22 Jun 2017 Constance Connolly · Prevention of Future Deaths report Inner South London
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Concerns raised 1
Failure to document significant findings and required follow-up investigations in discharge information View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Constance Connolly · 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
Constance Connolly died at home on 8 March 2016 from disseminated Nocardia infection, with severe chronic obstructive airways disease also recorded. She declined hospital admission, and planned outpatient investigations were not completed. The report identified concerns about inadequate follow-up, failures in handover and communication, incomplete discharge information, and the failure to arrange a replacement scan appointment, describing these as a system failure in urgent follow-up after discharge from A&E.
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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 document significant findings and required follow-up investigations in discharge information
Wider context from the report “There are four matters in the circumstances which cause concern
1. The doctor who ordered the scan did not conduct any follow up to see that it had been performed. The consultant chest physician said that handover of care was dangerous time and that it was his duty to do so.
2. The referring doctor notified the GSTT community palliative care team of the need to organize a MRI scan, on the understanding that the team was taking over care. The consultant in the palliative care team explained that their role was to advise the doctor responsible for care, which was at the time, the general practitioner. The referring doctor did not inform the general practitioner.
3. The discharge note to the GP from the A&E indicated a diagnosis of stroke (presumed before CT scan), did not mention the CT finding of cerebral lesions that may be metastases, nor the need for EMI scan and further investigation to conform diagnosis, nor the booking of a MRI scan
4. A member of the palliative care team rang the A&E department and was told that the scan appointment was the next day (17th). When the patient and her mother attended the next day, she was told that there was no appointment. Evidence was heard that the booking, which was on the basis of being an in-patient, is automatically cancelled if the patient becomes an out-patient and the clinical referral cannot be transferred to an outpatient appointment. A new referral and form needed to be completed. So the patient went home, and no further appointment was made.
The above evidence suggests a system failure in handover of patients who leave A&E with the need for urgent follow up.
” Source location Constance Connolly · 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 Send formal discharge notifications to GPs after self-discharge, including relevant tests, assessments and follow-up arrangements.
Verbatim wording from the response “Steps have been taken to ensure that regardless of patients self-discharging, a formal Discharge Notification is always sent to a patient’s GP, setting out all relevant tests/assessments performed and any follow-up arrangements if applicable. Responsibility sits with the admitting Consultant and Ward Managers, and this will be included in the junior doctors’ induction information package.” Source location 2017-0201-Response-by-Kings-College-Hospital
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How this respondent action was interpreted
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PFD Monitor interpretation Implement mandatory suspected and confirmed diagnoses, author and senior clinician fields on Emergency Department discharge letters to GPs.
Verbatim wording from the response “• There is currently a national recommendation from the Royal College of Emergency Medicine to improve and standardise communication from all Emergency Departments to GPs by October 2017 (the “ECDS” or Emergency Care Data Set). The ED’s IT team are working to implement this and this will include a mandatory ‘suspected and confirmed diagnoses’ step on all ED discharge letters to GPs with details of who wrote the discharge notification and the identity of the senior clinician overseeing the patient’s care.” Source location 2017-0201-Response-by-Kings-College-Hospital
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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 Develop a Trust-wide best-practice guide for discharge notifications and clinic letters, including self-discharge requirements, with local CCG collaboration.
Verbatim wording from the response “• The Trust is developing a Trust-wide best practice guide on Discharge Notification and clinic letter writing for clinical staff, in collaboration with the local CCGs. This will include clarification that a discharge notification is required for all patients who self-discharge.” Source location 2017-0201-Response-by-Kings-College-Hospital
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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 Upgrade the Emergency Department tracking system to distinguish completed, booked and pending investigations on GP discharge notifications.
Verbatim wording from the response “• The ED tracking system (Symphony) is planned for an upgrade, which is due by October 2017. This will enable ED GP Discharge Notifications to highlight and distinguish which investigations have been done (ideally with a result if verified), which are booked and which are still pending.” Source location 2017-0201-Response-by-Kings-College-Hospital
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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 concerns raised did not cause or contribute to the death, and the inquest found no failures of care contributed to it.
Verbatim wording from the response “As a preliminary point, we note that none of the concerns raised in the Report caused or contributed to Mrs Connolly’s death in light of the Conclusion reached at the Inquest hearing on 24 May 2017, namely “Natural causes contributed to by unintended consequences of necessary medical treatment”. The Report in particular states that no failures of care contributed to Mrs Connolly’s death.” Source location 2017-0201-Response-by-Kings-College-Hospital
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15 Jun 2017 Mr Kevin George Mann · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to document the amount of contrast handed over and ingested View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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 Kevin George Mann · 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 Kevin George Mann underwent an Ivor Lewis procedure for oesophageal cancer and subsequently developed a pneumothorax. A Visipaque contrast study was performed despite the pneumothorax, and contrast entered his left main bronchus; his respiratory condition deteriorated and he later died. Concerns included failures to check available imaging and an outstanding chest x-ray request, to stop the procedure when contrast entered the bronchus, and to document the amount of contrast used.
