Concerns raised 2
Failure to maintain consistent and adequately justified clinical records View source Failure to record concerns about self-harm risk in patients with apparent capacity 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
Danny Sweet · 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
Danny Sweet, who had a long history of mental health issues, took a staggered paracetamol overdose on 23 October 2015 and died the next day in Treliske Hospital. Concerns included the rapid transfer and discharge between mental health services despite earlier consideration of informal admission, difficulties assessing his inconsistent presentation, inconsistent treatment decisions and records, and an incomplete Serious Incident Report.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain consistent and adequately justified clinical records
Wider context from the report “I raise also whether there should be training to ensure that the entries in the notes and records are consistent . By way of illustration, where ████████ and ████████ decide to discharge Mr Sweet from their respective caseloads, they should justify those decisions in light of ████████'s earlier concern that Mr Sweet may need an informal admission into hospital .
” Source location Danny Sweet · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to record concerns about self-harm risk in patients with apparent capacity
Wider context from the report “Mr Sweet’s case raises a more general issue namely, how the Trust deals with patients (within the confines of the Law as currently drawn) who appear to have capacity and yet decline treatment/care even where family/friends state their condition is deteriorating.
I recognise this is a difficult issue. I wonder, however, whether in such situations, clinicians should record in the notes and records their concerns that patients have capacity and yet may go on to self-harm . Furthermore, I feel it may be worth reviewing if clinicians should share those concerns with family/friends who try and bring to attention the patient’s deteriorating condition. I recognise there will be an obvious need to respect the rules on confidentiality.
” Source location Danny Sweet · 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 Continue rolling out the SBAR structured record-keeping tool across all services.
Verbatim wording from the response “The Trust does provide training to staff in relation to record keeping and the importance of recording the rationale for decisions. We are already enhancing the record keeping of staff by implementing the “SBAR” (Situation, Background, Assessment, Recommendation) tool as standard in record keeping. This has been introduced to staff on our psychiatric inpatient wards and we will continue to filter this through across all services. We are therefore making efforts and taking action to introduce a more structured format to our records. This action is on-going.” Source location 2016-0275-Response-by-Cornwall-NHS-Trust
Open published response
22 Jul 2016 Stephen John Bird · Prevention of Future Deaths report Buckinghamshire
View report summary
Concerns raised 1
Failure to maintain complete, consistent and non-conflicting patient and 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.
Linked response
South Buckinghamshire Hospitals
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
South Buckinghamshire Hospitals
Establish zero-tolerance consultant recordkeeping requirements and communicate them to consultant staff.
View source
South Buckinghamshire Hospitals
Audit consultant medical records monthly and apply potential practising-privilege sanctions for non-compliance.
View source
South Buckinghamshire Hospitals
Provide monthly documentation training for staff at the Shelburne and Chiltern hospitals.
View source
South Buckinghamshire Hospitals
Undertake a corporate review of physiotherapist abbreviation use.
View source
South Buckinghamshire Hospitals
Use the issued physiotherapy abbreviation list for outpatient documentation.
View source
South Buckinghamshire Hospitals
Audit discharge follow-up phone-call documentation monthly.
View source See 3 more actions
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AI-generated summary
Stephen John Bird · 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
Stephen John Bird underwent surgery for an Achilles tendon injury on 6 May 2016 and died at home on 11 May 2016. The recorded cause of death was pulmonary embolism due to deep vein thrombosis following recent surgery. Concerns included incomplete, inconsistent or conflicting records and an investigation report containing assumptions that conflicted with documentary records.
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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 maintain complete, consistent and non-conflicting patient and clinical records
Wider context from the report “(1) The patient records, the documentation of consultations, clinical decisions, changes to previous assessment decisions and the discharge records were incomplete, inconsistent and/or conflicting and this was acknowledged during the Inquest hearing.
” Source location Stephen John Bird · 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 Establish zero-tolerance consultant recordkeeping requirements and communicate them to consultant staff.
