor Coy BAILEY · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the NHS health-check template to record negative family history of ischaemic heart disease.
Verbatim wording from the response “We have taken the following steps to update the family history of coronary heart disease (IHD).” Source location Response from Chuch Lane Surgery
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand family-history updates to annual chronic-disease checks, medication reviews, ECG appointments and standardised templates.
Verbatim wording from the response “Currently we assess family history during new patient checks and NHS health checks. We are expanding this practice to include updates on family history at additional points of contact, such as annual chronic disease checks and structured medication reviews, ECG appointments, and have integrated this into our standardised templates.
We have initiated the process of updating family history for all patients aged 25 and above. We have sent the message to all the patients aged >25yrs, to update their family history of IHD. All patients will be informed at registration that they will have to update their family history voluntarily if there are any changes. We have trained the staff to record it in our system. We are going to audit the new entry of family history of IHD every 12 months to assess the progress of our system.” Source location Response from Chuch Lane Surgery
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Begin updating ischaemic-heart-disease family histories for all patients aged over 25 and inform patients about voluntary updates at registration.
Verbatim wording from the response “Currently we assess family history during new patient checks and NHS health checks. We are expanding this practice to include updates on family history at additional points of contact, such as annual chronic disease checks and structured medication reviews, ECG appointments, and have integrated this into our standardised templates.
We have initiated the process of updating family history for all patients aged 25 and above. We have sent the message to all the patients aged >25yrs, to update their family history of IHD. All patients will be informed at registration that they will have to update their family history voluntarily if there are any changes. We have trained the staff to record it in our system. We are going to audit the new entry of family history of IHD every 12 months to assess the progress of our system.” Source location Response from Chuch Lane Surgery
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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 staff to collect and accurately record family-history information in the clinical system.
Verbatim wording from the response “Currently we assess family history during new patient checks and NHS health checks. We are expanding this practice to include updates on family history at additional points of contact, such as annual chronic disease checks and structured medication reviews, ECG appointments, and have integrated this into our standardised templates.
We have initiated the process of updating family history for all patients aged 25 and above. We have sent the message to all the patients aged >25yrs, to update their family history of IHD. All patients will be informed at registration that they will have to update their family history voluntarily if there are any changes. We have trained the staff to record it in our system. We are going to audit the new entry of family history of IHD every 12 months to assess the progress of our system.” Source location Response from Chuch Lane Surgery
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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 Audit new family-history entries every 12 months to assess system progress.
Verbatim wording from the response “Currently we assess family history during new patient checks and NHS health checks. We are expanding this practice to include updates on family history at additional points of contact, such as annual chronic disease checks and structured medication reviews, ECG appointments, and have integrated this into our standardised templates.
We have initiated the process of updating family history for all patients aged 25 and above. We have sent the message to all the patients aged >25yrs, to update their family history of IHD. All patients will be informed at registration that they will have to update their family history voluntarily if there are any changes. We have trained the staff to record it in our system. We are going to audit the new entry of family history of IHD every 12 months to assess the progress of our system.” Source location Response from Chuch Lane Surgery
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The family history was not disclosed during prior consultations, so it was unavailable for consideration in risk assessment and prescribing.
Verbatim wording from the response “It has been discovered that the patient's brother had a history of cardiovascular disease in 2006 and 2012, which was not disclosed during previous encounters in 2012, 2018, or recent visits. As a result, it is now clear that the patient had a family history of cardiovascular disease that was not reported in previous encounters. This information was not taken into account, and the patient was not prescribed any cardio protective medication due to the low cardiovascular risk score as per NICE guidelines.” Source location Response from Chuch Lane Surgery
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17 Oct 2023 Jason Mark BAYLEY · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to accurately record medication adherence in shared clinical records View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
St Andrew's Healthcare
Speak with colleagues who made inaccurate entries and remind them during management supervision about accurate record keeping.
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St Andrew's Healthcare
Audit medication-related Rio notes against ePMA records to assess the extent of inaccurate documentation.
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St Andrew's Healthcare
Disseminate messages to all colleagues on accurate record keeping and documenting missed medication doses in Rio.
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St Andrew's Healthcare
Require Care Plan Update Meetings and ward rounds to review patients’ previous two weeks of ePMA medication records.
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St Andrew's Healthcare
Assess whether ePMA can automatically create Rio progress notes documenting medication administration events.
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St Andrew's Healthcare
Investigate whether ePMA can alert responsible clinicians when consecutive medication doses are missed, including alert-fatigue effects.