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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 document the amount of contrast handed over and ingested
Wider context from the report “4. There was no documentation available within the records of the amount of contrast handed to Mr Mann or the amount of contrast ingested by him .
” Source location Mr Kevin George Mann · Prevention of Future Deaths report
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Concerns raised 1
Failure to record discussions about exceeding prescribed dosages View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Craig Stuart Hamilton · 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
Craig Stuart Hamilton died on 8 December 2016 from acute tramadol toxicity after taking excess Tramadol to relieve chronic pain and sleep before working the next day. The principal concerns were the absence of clear procedures for managing patients who obtain or take more medication than prescribed, and insufficient exploration of medication regimes, alternative pain management, and discussions about exceeding prescribed dosages.
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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 discussions about exceeding prescribed dosages
Wider context from the report “(4) Consideration for improved systems for discussing with patients the implications of them attempting to exceed prescribed dosages and recording that such discussions have taken place .
” Source location Craig Stuart Hamilton · Prevention of Future Deaths report
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5 Jun 2017 Derrick Lawrence Brocklehurst · Prevention of Future Deaths report Manchester South
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Concerns raised 2
Failure to recover care notes when care ceased View source Lack of documentation of carer visits View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Derrick Lawrence Brocklehurst · 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
Derrick Lawrence Brocklehurst was admitted to hospital after being found immobile and incontinent at home, with grade 4 pressure ulcers, and died on 2 December 2016 from a pulmonary embolus. Concerns included missing records of carer visits and the absence of a discharge summary from the hospital to the GP after his A&E attendance.
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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 recover care notes when care ceased
Wider context from the report “1. There was no documentation available of the carer visits. The care provided and any issues with the provision of care could not be established. They were not recovered by Social Services when care stopped. There was no system for recovery of care notes when care ceased.
” Source location Derrick Lawrence Brocklehurst · Prevention of Future Deaths report
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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 documentation of carer visits
Wider context from the report “1. There was no documentation available of the carer visits. The care provided and any issues with the provision of care could not be established. They were not recovered by Social Services when care stopped. There was no system for recovery of care notes when care ceased.
” Source location Derrick Lawrence Brocklehurst · 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 Remind care providers at the next Provider Forum about care-record maintenance, copying, recovery, failure recording and seven-year archiving obligations, then confirm these requirements in writing.
Verbatim wording from the response “a. The agenda for a Provider Forum, due to take place on 25 July 2017, included an item relating to Care Record Books. Unfortunately this forum was postponed. The item will be included on the agenda for the next Provider Forum at which providers will be reminded of their obligations and in particular the obligation to:” Source location 2017-0181-Response-by-Tameside-Metropolitan-Borough
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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 Run a weekly report of ended care packages and request providers to confirm recovery of each care record book or report recovery attempts and reasons for failure.
Verbatim wording from the response “c. With immediate effect on a weekly basis the Homecare Commissioning Team will run a report identifying which service users have ceased to receive care. The relevant provider will be sent a copy of this report with a request for confirmation that the care record book has been recovered from the service user. Where the provider states records cannot be recovered the provider must notify the Council, detail the attempts that have been made to recover the records and give reasons for not being able to do so;” Source location 2017-0181-Response-by-Tameside-Metropolitan-Borough
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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 Raise and discuss unrecovered care record books with providers at contract performance meetings.
Verbatim wording from the response “d. Where a provider has been unable to recover a care record book the matter will be raised and discussed with the provider at a contracts performance meeting. If necessary and appropriate to do so the Council will require the provider to take steps and measures to address the failure to recover record book.” Source location 2017-0181-Response-by-Tameside-Metropolitan-Borough
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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 Amend District Nursing note-keeping and strengthen retrieval of central patient notes.
Verbatim wording from the response “The Trust’s District Nursing Service, which covers the Tameside and Glossop locality, has recently amended the process in relation to note keeping and strengthened the process for retrieval of notes.” Source location 2017-0181-Response-by-Tameside-Glossop-Integrated-Care
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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 contemporaneous visit records, disseminate the supporting procedure and monitor staff compliance.
Verbatim wording from the response “The new process requires a separate carbonated evaluation sheet to be completed for each and every visit (excluding those for routine insulin or low molecular weight injections) and brought back to base immediately thereafter so that it can be filed in the central notes. A standard operating procedure has been produced and disseminated to all staff within the District Nursing Service setting out the new process and compliance will be monitored by the Team Leaders.” Source location 2017-0181-Response-by-Tameside-Glossop-Integrated-Care
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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 unavailable care records were considered an isolated incident rather than evidence of a systemic failing.