Verbatim wording from the response “1. At the Hospital Medical Advisory Committee (MAC) meeting on 21 July 2016 the consultant record keeping was discussed. The committee took a serious stance on the standard of record keeping by consultants and it was agreed that there would be zero tolerance to non-compliance of GMC Good Medical Practice Guidelines on completion of medical records. Consultant medical records will be audited by the Director of Clinical Services on a monthly basis and non-compliance by any consultant may result in suspension of the consultant’s BMI practising privileges. The MAC Chair and Executive Director wrote to the consultant body of both BMI Shelburne and BMI Chiltern Hospital accordingly on 25 August 2016.” Source location 2016-0265-Response-by-South-Buckinghamshire-Hospitals
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 consultant medical records monthly and apply potential practising-privilege sanctions for non-compliance.
Verbatim wording from the response “1. At the Hospital Medical Advisory Committee (MAC) meeting on 21 July 2016 the consultant record keeping was discussed. The committee took a serious stance on the standard of record keeping by consultants and it was agreed that there would be zero tolerance to non-compliance of GMC Good Medical Practice Guidelines on completion of medical records. Consultant medical records will be audited by the Director of Clinical Services on a monthly basis and non-compliance by any consultant may result in suspension of the consultant’s BMI practising privileges. The MAC Chair and Executive Director wrote to the consultant body of both BMI Shelburne and BMI Chiltern Hospital accordingly on 25 August 2016.” Source location 2016-0265-Response-by-South-Buckinghamshire-Hospitals
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide monthly documentation training for staff at the Shelburne and Chiltern hospitals.
Verbatim wording from the response “2. Documentation training for staff at BMI Shelburne and BMI Chiltern Hospitals commenced on 15 August 2016 and is on-going on a monthly basis.” Source location 2016-0265-Response-by-South-Buckinghamshire-Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake a corporate review of physiotherapist abbreviation use.
Verbatim wording from the response “3. Corporate review of the use of abbreviations by physiotherapists is to be undertaken by BMI’s Group Clinical Services Director and the National Lead for Physiotherapy Services this month. In the meantime a list of abbreviations issued by The National Lead for Physiotherapy Services for outpatient documentation only is in use.” Source location 2016-0265-Response-by-South-Buckinghamshire-Hospitals
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the issued physiotherapy abbreviation list for outpatient documentation.
Verbatim wording from the response “3. Corporate review of the use of abbreviations by physiotherapists is to be undertaken by BMI’s Group Clinical Services Director and the National Lead for Physiotherapy Services this month. In the meantime a list of abbreviations issued by The National Lead for Physiotherapy Services for outpatient documentation only is in use.” Source location 2016-0265-Response-by-South-Buckinghamshire-Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit discharge follow-up phone-call documentation monthly.
Verbatim wording from the response “4. A monthly audit of discharge follow-up phone call documentation has been introduced and commenced on 1 August.” Source location 2016-0265-Response-by-South-Buckinghamshire-Hospitals
Open published response
14 Jul 2016 Fred Whittaker · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Lack of recording of reasons, requests or decisions to stop prescribing a drug in 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.
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
Fred Whittaker · 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
Fred Whittaker, who had schizophrenia and was known to abuse drugs and alcohol, attended hospital with chest pains and drowsiness after taking codeine, alcohol and methadone, but self-discharged and went home. He was found dead in his flat the following morning; the inquest concluded that he died from developing bronchopneumonia and combined codeine, methadone and alcohol toxicity. A principal concern was that Clonazepam was restarted in error after his psychiatrist had requested that it be stopped, reflecting inadequate recording and procedures for discontinued prescriptions.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of recording of reasons, requests or decisions to stop prescribing a drug in clinical records
Wider context from the report “An important issue in the Inquest was the continued prescription of Clonazepam by the Heaton Moor Medical Centre despite the written request on 17th August 2015, from Mr Whittaker’s treating psychiatrist, ████████ that this medication be stopped.
The evidence given to me by ████████ a partner at the Heaton Moor Medical Centre, suggests that although the prescription was stopped it was started again in error.
