1 Jun 2015 David Glyn Price · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to maintain complete, dated, signed and attributable handwritten medical and nursing notes View source
This report raised 3 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 Glyn Price · 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 Glyn Price suffered a heart attack in early June 2011 and underwent surgery at Wythenshawe Hospital, during which a swab was inadvertently left inside his body attached to his heart; this gradually formed an abscess. Concerns included continued warfarin prescribing despite missed anticoagulation appointments, poor handwritten clinical records, failure to act on imaging showing a foreign body, and inadequate swab-count procedures.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain complete, dated, signed and attributable handwritten medical and nursing notes
Wider context from the report “2. The quality of the handwritten notes (both medical and nursing) was nothing short of very poor . They were frequently undated, unsigned and there was no indication in block letters as to who was completing the notes, his/her professional status etc.(For UHSM)
” Source location David Glyn Price · Prevention of Future Deaths report
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15 May 2015 Sara Jane Green · Prevention of Future Deaths report Manchester South
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Concerns raised 2
Failure to complete medical consultation records contemporaneously View source Failure to verify the accuracy of dictated medical consultation records View source
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
Sara Jane Green · 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
Sara Jane Green died at Cheadle Royal Hospital on 18 March 2014 after being found with wire spiral binding wrapped around her neck; resuscitation was unsuccessful. The inquest identified concerns about her prolonged admission and the inadequate or unavailable provision of placements and discharge arrangements. It also identified concerns about delays in medical record-keeping, which could prevent important information from being available to staff and create a risk of harm to patients.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to complete medical consultation records contemporaneously
Wider context from the report “During the course of the evidence it was discovered that the medical staff (not the nursing staff or other healthcare professionals) were not making contemporaneous records of consultations or attendances with Sara . On occasions there were days passing between a consultation and the medical record being completed .
Some examples are below:
The record of a consultation on 30 January 2014, timed to have taken place at 15:30 hours was not entered until 09:21 hours on 7 February 2014.
The record of a consultation that took place on 4 February 2014 was not entered until 7 February 2014, and was not checked for its accuracy until 10 February 2014.
The record of a consultation that took place on 25th February 2014 was not entered until 4 March 2014, and was not checked for its accuracy until 10 March 2014.
I was advised that the method of record-keeping employed is that the consultation is dictated and it is then entered into the records by a secretary. In terms of the record being checked for accuracy, the entry is then simply read by the relevant practitioner without any reference to any hand written note, nor hearing the dictation.
It was accepted by one of the doctors subscribing to such a practice that this was an unacceptable practice. That such a late entry into the records of a consultation did not comply with the General Medical Council guidelines for 'Good Medical Practice 2013'.
19. Documents you make (including clinical records) to formally record your work must be clear, accurate and legible. You should make records at the same time as the events you are recording or as soon as possible afterwards.
As I understand one of the purposes of clear, accurate, legible and up-to-date record-keeping is the dissemination of information to others caring for a patient. In circumstances where days may pass before the record of a consultation/assessment is available to others caring for a patient the passing on, or easy availability, of important information will be denied. That, in my view, places patients at risk.
The evidence received on this issue at the Inquest suggests that the system of record-making has not changed but that the entry must now be completed within 24 hours of the consultation .
In my view that remains an unacceptable period of time and does not comply with the General Medical Council guideline of completing records "as soon as possible afterwards".
It was suggested to me that those healthcare professionals accompanying the medical practitioner(s) on ward rounds and at consultations would pass on any important information at a handover. I am not satisfied that this coordination of information in this manner is entirely appropriate, and that it does not adequately compensate for the lack of contemporaneity.
That a delay, of up to 24 hours, in 'writing up' the record of a medical consultation may result in important information not being available to, or easily accessible to, other healthcare professionals involved in the care of a patient , or give rise to the possibility of a misinterpretation of that information, or of the information being inaccurate, if it is passed on orally while waiting for the entry to be 'written up'. This gives rise to a risk of harm to the patient.