Verbatim wording from the response “26. The Council regrets that no documents relating to the care visits were available to the Coroner. However the Council believes that this was an isolated incident rather than an example of a systemic failing and it is only very rarely that a care provider is unable to provide to the Council when requested the actual care record book from a service user’s property.” Source location 2017-0181-Response-by-Tameside-Metropolitan-Borough
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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 Providers cannot recover care records from a property without cooperation because they cannot enter after care has ended.
Verbatim wording from the response “18. There will be circumstances where the Council and the provider receive no prior notification of care ending (such as when a service user is admitted without notice to hospital and subsequently dies). In such circumstances the provider will be notified by the Home Care Commissioning Team that care has ended. The provider must take steps to try and recover the care record book. The provider will rely on the information of whoever may still be residing at the service user’s home, such as family members and others, to recover the care records. However if cooperation is not forthcoming the provider cannot enter the property to recover the records knowing that the service user isn’t present and that the contract to provide care has ended.” Source location 2017-0181-Response-by-Tameside-Metropolitan-Borough
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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 stated actions and proposals were considered sufficient to minimise the risk of care records being unavailable at future investigations and inquests.
Verbatim wording from the response “28. The Council trusts these actions and proposals are sufficient to satisfy that Coroner that the Council does take this issue seriously, that there is a system in place for the recovery of care record books and that care providers will be advised of their record keeping obligations. This in turn will minimise the risk of care record books not being available at future Investigations and Inquests.” Source location 2017-0181-Response-by-Tameside-Metropolitan-Borough
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30 May 2017 Mrs Sarah Poole · Prevention of Future Deaths report Black Country
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Concerns raised 1
Failure to record and endorse the reviewing doctor’s name on ECGs View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mrs Sarah Poole · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Sarah Poole was admitted to hospital with sudden headache and back pain, but an abnormal ECG was incorrectly considered normal and she was discharged home. She was readmitted the following day, diagnosed with an aortic dissection and underwent emergency surgery, but developed complications and died on 5 November 2016. The principal concern was a failure to record and endorse the reviewing doctor’s name and to consider previous abnormal ECG results during handover.
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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 and endorse the reviewing doctor’s name on ECGs
Wider context from the report “1. Evidence emerged during the inquest that there were failures to record and endorse the name of the Doctor reviewing the ECG and a failure to take into account previous abnormal ECG results during the handover from the paramedic staff.
” Source location Mrs Sarah Poole · 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 Require Senior Decision Makers to review and sign off all ECGs, and audit compliance monthly.
Verbatim wording from the response “The Emergency Department has instigated a policy that all ECGs must be reviewed and signed off by a Senior Decision Maker, i.e. a middle grade Doctor or Consultant.” Source location 2017-0176-Response-by-The-Royal-Wolverhampton-NHS-Trust
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26 May 2017 Doreen Helen MILLER · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 1
Failure of the healthcare-record archiving system to retain and provide records View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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
Doreen Helen MILLER · 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
Doreen Helen MILLER, a vulnerable and housebound adult, was discharged home after an intermediate-care placement despite concerns about unusual toileting behaviour, possible cognitive impairment, self-neglect and limited provisions. She was found severely hypothermic in her cold, dark flat the next morning and died at hospital on 13 January 2016. The principal concerns included safeguarding referrals not being properly investigated, important cognitive information not being communicated, poor record-keeping and decision-making, insufficient assessment of mental capacity, and inadequate systems for reviewing serious incidents and learning from them.
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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 of the healthcare-record archiving system to retain and provide records
Wider context from the report “c) (Wiltshire Council, Wiltshire Health & Care and Great Western Hospital) As a general comment, my view in relation to the quality and substance of case notes was that they were poor in quality. My investigation was hampered due to the fact that the Archiving System at Great Western Hospital for Doreen’s therapy led healthcare notes failed in that the notes or at least the scanned images were lost and were not available . Given that some notes were recorded on the Wiltshire Council Care First System and the evidence was that the Healthcare records would not have been significantly different my concerns remain. Crucial and important decisions did not contain any rationale as to why and the basis upon which that decision was being made. As indicated when I summed up the evidence my view is that recording a rationale can act as a check in relation to the decision making process itself as it forces the author to consider the process and information that has led to that decision being made.
I also have concerns in relation to the way MDT’s work and reach decisions. The decisions very much appear in relation to the case decision amongst relevant members of the team as opposed to an individual making the decision based on information provided by relevant team members. There was no leadership. My concern as regards this consensual approach is that no-one actually takes ownership and responsibility for the decision itself and a consensual approach as evidenced in Doreen’s case can in my view lead to a situation whereby there is a false sense of reassurance in believing that nothing more could be done for Doreen that in this case led to wrong decisions being taken.