████████ advised that,
a) On receipt of ████████ request the drug was moved from the Repeat Prescription list to the Past Prescription list, without any reference in the records of the reason as to why the Clonazepam was being stopped.
b) On or about the 19th August 2015 the pharmacy which administered Mr Whittaker’s medication requested a repeat prescription.
c) It was likely that upon receiving that request Clonazepam was simply moved back on to the repeat prescription by one of the doctors at the Practice on being advised by an administrator of the Pharmacy’s request.
This is clearly an unacceptable error.
I accept that, on this occasion, this error played no part in Mr Whittaker’s demise but it is not difficult to imagine a completely different set of circumstances where such an error would give rise to a risk of death.
████████ evidence was that there were no standard directions as to how to manage this as a situation and that other practices may adopt the same simple policy of transferring the drug from one list to another.
1. That Heaton Moor Medical Centre does not have a mechanism whereby the reasons or requests or decisions that a patient is no longer to be prescribed a particular drug are recorded in the clinical records.
2. That this poor practice may not be limited to Heaton Moor Medical Centre and is replicated in many GP practices in the Northwest and indeed, nationally.
” Source location Fred Whittaker · Prevention of Future Deaths report
Open source report
30 Jun 2016 baby Dominic Smith · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2
Failure to document rationale for clinical discretion View source Inadequate clinical record keeping View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
baby Dominic Smith · 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
Baby Dominic Smith was born on 2 June 2015 after a prolonged labour and died at approximately 18 hours of life following a collapse. The report describes pneumonia as the cause of death and identifies concerns including failure to recognise possible rupture of membranes and infection risk, inadequate maternal and neonatal observations, failure to escalate deterioration, delayed antibiotic treatment, and communication and record-keeping problems.
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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 document rationale for clinical discretion
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion ;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Source location baby Dominic Smith · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate clinical record keeping
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping ;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Source location baby Dominic Smith · 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 Conduct rolling audits of communication and documentation to identify compliance gaps and remedial measures.
Verbatim wording from the response “The Division of Women and Children’s is undertaking a programme of rolling audits on communication and documentation. The purpose is to ensure compliance with policy standards and to identify areas where there are challenges in order to implement remediating measures.” Source location 2016-0240-Response-by-The-Pennine-Acute-Hospital-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 Implement the commissioned improvement programme to embed reliable communication, handover and documentation processes in clinical practice.
Verbatim wording from the response “The division has commissioned an improvement programme of work focusing on these three areas in order to fully embed effective and reliable processes into clinical practice.” Source location 2016-0240-Response-by-The-Pennine-Acute-Hospital-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The NHS Trust, rather than the College, is responsible for responding on local communication, record keeping, policies and procedures.
Verbatim wording from the response “Given that we do not have all the details of the tragic death of Baby Smith, the RCPCH is unable to comment on the specifics of the case and the Pennine Acute Hospitals NHS Trust has been asked to respond directly on local communication, record keeping and policies and procedures.” Source location 2016-0240-Response-by-RCPCH
Open published response
28 Jun 2016 David Michael little · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure to keep clear records of inpatient radiology transfers, purposes, procedures and ward returns 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
David Michael little · 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 Michael Little was admitted to hospital with abdominal pain and a suspected small-bowel mass. His condition worsened, and a scan revealed a blockage caused by ischaemic bowel; delays in scanning, reporting, and insertion of an NG tube meant that surgery was considered when it was deemed too late. The report raised concerns about poor record-keeping, lack of a clear diagnostic and monitoring pathway, failure to recognise the seriousness of bowel obstruction, and poor communication among staff and with the family.
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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 clear records of inpatient radiology transfers, purposes, procedures and ward returns
Wider context from the report “1. There was strong evidence of a failure by the hospital staff to keep clear records of when an inpatient was to be taken to “radiology”, for what purpose, whether the procedure had been carried out, whether the patient had been returned to the ward . In the present case, Mr Little was taken ‘by mistake’ in the belief that he was another patient, and it was only on arrival at radiology that this was realised when they decided to proceed with his scan which had been planned for the following day.