” Source location Sara Jane Green · 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 verify the accuracy of dictated medical consultation records
Wider context from the report “During the course of the evidence it was discovered that the medical staff (not the nursing staff or other healthcare professionals) were not making contemporaneous records of consultations or attendances with Sara. On occasions there were days passing between a consultation and the medical record being completed.
Some examples are below:
The record of a consultation on 30 January 2014, timed to have taken place at 15:30 hours was not entered until 09:21 hours on 7 February 2014.
The record of a consultation that took place on 4 February 2014 was not entered until 7 February 2014, and was not checked for its accuracy until 10 February 2014 .
The record of a consultation that took place on 25th February 2014 was not entered until 4 March 2014, and was not checked for its accuracy until 10 March 2014 .
I was advised that the method of record-keeping employed is that the consultation is dictated and it is then entered into the records by a secretary. In terms of the record being checked for accuracy, the entry is then simply read by the relevant practitioner without any reference to any hand written note, nor hearing the dictation .
It was accepted by one of the doctors subscribing to such a practice that this was an unacceptable practice. That such a late entry into the records of a consultation did not comply with the General Medical Council guidelines for 'Good Medical Practice 2013'.
19. Documents you make (including clinical records) to formally record your work must be clear, accurate and legible. You should make records at the same time as the events you are recording or as soon as possible afterwards.
As I understand one of the purposes of clear, accurate, legible and up-to-date record-keeping is the dissemination of information to others caring for a patient. In circumstances where days may pass before the record of a consultation/assessment is available to others caring for a patient the passing on, or easy availability, of important information will be denied. That, in my view, places patients at risk.
The evidence received on this issue at the Inquest suggests that the system of record-making has not changed but that the entry must now be completed within 24 hours of the consultation.
In my view that remains an unacceptable period of time and does not comply with the General Medical Council guideline of completing records "as soon as possible afterwards".
It was suggested to me that those healthcare professionals accompanying the medical practitioner(s) on ward rounds and at consultations would pass on any important information at a handover. I am not satisfied that this coordination of information in this manner is entirely appropriate, and that it does not adequately compensate for the lack of contemporaneity.
That a delay, of up to 24 hours, in 'writing up' the record of a medical consultation may result in important information not being available to, or easily accessible to, other healthcare professionals involved in the care of a patient, or give rise to the possibility of a misinterpretation of that information, or of the information being inaccurate , if it is passed on orally while waiting for the entry to be 'written up'. This gives rise to a risk of harm to the patient.
” Source location Sara Jane Green · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind hospital and senior management leaders across the Healthcare Division to ensure contemporaneous clinical record keeping.
Verbatim wording from the response “Prior to receipt of your PFD report and based on your comments at the inquest, on Tuesday, 12 May 2015 our Group Medical Director, ████████, wrote to the Hospital Medical Directors at all 42 of the Priory Group Healthcare Division hospitals reminding them of the requirement to ensure that service user records were completed during the course of ward rounds, Care Programme Approach review meetings and multi-disciplinary team meetings.” Source location 2015-0190-Response-by-Priory-Group
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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 Share examples of good practice for completing clinical records collaboratively during consultations and multidisciplinary meetings.
Verbatim wording from the response “At the Healthcare Medical Directors’ Meeting held on Tuesday, 30 June 2015, staff were further reminded by Group Director of Safety, ████████, of the need to ensure contemporaneous record keeping including in relation to ward rounds, Care Programme Approach review meetings, multi-disciplinary team meetings, individual one-to-one consultations and assessments. A context was given for the directive and those present were reminded of the General Medical Council guidelines.” Source location 2015-0190-Response-by-Priory-Group
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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 Consider rolling out collaborative screen-based clinical record completion across appropriate Healthcare Division cases.