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AI-generated summary
Jason Mark BAYLEY · 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
Jason Mark BAYLEY, who had chronic constipation while detained for treatment at St. Andrew's Healthcare, developed intestinal pseudo-obstruction and died at hospital on 28 December 2022. Concerns included repeated inaccurate recording of medication adherence in the Rio notes, which stated that all medication had been taken when doses of lactulose had been refused, creating a risk that staff might misunderstand whether medication had been taken and fail to plan appropriate care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to accurately record medication adherence in shared clinical records
Wider context from the report “2. On most days between 4/12/22 and 25/12/22 when he was a detained patient on Speedwell Ward at St. Andrew's Healthcare, Mr Bayley refused to take at least one of his daily doses of lactulose which he was prescribed as part of a regime of laxatives for constipation. While these refusals were documented in the Electronic Prescribing and Medicines Administration document, there were four occasions when it was incorrectly documented that all medication had been taken under the 'Medication Adherence' section in the Rio notes .
3. The Rio notes are the daily working records to which all staff have access. The reporting of medication adherence is specifically prompted in the Rio notes. It is of concern that, owing to a breakdown in communication between staff, the Rio notes repeatedly stated that all medication had been taken when it had not .
4. I am concerned that accurate documentation of whether medication has been taken in the Rio notes is an important safeguard against harm and a mechanism to promote appropriate care planning. I am concerned that there may be a risk to the life of some patients if staff understand that medication has been taken when it has not.
” Source location Jason Mark BAYLEY · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Speak with colleagues who made inaccurate entries and remind them during management supervision about accurate record keeping.
Verbatim wording from the response “3.1 Having compared the missed doses of lactulose with the inaccurate Rio notes we have noted that on every occasion the Rio note was made by a colleague who was different to the one who administered the medication. During this period, where Mr Bayley missed a dose of lactulose and the Rio note documenting the shift handover was made by the person who administered his medication the Rio note is accurate. The staff making these notes vary in seniority from healthcare assistants to a deputy ward manager.” Source location Response from St Andrew's Healthcare
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit medication-related Rio notes against ePMA records to assess the extent of inaccurate documentation.
Verbatim wording from the response “4.1 In order to address the issue with the inaccuracy of the Rio notes that relate to medication the Charity is undertaking the following actions:” Source location Response from St Andrew's Healthcare
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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 Disseminate messages to all colleagues on accurate record keeping and documenting missed medication doses in Rio.
Verbatim wording from the response “Action 2: Reminding staff of the importance of good record keeping
4.3 The Charity has a weekly clinical briefing called the Pulse which is received by all colleagues. We have included a message on the importance of accurate record keeping as well as another on the importance of documenting in Rio if a patient misses a dose of medication.” Source location Response from St Andrew's Healthcare
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require Care Plan Update Meetings and ward rounds to review patients’ previous two weeks of ePMA medication records.
Verbatim wording from the response “Action 3: Ensuring CPUMs review EPMA data
4.4 The Charity senior clinicians have communicated to their medical colleagues that every Care Plan Update Meeting/Ward Round should include a review of the last two weeks medication records on ePMA. This will ensure missed doses of medication will be noticed even if the Rio notes are incorrect.” Source location Response from St Andrew's Healthcare
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess whether ePMA can automatically create Rio progress notes documenting medication administration events.
Verbatim wording from the response “Action 4: Investigating a technical solution
4.5 The Charity is currently undertaking a project to consider if ePMA can automatically make a Rio progress note documenting medication administration events. This would negate the need for this information to be included in the shift summary notes.” Source location Response from St Andrew's Healthcare
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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 whether ePMA can alert responsible clinicians when consecutive medication doses are missed, including alert-fatigue effects.
Verbatim wording from the response “4.6 In addition, the Charity is investigating if an ePMA can send a patient’s responsible clinician an alert if consecutive doses of medication are missed by a patient. In addition to the technical feasibility of this proposed development, the Charity also needs to consider the effect of ‘alert fatigue’ in the sense that the effectiveness of such alerts will be reduced if key clinicians receive too many alerts as they will start to be ignored.” Source location Response from St Andrew's Healthcare
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing ePMA records, regular care reviews and the Patient Safety Dashboard adequately address risks from inaccurate medication information in Rio notes.
Verbatim wording from the response “5.3 We would also highlight that you may not have been provided with detailed information of how the Charity’s EPR systems operate and are reviewed, which would have given you a better understanding of how the ePMA is used by clinicians. The Charity’s position is that the prominent system for checking the prescribing and administration of medication is ePMA which is regularly checked by doctors and is used by nurses at every instance of medication administration. There are therefore controls in place which address the risk of incorrect information about medication administration being entered into the progress notes of Rio, which is not the main system for medication management.” Source location Response from St Andrew's Healthcare
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.