” Source location Doreen Helen MILLER · Prevention of Future Deaths report
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8 May 2017 David Sheppard · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to keep acute and contemporaneous event notes with timings View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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
David Sheppard · 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
David Sheppard choked on a doughnut at Boldmere Court on 31 July 2016 and suffered a cardiac arrest and severe hypoxic brain injury. He was taken to Good Hope Hospital, where treatment was withdrawn, and he died on 3 August 2016. The principal concerns were inadequate emergency response, poor communication, failures in record keeping, insufficient first-aid training, and inadequate post-event investigation.
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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 keep acute and contemporaneous event notes with timings
Wider context from the report “2. Record keeping. Staff failed to keep an acute and contemporaneous note of the events that occurred with timings . This made reconstruction of the event extremely difficult.
” Source location David Sheppard · Prevention of Future Deaths report
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26 Apr 2017 John Davies · Prevention of Future Deaths report Manchester South
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Concerns raised 3
Insufficient detail in care home notes View source Failure to complete District Nursing Team patient records within required timescales View source Insufficient detail in patient records completed by the District Nursing Team View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
John Davies · 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
John Anthony Davies had Lewy body dementia and Parkinson’s disease and died on 23 October 2016 after deterioration following an infected pressure sore. Concerns included inadequate risk assessment when his care needs changed, poor communication and information sharing, incomplete records, lack of continuity of care, difficulties securing a suitable nursing home placement, and failures relating to pressure-relieving strategies.
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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 detail in care home notes
Wider context from the report “6. The Care Home notes were lacking in detail
” Source location John Davies · Prevention of Future Deaths report
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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 complete District Nursing Team patient records within required timescales
Wider context from the report “3. Patient records completed by the District Nursing Team lacked detail and were not completed in the required timescales .
” Source location John Davies · Prevention of Future Deaths report
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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 detail in patient records completed by the District Nursing Team
Wider context from the report “3. Patient records completed by the District Nursing Team lacked detail and were not completed in the required timescales.
” Source location John Davies · 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 Appoint a Named Nurse for the residential home.
Verbatim wording from the response “A new Named Nurse has been appointed to the residential home involved in this case. This nurse will ensure communication and documentation is improved and this will be overseen by the DN Caseload Holder (Band 6 Nurse). The Named Nurse now attends monthly meetings at the residential home with the manager and the staff to ensure all aspects of patients’ care are discussed and communicated to the DN team. The home manager will also invite Adult Social Care staff, District Nursing staff, GP and home care staff to the meeting for ongoing discussion of the patients’ care.” Source location 2017-0138-Response-by-Stockport-NHS-Trust
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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 Address District Nursing documentation deficiencies with staff and facilitate a reflective session on nursing care.
Verbatim wording from the response “Patient records complete by the District Nursing Team lacked detail and were not completed in the required timescale.” Source location 2017-0138-Response-by-Stockport-NHS-Trust
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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 District Nursing patient notes and repeat the audit to confirm improvements are sustained.
Verbatim wording from the response “The Trust accepts that the patient’s District Nursing notes did lack detail especially around the deterioration of the patient’s physical and mental health and were not completed in the required timescale. This has been addressed with the team and a reflective session has been facilitated regarding the patient’s nursing care. An audit of the team’s patients’ notes has been carried out by the DN Clinical Lead and improvements have been noted. The Patient Records audit is being repeated to ensure that the improvements have been sustained.” Source location 2017-0138-Response-by-Stockport-NHS-Trust
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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 Care home notes are the care home's responsibility, so the concern should be forwarded to the care home.
Verbatim wording from the response “The Care Home notes are not the responsibility of the Trust, and we respectfully request that this concern is forwarded to the Care Home.” Source location 2017-0138-Response-by-Stockport-NHS-Trust
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25 Apr 2017 Linsay Bushell · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 1
Inadequate recording and documentation of self-harming behaviour and triggers View source
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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
Linsay Bushell · 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
Linsay Bushell, aged 37, died on 13 October 2014 after being found having self-ligatured under her bed while detained in a psychiatric ward; the medical cause was asphyxia due to compression of the neck due to ligature strangulation. The report identified concerns including inadequate access to psychological therapies, limited understanding and documentation of self-harm, poor handover and observation records, fragmented care, delays in finding suitable placement, and insufficient staff training and support.
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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 Inadequate recording and documentation of self-harming behaviour and triggers
Wider context from the report “The Court heard evidence that 40% to 50% of mentally disordered female patients suffered from EUPD rather than mental illness and yet there was no provision or priority for therapeutic psychological services to be commissioned in the NHS England Area.