Verbatim wording from the response “I should add that during the meeting on 30 June 2015, aspects of good practice were identified and shared. An example of good practice was raised by one of the Medical Directors who had other colleagues of the efficiencies and positive experiences found in response to the clinical record being projected on to a screen and completed with the active involvement of the service user and the multi-disciplinary team during the meeting itself. This action enables the service user to see what is being recorded and thus helps to promote insight and his/her involvement in their care. We will consider how this practice can be rolled out across the Healthcare Division in appropriate cases.” Source location 2015-0190-Response-by-Priory-Group
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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 Review information technology and resolve identified connectivity problems to support faster contemporaneous record updates in clinical meeting rooms.
Verbatim wording from the response “In light of your concerns, we have been reviewing how we can use information technology to enable clinicians and others to update medical records more quickly. As a starting point, tests have been carried out in relation to wi-fi capability, efficiency and security in those clinical meeting rooms across the Healthcare Division where the absence of fixed computer equipment prevents staff updating contemporaneous records during the consultation or shortly afterwards. The purpose of this is to facilitate the use of tablet computers by staff in these rooms. Where connectivity problems were identified these are either fully resolved or will be resolved by Wednesday, 30 September 2015.” Source location 2015-0190-Response-by-Priory-Group
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a tablet-computer pilot at two hospitals for contemporaneous record keeping during clinical meetings.
Verbatim wording from the response “In addition, a pilot study has been undertaken at two of our hospitals using different types of tablet computers for use in ward rounds, Care Programme Approach review meetings and multi-disciplinary team meetings. We expect the pilot to complete by the end of this month and depending on the findings and recommendations, where appropriate we will procure any additional equipment that most effectively meets the needs of our staff. We are optimistic that having access to tablet computers should enable staff to load medical records on to the Care Notes clinical record system during or shortly after a consultation. We expect this process to be completed by Wednesday, 30 September 2015. In the meantime, where the current absence of computer access prevents immediate entry of the contemporaneous records, the meetings will continue to be documented within 2-3 hours following a consultation.” Source location 2015-0190-Response-by-Priory-Group
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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 monitoring the promptness of medical staff clinical documentation through local governance, audit, supervision and appraisal arrangements.
Verbatim wording from the response “We will also continue to monitor how promptly our medical staff are documenting all service user consultations on an ongoing basis. Monitoring is undertaken as part of monthly local governance and audit arrangements. Record keeping is also routinely considered as part of medical supervision and annual appraisal.” Source location 2015-0190-Response-by-Priory-Group
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Concerns raised 1
Failure to make detailed notes in detainees’ custody medical records 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.
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AI-generated summary
Name not published · 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
The deceased was arrested on 2 October 2011 and held in custody, where he received prescribed methadone and medication for alcohol withdrawal. He was found unresponsive in his cell shortly before 9.00pm on 3 October 2011; the recorded medical cause of death was methadone intoxication, with alcohol withdrawal in a chronic alcoholic also identified. Concerns included communication between medical practitioners and custody staff, inconsistent observation levels, joint training, and training on drug and alcohol-related risks.
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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 make detailed notes in detainees’ custody medical records
Wider context from the report “1. That consideration be given to issuing guidance that whenever a detainee is attended upon by a medical practitioner there should be a verbal consultation between the medical practitioner and custody sergeant as to any issues of concern and the level of observations to be had for that detainee in addition to the medical practitioner making detailed notes on the detainee’s custody medical record .
” Source location Name not published · 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 Review Detention and Custody Authorised Professional Practice to consider guidance on medical practitioner–custody sergeant consultation, observation levels and detailed medical records.