” Source location David Michael little · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Radiology Requesting and Reporting Policy requiring documentation of radiology discussions, appointment changes and communication with responsible clinicians.
Verbatim wording from the response “Following Mr Little’s death, the department has published a ‘Radiology Requesting and Reporting Policy’ in February 2016 (Document 1 attached). The Policy requires the clinician to document the discussion in the clinical notes of the request made to Radiology and the response given. Once the scan is requested, the Radiology department must then ensure that they document any changes to the planned appointment and communicate them with the responsible clinician. It is clear that at the time of Mr Little’s death, the communication appeared to be confusing and there are insufficient documented records to confirm what conversations actually took place at the time.” Source location 2016-0237-Response-by-Tameside-Hospital-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 Develop and implement a radiology tracking and handover process documenting preparation requests, patient identification, scheduled investigations, completed investigations and return observations.
Verbatim wording from the response “In addition, there is currently a documented tracking/handover policy in draft (Document 2 attached) which will document any specific requests that are given to the patient via the ward staff to prepare them for their investigation, e.g. nil by mouth or the requirement for a full bladder. It will include a feedback form that the porter will take to the ward when collecting the patient for a member of the nursing staff to sign to confirm the patient’s identification and the test/imaging the patient is scheduled for. On return of the patient to the ward, the sheet will document what investigation has taken place and any special observations required. This form will form a part of the radiology record and be filed in the patient’s notes.” Source location 2016-0237-Response-by-Tameside-Hospital-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The patient was not taken to radiology by mistake; Radiology records show his scan was scheduled and expected that day.
Verbatim wording from the response “1. There was strong evidence of a failure by the hospital staff to keep clear records of when an inpatient was to be taken to “radiology”, for what purpose, whether the patient had been returned to the ward. In the present case, Mr Little was taken ‘by mistake’ in the belief that he was another patient, and it was only on arrival at radiology that this was realised when they decided to proceed with his scan which had been planned for the following day.” Source location 2016-0237-Response-by-Tameside-Hospital-NHS-Trust
Open published response
24 Jun 2016 Kirsty Childs · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 1
Failure to record conclusions and advice from earlier calls View source
This report raised 8 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
Kirsty Childs · 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
Kirsty Childs, aged 20, developed severe abdominal symptoms and repeatedly sought advice from NHS Direct and other services between 31 December 2012 and 2 January 2013. She was not admitted to hospital and was later found dead at home; the inquest recorded septic shock caused by an undiagnosed and untreated mesenteric venous thrombosis. The principal concerns included incorrect telephone triage, failure to review earlier calls, medically unqualified staff selecting questionnaires, the ability to override recommended outcomes, and poor information-sharing between agencies.
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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 conclusions and advice from earlier calls
Wider context from the report “5. It was not possible at the inquest to review what details were recorded. I was concerned that details of earlier calls may not contain the conclusion and advice given to the patient . This information may be of significant assistance to ensure that if the patient calls again, appropriate care and advice is given.
” Source location Kirsty Childs · Prevention of Future Deaths report
Open source report
20 Jun 2016 Michael Guy Hutchence · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure to maintain accurate nursing and medical notes View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Michael Guy Hutchence · 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
Michael Guy Hutchence broke his lower leg after slipping on an icy pavement and died in hospital on 28 January 2016. The report raised concerns about repeated ward moves, staffing and record-keeping, weight-based anticoagulant dosing and inconsistent weight recording, inadequate equipment for leg elevation, and delays to surgery after two operation kits were found to be non-sterile. The stated medical cause of death included bronchopneumonia, deep vein thrombosis and pulmonary embolus, and fractured tibia and fibula.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain accurate nursing and medical notes
Wider context from the report “2. The quality and accuracy of the nursing and medical notes left much to be desired and it was noted that he was cared for by non-specialist nurses on a number of occasions and even when he was in the I.T.U. he was looked after by a trainee nurse.