The Jury found:
Para 3
1. Linsay Bushell was certified as having died on the evening of 13th October, 2014. at the Royal Liverpool University Hospital.
2. Linsay Bushell came by the fatal event that caused her death at 20.20 at room 2 on the Brunswick Ward at the Broad Oak Unit on 13th October 2014.
3. The medical cause of Linsay's death was Asphyxia due to Compression of the Neck due to Ligature Strangulation.
4. Linsay put herself in the position in which she was found however her intention was unclear.
5. At the time of her death and for most of her adult life, Linsay had suffered from a form of mental disorder namely an unstable borderline personality disorder.
6. The real and imminent risk of self-harm or suicide was recognised during Linsay's care at the Broad Oak Unit in the time leading up to her death.
7. The risk was managed adequately and effectively during Linsay's period as an in-patient.
8. The jury accept the admissions of Mersey Care NHS Foundation Trust and adopt the findings that the Trust has made.
a. In the Trust Position Statement
Mersey Care considers the death of any service user with the utmost seriousness and care. As an organisation it is committed to providing a high standard of care to service users generally. If, in connection with any patient under its care, mistakes have been made whether in the form of individual errors or as a result of system or structural defects, then the Mersey Care Trust Board is committed to uncovering those errors, correcting them and learning lessons from them.
2. Following the death of Linsay Bushell on 13th October 2014, Mersey Care instigated an investigation into her death, including the wider circumstances of her death, to find out whether there were shortcomings in the care provided to Linsay and, if so, devise ways of improving practice. That investigation was an internal review and root cause analysis by a multi-disciplinary panel which included an external medical reviewer. Its Terms of Reference were agreed by the Trust Board and were deliberately wide so as to pick up deficits in care or indeed examples of good practice throughout Linsay's involvement with the Trust and so enable as deep a learning exercise as possible in what was acknowledged to be a complex clinical picture. The review panel considered relevant documents and interviewed members of staff and the investigator's report was provided to Mersey Care Trust Board in December 2015.
3. Following the internal investigation, the Trust Board instructed ████████ the Chief Operating Officer of the Local Services Division to consider the report of the internal investigation and undertake her own review and appraisal of the circumstances of the death. She was also instructed to devise a workable and practical strategy to address the issues which were raised by the internal review and her own consideration of the material.
4. The Trust is committed to transparency and accountability. The purpose of this Position Statement is to advise the Court and Linsay's family of the Trust's response to the work which has been undertaken internally by the Trust and of the approach which will be taken to the forthcoming inquest into Linsay's death. It is hoped that, by doing so, the Court's case management task in respect of the forthcoming inquest will be facilitated; also importantly that Linsay's family will be reassured by their understanding that an approach which is consistent with the conclusions of the internal review of the death is to be adopted at the inquest.
5. The conclusions of the internal review include some examples of good or notable practice and many areas where the service or care provided to Linsay fell short of the desired standards. Following concerns raised by a member of staff, the Review Team considered the contents, including the conclusions, of the internal review undertaken. Having done so, the Review Team adheres to the conclusions which were expressed in the report. The Trust Board fully acknowledges that mistakes had been made in Linsay's care when she was a resident on Broad Oak Unit and that these mistakes afforded Linsay the opportunity to ligature on 13th October 2014. The Trust accepts responsibility for Linsay's death. Whilst understanding that no apology will fully assuage the feelings of Linsay's family and those who were close to her, the Trust nonetheless offers that apology. It is made with sincerity.
6. The review panel considered that Linsay's psychiatric condition was complex. Her condition fluctuated in response to stressors such as bereavement and illicit drug use. However, a main theme to emerge from the internal review panel report was the failure of the Trust to provide Linsay with a service that was psychologically driven at all levels of care. The Trust accepts this criticism.
It is accepted that psychology interventions were not available on a consistent basis throughout Linsay's residence on the Unit and that ward staff were inadequately supported in their provision of such care and treatment.
a. Whilst an attempt to understand the motivation for self-harming behaviour is apparent from the Acute Care Plans (which were not available to the panel) the Trust accepts that this was inadequate. The Trust also accepts that the record keeping and standard of documentation was inadequate so that a more detailed picture of Linsay's self-harming behaviour and its triggers was not available . As a result, staff were hampered in considering the best ways of limiting and controlling Linsay's self-harming behaviour.
b. Whilst understanding that patients suffering from Personality Disorders may present a complex management problem, a focused and co-ordinated approach to finding the most appropriate establishment to meet Linsay's needs was not adopted. It was recognised that Brunswick Ward did not meet Linsay's short or long-term needs. Although efforts were made by the Care Co-ordinator to locate the most appropriate placement for Linsay, funding was not immediately available. This had the effect of causing Linsay distress and disappointment. The Trust accepts this criticism.
c. Staff were not sufficiently trained and supported in their understanding of Emotionally Unstable Personality Disorders and the high suicide rate associated with this condition particularly during long term hospital stays. Again, the Trust accepts this criticism.