Verbatim wording from the response “1. That consideration be given to issuing guidance that whenever a detainee is attended upon by a medical practitioner there should be a verbal consultation between the medical practitioner and custody sergeant as to any issues of concern and the level of observations to be had for that detainee in addition to the medical practitioner making detailed notes on the detainees custody medical record.” Source location 2015-0138-Response-by-College-of-Policing
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7 May 2015 Mrs. Evelyn KENNEDY · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 3
Failure to record NEWS scores on drug charts View source Incomplete and poor repositioning records View source Failure to record bowel movements View source
This report raised 22 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
Mrs. Evelyn KENNEDY · 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. Evelyn KENNEDY was an 89-year-old woman who died in hospital on 29 October 2014 after admission following recurrent falls. The inquest concluded that she died of hospital-acquired pneumonia and that her death was probably accelerated by a short time because of the effects of her five-day admission to the Acute Medical Unit. Concerns included incomplete handover and poor personal care, missing identification and risk bands, inadequate monitoring and documentation, missed medication and nutritional support, and failures to escalate clinical deterioration.
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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 NEWS scores on drug charts
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” Source location Mrs. Evelyn KENNEDY · 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 Incomplete and poor repositioning records
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” Source location Mrs. Evelyn KENNEDY · 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 bowel movements
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” Source location Mrs. Evelyn KENNEDY · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor documentation more closely and provide nurses with real-time feedback.
Verbatim wording from the response “Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:” Source location 2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-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 Review and condense Acute Medical Unit documentation into multidisciplinary paperwork that directs care and reduces duplication.
Verbatim wording from the response “Extensive and complex work is also being undertaken to” Source location 2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
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17 Apr 2015 Robert Watt · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 2
Failure to record clinic cancellations in medical records View source Lack of documentation of urology referrals and forward management of haematuria 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
Robert Watt · 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
Robert Watt had suspected bladder cancer symptoms, including haematuria, weight loss and rectal bleeding, but investigations and specialist review did not identify the cancer until it was advanced and incurable. The report identified concerns about communication of a cancelled haematuria clinic appointment, incomplete medical records, reliance on junior doctors for specialist advice, and the lack of urological review when malignancy was suspected.
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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 clinic cancellations in medical records
Wider context from the report “ii. The letter communicating the cancellation of the clinic was not sent to the deceased, nor was it placed on the medical records
” Source location Robert Watt · 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 urology referrals and forward management of haematuria
Wider context from the report “iii. There is no documentation relating to the referral to urology and forward management of haematuria within the medical records
” Source location Robert Watt · Prevention of Future Deaths report
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25 Mar 2015 Mr Harold Ambrose and Mrs Wendy Ambrose · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure to record and flag firearms licence information in medical records and systems View source
This report raised 2 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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Mr Harold Ambrose and Mrs Wendy Ambrose · 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 Harold Ambrose shot his wife, Mrs Wendy Ambrose, and then himself; police found both bodies. Mr Ambrose had a shotgun licence and developed worsening mixed dementia, but neither his GP nor the mental health trust referred the matter to the police firearms department. The report identified that there was no requirement for them to notify police about mental health concerns when aware that a patient held a firearms licence.
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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 flag firearms licence information in medical records and systems
Wider context from the report “Mr Ambrose had held a shotgun licence since November 1987. This was renewed every 5 years at which time there was a full review. The last review was in 2011. On 18th November 2011 a letter from Essex Police Firearms Department was sent to his GPs surgery notifying them that he was a shotgun holder. No further details from this letter were entered onto his medical record and the fact that he was a firearms holder was not flagged on their system .
In 2011 Mr Ambrose did not have any mental health problems. In September 2012 he was diagnosed with mixed dementia and this gradually worsened. He was receiving some input from the North Essex Partnership University NHS Foundation Trust (NEPT) following a referral from the GP in October 2012. Mr Ambrose made NEPT aware that he had a shotgun license in his initial assessment in November 2012.
In May 2013 he was prescribed Alzheimer’s medication and was advised not to drive due to his cognitive impairment. In January 2014 it was clear that there had been a decline in his mental abilities and this decline continued.
Although his mental health was clearly deteriorating neither the GP or NEPT referred this case to Essex Police Firearms Department. In evidence a representative of Essex Police said had they been made aware of his Mental Health problems they would have initiated a review of Mr Ambrose’s fitness to hold a shotgun licence. There is no requirement that GPs or Mental Health Trusts notify the police of concerns about patients mental health when they are aware that they have a firearms licence.