” Source location Michael Guy Hutchence · 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 Install and roll out an electronic patient record integrating healthcare information and standardising documentation and care pathways.
Verbatim wording from the response “The Trust is currently in the process of installing an electronic patient record (EPR) system, which is a computerised version of the entire healthcare record. Instead of hospital staff using a mixture of paper and electronic records, information will be available to them online in one place. We already use a variety of electronic systems to help staff look after our patients, but the EPR will bring all this information together.” Source location 2016-0228-Response-by-Stockport-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 Undertake monthly live spot audits of 30 inpatient records to improve written-record quality during the electronic-record rollout.
Verbatim wording from the response “The EPR will improve patient safety and outcomes by standardising pathways underpinned by best practice, it will remove issues relating to the illegibility of written records and will also assist with the completion of important documents, as the system will employ a ‘force function’, meaning the record cannot be left incomplete. The roll out for the system will be completed in 2017. In the meantime we will continue to try to improve our written records by undertaking monthly ‘live’ spot audits of 30 inpatient records across the wards.” Source location 2016-0228-Response-by-Stockport-NHS-Trust
Open published response
Concerns raised 1
Unavailability of centile charts in handheld maternity records View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Charlie Mark Jermyn · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Charlie Jermyn was born at home on 9 May 2015 and developed sleepiness, feeding difficulty and possible respiratory distress. He stopped breathing during a routine visit the following day and died in hospital despite resuscitation attempts. The principal concerns were delayed recognition and referral for suspected sepsis, inadequate telephone triage and recording, insufficient observations, and wider shortcomings in midwifery guidance, equipment and training.
Read the report on judiciary.uk
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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 centile charts in handheld maternity records
Wider context from the report “5. There was a recommendation by the Midwife Consultant that centile charts for each baby should be available in all hand held maternity records to assist midwives identify babies who are potentially at risk.
” Source location Charlie Mark Jermyn · Prevention of Future Deaths report
Open source report
19 May 2016 Samuel Rodney Darren BLAIR · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to enter collateral history into the main clinical records View source
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Samuel Rodney Darren BLAIR · 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
Rodney Blair, who had a history of paranoid schizophrenia, alcohol dependency, multiple drug use and depression, was remanded in custody at HM Prison Pentonville and was found hanging in his cell on 2 August 2015. The inquest concluded that his death was suicide, with several contributing factors. Concerns included gaps in assessment and management of his mental health and antidepressant treatment, and delays and procedural issues in the prison emergency response.
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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 enter collateral history into the main clinical records
Wider context from the report “2. She later uploaded to the computer system the collateral history she had been sent as a Word document, but did not input any of it into the main body of the records , nor did the psychiatrist who made the note at the multi disciplinary team meeting in prison on 7 July 2015 at which Mr Blair was discussed.
” Source location Samuel Rodney Darren BLAIR · 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 Concerns 2, 3 and 4 relate to BEH-MHT services rather than the services addressed by this response.
Verbatim wording from the response “Response: We refer you to the response provided by BEH-MHT as these concerns are relating to their services rather than the services of Care UK.” Source location 2016-0196-Response-by-Care-Uk
Open published response
16 May 2016 Jonathan Lewis Fry · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 1
Inconsistent or incomplete medical records View source
This report raised 4 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
Jonathan Lewis Fry · 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
Jonathan Lewis Fry was admitted after an unwitnessed fall and was diagnosed with an L1 compression fracture. He later became increasingly unwell and was found unresponsive on 20 April 2015; the post-mortem cause of death was recorded as pulmonary embolism due to deep venous thrombosis. The principal concerns were the absence of senior Consultant review, inadequate follow-up of tests and results, and inconsistent or incomplete medical records.
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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 Inconsistent or incomplete medical records
Wider context from the report “3 ) Medical records were inconsistent and / or incomplete leading to a lack of clarity as to reviews and care plan .
” Source location Jonathan Lewis Fry · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.