7. Further themes to emerge from the internal review included: the lack of implementing a co-ordinated approach to checking patients after handover; that handover documentation was scant; that documentation of observation levels was insufficiently clear; that there were limited interventions regarding substance misuse and its effect on Linsay's self-harming behaviour and that ward management needed greater support. All of these observations and criticisms are accepted by the Trust.
8. ████████ has been tasked with reviewing Linsay's care during her residence on Brunswick Ward and reviewing the conclusions of the internal report. She is involved in the wider Trust initiatives which include reducing the risk of suicide by patients and enhancing the understanding and treatment of those patients who suffer from Personality Disorders. She has set out the steps which have been taken in her statement. The key points are as follows:
a. Given the wide understanding that those suffering from Personality Disorders are best managed in the community, a Personality Disorder Hub has been established in the community. This is now led by ████████ a Consultant Psychiatrist in Psychotherapy, and is intended to co-ordinate and manage the care of patients with Personality Disorders within the community. The objective is that, where possible, admissions to hospital are kept short, or avoided altogether. This involves close and collaborative working by all of those involved in the patient's care. This is facilitated by the PD Hub.
b. Case managers have been recruited and assigned to service users who attend the emergency services regularly (as a consequence of self-harming behaviour). These case managers work closely with the PD Hub and focus care on the individual. The care given is psychologically based. It is targeted at helping the patient to devise strategies to limit self-harming behaviour.
c. Borderline Personality Disorder Guidelines have been devised which stipulate that meetings of professionals should take place in complex cases and a specific Extended Care Plan should anticipate and considers care both in the community and in inpatient units. The objective is to provide a coherent and co-ordinated plan of care which is tailored to the particular needs and challenges posed by the particular patient.
d. Nursing staff have received training in Personality Disorders. Complex Case discussions take place on all wards. This is intended to enable multi-disciplinary team discussion between professionals in particularly challenging cases.
e. A daily Bed Management system has been introduced which, amongst other objectives, is intended to ensure that patients with Personality Disorders are discharged back into the community with minimum delay and with an appropriate support package.
9. Although ████████ describes in her statement the various responses which have been made by the Trust to improve the management of patients with Personality Disorders, the individual elements are intended to work as only part of an integrated model. The strength of the structure lies in its overarching objective of transforming the approach generally to meeting the needs of those with Personality Disorders, recognised as presenting a particular set of challenges to any healthcare organisation.
10. ████████ also addressed in her statement the further steps which have been taken to support staff in complying with Trust policies, including the Care Programme Approach, observation levels, suicide prevention and training, record keeping and shift handover documentation. Regular audits for compliance and ongoing support is undertaken. There has been a review of leadership roles within the Unit generally including Brunswick Ward and support and guidance for those occupying a leadership role is regularly provided.
11. As ████████ has stated, although much has changed since Linsay's death, there is no room for complacency. She and others within the Trust will continue their work and undertake a regular evaluation of service levels.
12. It is hoped that Linsay's family are encouraged in their understanding that the Trust have taken Linsay's death very seriously indeed. Lessons have been learned. Her death has been a catalyst for change for the better.
b. In the implementation of Lessons learnt the Trust further accepts
1. The review team identified this as "a very complex case" and noted that "it is unclear whether or not LB harmed herself with a view to achieving death or in an effort to gain help from staff which had happened on many occasions before during her in-patient stay".
a. The review team reached a number of critical conclusions relating to the care which Linsay received during the course of her involvement with the Trust. The principal conclusions were as follows:-
b. Limited understanding and analysis of self-harming behaviour. The review team noted that Linsay was described as undertaking self-harming behaviour on many occasions and that her 'ligaturing' was used in the notes in a generic sense with no specific details given on many occasions. The review team concluded that despite repeated attempts at self-harm with the same behaviour, insufficient effort was made to look at this particular risk. They also concluded that the notes did not pick up exploration of the reasons behind many self-harm attempts. Instead, they thought it was generally assumed that Linsay's self-harming behaviour was as a result of either drugs or some form of stress or 'loss' and that a more detailed exploration of her episodes of self-harm might have proved useful in terms of developing preventative strategies. Linsay did not have a "safety plan" as this was not Trust policy at the time. However, she did have a Care Plan.