” Source location Mr Harold Ambrose and Mrs Wendy Ambrose · Prevention of Future Deaths report
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25 Mar 2015 Bryan Herbert Whitby · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to record who requested further blood tests View source
This report raised 10 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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Bryan Herbert Whitby · 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
Bryan Herbert Whitby had chronic kidney disease and underwent a CT scan while his renal function was deteriorating and he was taking metformin. After the scan, further deterioration was identified, but there were delays and failures in escalating the results, arranging urgent admission, recognising his serious condition, providing treatment, and transferring him to the High Dependency Unit; he died shortly after admission there. The principal concerns included communication and escalation failures, inadequate recognition and treatment of acute illness, and delayed critical-care transfer.
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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 who requested further blood tests
Wider context from the report “3. There is no record of who requested further blood tests on the 6th May .
” Source location Bryan Herbert Whitby · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to maintain complete and consistent nursing and clinical records View source
This report raised 2 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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Elsie May Hayward · 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
Elsie May Hayward was admitted to hospital after a fall at home and was being treated for sepsis. During her admission, she sustained four falls, including a likely fall from her bed that caused a head injury and subdural haematoma; her condition deteriorated and she died three days later. Concerns included overstretched staffing, inadequate post-head-injury observations, and omissions and inconsistencies in clinical records and communication.
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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 maintain complete and consistent nursing and clinical records
Wider context from the report “3. There were extensive omissions in the note taking and a clear inconsistency between the “nursing notes” and “clinical notes” resulting in confusion and breakdown of communication between the nursing staff and the medical team .
” Source location Elsie May Hayward · 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 Remove the core care plan and require individualised care plans for all patients.
Verbatim wording from the response “The omissions and inconsistencies in notetaking has been recognised and immediate action has been taken to remove the “core-care plan” and staff will now write individualized care plans for all patients. Further checks have been made in all other areas within Medicine to ensure the core care plan is not being used. The “real time” documentation has also been removed so that only one clinical note is in use.” Source location 2015-0224-Response-by-Cardiff-Vale-University-Health-Board
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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 Remove real-time documentation so that one clinical note is used.
Verbatim wording from the response “The omissions and inconsistencies in notetaking has been recognised and immediate action has been taken to remove the “core-care plan” and staff will now write individualized care plans for all patients. Further checks have been made in all other areas within Medicine to ensure the core care plan is not being used. The “real time” documentation has also been removed so that only one clinical note is in use.” Source location 2015-0224-Response-by-Cardiff-Vale-University-Health-Board
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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 and disseminate a new care plan across clinical areas using Falls Focus Group champions as required.
Verbatim wording from the response “The Medicine Clinical Board representatives at the Vulnerable Adult Risk Management Group (VARMG) will support the development and dissemination of a new care plan to all clinical areas, utilising champions from the newly formed Falls Focus Group as required.” Source location 2015-0224-Response-by-Cardiff-Vale-University-Health-Board
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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 participating in the all-Wales programme to progress a single electronic patient record.
Verbatim wording from the response “The UHB, in line with all other Health Boards in Wales does not have a single electronic patient record in place but will continue with all Wales work to progress this agenda which would inevitably bring significant patient safety benefits. The continuous improvement plan has been presented and discussed at the Medicine Clinical Board formal Board meeting and has also been shared at the UHB Quality, Safety and Patient Experience Committee meeting. The Directorate is required to regularly review the improvement plan and provide assurance to the various quality and safety monitoring mechanisms. An update on progress will be presented at the September 2015 Quality, Safety and Patient Experience Committee.” Source location 2015-0224-Response-by-Cardiff-Vale-University-Health-Board
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12 Mar 2015 NICOLA ANNE TWEEDY · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Incomplete nursing discharge notes covering required pre-discharge checks View source
This report raised 6 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
NICOLA ANNE TWEEDY · 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 Tweedy underwent elective varicose vein surgery as a day-case patient on 27 March 2014 and was found collapsed and died at home on 29 March 2014. The inquest recorded pulmonary embolism following recent varicose vein surgery. Concerns included incomplete thromboprophylaxis risk assessment, missing procedure and aftercare leaflets, and incomplete discharge checks and documentation.
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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 Incomplete nursing discharge notes covering required pre-discharge checks
Wider context from the report “Nursing notes on discharge did not fully cover all the factors required to be checked before a patient is discharged.
” Source location NICOLA ANNE TWEEDY · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the day-case discharge process outside the Day Procedure discharge pathway for consistency.
Verbatim wording from the response “Our Action Plan on this case explained that whilst this issue was covered by the existing Day Procedure (DPD) discharge checklist, the process applying to day-case patients outside the DPD was to be reviewed to ensure that this was consistent.” Source location 2015-0095-Response-by-Norfolk-Norwich-University-Hospitals
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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 Trust’s implemented Action Plan was considered to have addressed the reported care concerns, with learning and improvement demonstrated.
Verbatim wording from the response “I note that you have sent your report to the Norfolk and Norwich University Hospital NHS Foundation Trust. My officials have liaised with the Foundation Trust about your report and I understand that it has fully considered and responded to each of your concerns relating to the care of Mrs Tweedy. I can report that a recent independent external inspection found that the Foundation Trust had implemented an Action Plan, to address the issues raised by this case, and that this demonstrated that learning and improvement had taken place.” Source location 2015-0095-Response-by-Department-of-Health
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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 Professional regulatory bodies are responsible for investigating registrants’ alleged failures to meet standards and taking necessary safeguarding action.
Verbatim wording from the response “Lastly, as some of the actions of medical and nursing staff are subject to criticism in your report, I wish to take this opportunity to remind you of the role of the professional regulatory bodies and their fitness-to-practise processes.” Source location 2015-0095-Response-by-Department-of-Health
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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 Department cannot become involved in or comment on individual cases.
Verbatim wording from the response “health and well-being of the public. The Department cannot get involved with or comment on individual cases.” Source location 2015-0095-Response-by-Department-of-Health
Open published response
6 Mar 2015 Connor Adrian Turner · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Failure to record oxygen-apparatus readiness and user competence checks in case notes 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.
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AI-generated summary
Connor Adrian Turner · 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
Connor Adrian Turner, who had cystic fibrosis, congenital heart disease and required oxygen, stopped breathing while shopping with his parents after the oxygen cylinder valve was found to be off. His death was unascertained, with the inquest stating that lack of oxygen was a contributory factor. The concerns identified included the absence of a system to train and supervise parents or carers in transferring and checking portable oxygen equipment before leaving hospital.
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 Failure to record oxygen-apparatus readiness and user competence checks in case notes
Wider context from the report “(1) There is no system in place for nursing staff to instruct and train parents and carers in the transfer of the oxygen supply from the main supply to a portable oxygen cylinder.
(2) That parents and carers should be initially supervised in forming this task until they are deemed to be competent to do so.
(3) That when a transfer has been made in preparation for the patient leaving the hospital, albeit temporarily, the patient should not be allowed to leave until an independent check has been made and all concerned are satisfied that the apparatus is functioning correctly and that those taking the patient out of hospital are competent to use the apparatus and that the appropriate reference to this should be made in the case notes .
” Source location Connor Adrian Turner · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a risk assessment for parent-supervised off-ward trips, documenting training, competence, responsibilities, permitted absence, and checks before each trip.
Verbatim wording from the response “Evidence was given at the inquest of the actions that have been implemented following the publication of the investigation report. In summary, the clinical team has devised and implemented three documents which are completed by staff and parents. These are:” Source location 2015-0082-Response-by-Leeds-Teaching-Hospitals
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Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.