c. Failure to implement a co-ordinated approach towards checking the safety of patients following handover. Staff told the reviewers there was no co-ordinated approach to allocating tasks on the night in question. On that night there was no formal "walk around" undertaken by a qualified member of staff as required by policy. The review team concluded that it was essential that generic safety systems such as the handover check are implemented very robustly as they are the alternative to individual observations being used which in this case were thought to have a negative effect on Linsay.
d. Poor quality of handover information. The handover notes were frequently scant in content. There was no standard template as to what should be included in handover. The review team was unclear how the nursing handover was quality controlled. On just one occasion it was mentioned in handover that Linsay had ligatured during the day but despite the frequency of this behaviour the handover notes did not capture this at all.
e. Confusion about observation levels. There were occasions when it was unclear what level of observation Linsay was on. On the day of the incident staff told the reviewers they were informed that Linsay had been on leave with a member of staff and that it had gone very well, that she was settled and had just had a take-away meal. There was no discussion as regards any risk that Linsay may have been at, taking into account previous behaviour after leave. Recording of changes in observation levels were frequently unclear.
f. No process to monitor the completion of CPA documentation. The review team could not identify the processes that were in place to ensure that all patients had an up to date risk management plan and care plan hence they found that the plans in place for Linsay were not current although Linsay did in fact have a current care plan.
g. Limited content and poor quality of documentation. Documentation of observation levels was not as clear as it should have been and given her very high risk it was important to document any observation changes and the reasoning behind this. This might help build up a picture of the best way of mitigating any potential risk from any form of self-harm, particularly with that associated with ligaturing. It would also help staff adopt a more 'psychological' approach to care rather than using physical intervention like high observation levels or PRN medication if 'agitated', the latter of which was similar in a way to her 'substance misuse. The review team noted that staff did spend a lot of time talking to Linsay but the notes did not capture any questioning as to why she had tried to self-harm at a particular time.
h. Limited interventions regarding substance misuse as an inpatient. Linsay's highest risk of suicide seemed to be in the aftermath of substance misuse. Whilst this was commented on, specialist measures to try and mitigate it were not put in place. The addiction case worker did not attend multi-disciplinary team meetings whilst on the ward, though they did see Linsay whilst she was an inpatient in Childwall Brook Nursing Home. The reviewers noted that the care appeared to be fragmented in that different parts of the services did not plan or deliver the care that was needed together.
i. Poor coordination of referral to a specialist provider. The team pursued a variety of specialist placements in an attempt to meet Linsay's care needs going forwards. One of them, Cambrian Care, undertook an assessment and accepted Linsay as they felt that they had the ability to provide her with the appropriate care required. When the funding was requested it was rejected by the Clinical Commissioning Group (CCG). It was at this time that the funding of Out of Area Placements was being changed with the Trust being given the delegated responsibility for allocating resources on behalf of the CCG. Consequently Linsay's future needs were re-assessed and internal placements were considered in the Trust's own services. The review was completed a short time before Linsay's death, and recommended that an Out of Area specialist placement should be supported. The review team felt that the whole process of having Linsay assessed externally and then the process being stopped would have raised her expectations inappropriately. The significant delay in undertaking a review process was felt by the review team to have kept Linsay in an area that was recognised as not being able to meet all her short and long term needs.
j. Ward Management. Brunswick ward was a very busy admission ward. The Ward Manager did not have a background in leading such a ward nor did the Modern Matron who came from a community background. This meant that senior challenge and specific clinical guidance for staff was not available. During interviews it was suggested that there had been some friction between nurse management on the ward that may have contributed to a background of poor team working. The review team advised that it was important staff were led by experienced managers who understand both the management processes and the clinical area they are responsible for.
k. Transfer of Patients from one organisation to another. The review team identified and amongst staff that patients could not be transferred from one organisation to another until they were "stable". This was impracticable for cases like Linsay's as she was rarely, if ever, stable. She lived in an area inaccessible to her treating psychiatry service when she lived in Kensington whilst remaining under 5 Boroughs Partnership NHS Foundation Trust's care. The review team concluded that regular engagement with local Mersey Care services might have avoided Linsay's final admission.
l. Lack of implementing a clear care pathway. Linsay had a diagnosis of Emotional Unstable Personality Disorder which is associated with a high suicide rate long-term. This is particularly increased during extended in-patient stays. Staff stated during interview that they had not had training related to self-harming behaviour or in the care of people with an Emotionally Unstable Personality Disorder. The reviewers could not identify a clear pathway that was being followed to care for Linsay which took into account her complex needs. Whilst staff appeared to have worked hard at building a relationship up with Linsay the review team concluded that it was generally at a superficial level. The review team noted that the Trust had a Borderline Personality Disorder strategy and guidance but could not find that it was implemented or understood by staff. The review team recognised the national view is that admissions for people with a Borderline Personality Disorder are often counterproductive to improving the mental state of a patient and at worst contribute to difficulties and worsening of the condition. How and when clinicians feel able to take managed and considered “positive” risks is important. How these issues are factored into an extended care plan and the support that clinicians can receive on these cases needs to be clear and thought through by the Trust. The review team are aware that this work was on going within the organisation.
m. Lack of specialist psychological work/guidance to staff. The review team found that specialist interventions were not available on a consistent basis. The review team found that there was inconsistent availability of psychology on the ward environment during the last period of Linsay's admission. The review team were told that Linsay was not amenable to psychological interventions and had tried different modalities in the past. It was a concern that whilst Linsay may not have wanted or been able to avail herself of therapy the overall strategy of care should have been directed and guided from a more psycho-therapeutic perspective.
2. The review team could not identify one specific root cause but felt that the contributory factors interacted together to create a situation whereby Linsay remained distressed on the ward, with limited up take of psychological therapy to help reduce the distress seemingly enhanced by her recent losses. The staff clearly tried hard to work with her but with limited knowledge. There was a sense of fragmented care in that specialist services such as those offered by the addiction team were not engaged in the ward discussions despite Linsay engaging with them during her short stay at Childwall Brook Nursing Home. The period to identify a suitable placement for Linsay seemed overly protracted and seemed to focus thoughts on an external answer to the escalating situation.
Discontinuity of Care/Management of Care
3. The Trust has done a lot of work looking at how to develop the service it offers to service users with a diagnosis of personality disorder. It has developed Guidelines for the management of these individuals and established a Personality Disorder Hub (PD Hub) headed by ████████ a Consultant Psychologist, in November 2014. These Guidelines are produced at pages 311 - 355 of the Inquest Bundle B.
4. The Trust's Borderline Personality Disorder Guidelines advise that in complex cases there should be a meeting of professionals followed by the development of a specific Extended Care Plan (ECP). The ECP starts with a formulation/summary of the history and care provided, and then describes the type of care that should be provided in different settings including inpatient units.
5. Evidence suggests that prolonged or repeated hospital admissions are not helpful for service users with a diagnosis of personality disorder. The PD Hub aims to keep admissions to hospital as short as possible and to avoid them altogether where appropriate. The Trust has recruited individual psychologists and nurses trained and qualified in managing patients with a personality disorder diagnosis to work as case managers for this group of service users. They are responsible for managing the care of the most complex service users regardless of where the service user goes and thus are able to provide continuity of care and work with other care teams to provide consistency of approach.
6. The team initially identified 40 service users who attended A&E on a regular basis and allocated these to the 4 case managers then in post so that each case manager was responsible for 10 service users. Given the success of this work more case managers have been recruited so that the most complex service users who have increased need now have a specialist case manager.
7. The case managers are focussed care for the individual. The approach to care is psychologically based and will include the case manager working with the service user to look at their risk taking and what triggers it. They will then work with the service user to develop strategies to enable the service user to cope with these triggers. Triggers may include memories of past abuse.
8. The Trust is working towards extending the recently introduced day service available for people with personality disorder as part of our evidenced based PD pathway.
9. The aim is to help the service user to manage their condition differently and thus avoid hospital admission if possible.
Risk Assessment/Care Planning
10. Linsay's mental state, level of distress, reported symptomology and self-harming or suicidal behaviour fluctuated quite markedly during her admission. I accept that there was an unstructured approach to reviewing and planning interventions with Linsay which meant there was no collaboratively developed understanding of her risk.
11. Staff are expected to reassess the risks following each ligature incident and episode of self-harm and document the fact that an assessment had taken place and the conclusions reached. Such reviews ought to have included a detailed exploration of Linsay's mental state, her thoughts and feelings and the level of observation she required.
” Source location Linsay Bushell · Prevention of Future Deaths report
Open source report
21 Apr 2017 David Thomas Evans · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Failure to routinely store records of FAST ultrasound examinations View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one 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
David Thomas Evans · 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
David Thomas Evans presented with severe abdominal pain and an ultrasound scan revealed an aortic diameter of 40mm, but no further investigation was conducted and he was discharged. He was later admitted with a ruptured aortic aneurysm, underwent emergency surgery, and died later that day from complications following a ruptured thoraco-abdominal aneurysm. Concerns included inadequate training and supervision for the FAST ultrasound examination, the routine non-retention of scan records, and insufficient escalation of care when a symptomatic patient has an identified abdominal aortic aneurysm.
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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 routinely store records of FAST ultrasound examinations
Wider context from the report “(2) The evidence revealed that records of FAST ultrasound examinations are not routinely stored preventing evaluation of scans to be undertaken after the event .
” Source location David Thomas Evans · Prevention of Future Deaths report
Open source report
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Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.
