Recurring concern

Unsafe rapid tranquillisation processes

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First reported 27 Mar 2015•Latest report 17 Jun 2026

Definition

What this concern includes

Includes failures of controls specifically dedicated to rapid tranquillisation, including clinical decision-making, medication and guidance selection, monitoring, vital-sign observation, documentation, escalation and staff understanding or application of relevant policy.

Not included

Excludes generic documentation, training, staffing or policy deficiencies that are not specifically tied to rapid tranquillisation.
Excludes restraint or sedation concerns where rapid tranquillisation is not the identified process or intervention.
Excludes failures limited to unrelated anaesthetic, emergency-treatment or medication-management processes.
Excludes adverse outcomes or individual clinical errors where no deficiency in a rapid-tranquillisation control is identified.

Reports: 5
Individual concerns: 10
Date range: 2015–2026
Stated actions: 19

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care3

Barts Health NHS Trust1

East London NHS Foundation Trust1

Metropolitan Police Service1

North London NHS Foundation Trust1

Nottinghamshire Healthcare NHS Foundation Trust1

University Hospitals of Leicester NHS Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

17 Jun2026
Suffolk
Concerns raised1
1. Lack of national guidance and timelines for administering medication in Mental Health agitation or Mental Health crisis
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.
Respondent positions 1
1. Position
  Responsibility for relevant clinical guidance, NHS service delivery and oversight sits with NHS England.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Jake Harvey READ · 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

Jake Harvey READ was declared deceased at home on 5 May 2025 after sustaining self-inflicted knife injuries. He had attended an emergency department two days earlier seeking mental health support but left before planned Diazepam was prescribed. The principal concerns were the absence of national guidance or timelines for administering medication during mental health agitation or crisis, and the lack of direct access to the medication for a qualified non-medical prescriber, which contributed to a delay in prescribing.

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
Lack of national guidance and timelines for administering medication in Mental Health agitation or Mental Health crisis
Wider context from the report
“My primary concern in Jake's case is that evidence heard that there is no national guidance or timelines in place for the administration of medication required in cases where an individual has been identified as being in a state of Mental Health agitation or Mental Health crisis. On the 3rd May 2025 Jake arrived at the Emergency Department of the Ipswich Hospital at 16:36. Jake was identified as requiring a consultation with the Mental Health Liaison Team at 17:05. Two staff from the Mental Health Liaison Team first met Jake at 17:30. At approximately 18:20-1830 it was identified that Jake required a dose of Diazepam to calm his agitation, to allow for a more effective Mental Health Assessment. Prior to administration of the Diazepam clinical observations were required and these were being completed at 18:35. The observations showed no contraindications for the administration of Diazepam. However, the Diazepam was not prescribed to Jake until 21:19, some 2 hours and 44 minutes after the clinical observations had shown no contraindications for the administration of Diazepam. It is believed that Jake had left the Emergency Department at some time between 19:00 and 19:30. It was not possible to identify on the available evidence whether the administration of Diazepam to Jake on the 3rd May would have prevented his death. However, it was acknowledged that there was a chance that had the Diazepam been administered, it might have changed the tragic sequence of events leading to Jake's death. Evidence heard that in some medical cases clinical staff are given a clear timeline in guidance as to when it is expected a required medication is to be administered (sepsis being cited as an example). The court was told that no such guidance exists for the administration of drugs in Mental Health cases. In Jake's case clinical staff stated that had such a timeline been in place, this would have prompted staff to prescribe and administer the necessary drug earlier than it was. ”
Source location
Jake Harvey READ · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Responsibility for relevant clinical guidance, NHS service delivery and oversight sits with NHS England.

Verbatim wording from the response
“The report raises concerns about the availability of guidance on the administration of medication to patients in a state of agitation or crisis, particularly in relation to timelines; and the ability of non-medical prescribers to both prescribe and access prescription medicines in emergency departments for patients presenting in such circumstances. Responsibility for these matters, including relevant clinical guidance, service delivery and oversight of NHS services, sits with NHS England. NHS England is also responsible for coordinating the regional response where appropriate and is therefore best placed to provide a detailed response to the concerns identified in your report.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 14 August 2026
Open published response
13 May2024
East London
Concerns raised1
1. Failure to make and evidence a reasoned decision on rapid tranquilisation
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.
Actions described in response 3
1. Action
  Deliver an A&E induction programme covering mental capacity, contemporaneous documentation, emergency medicines, sedation and escalation.
  Stated by Barts Health NHS TrustStated planned
2. Action
  Arrange consultant attendance for specified emergency procedures in line with professional guidance.
  Stated by Barts Health NHS TrustStated planned
3. Action
  Update rapid-tranquilisation guidance to require senior, clearly documented decision-making when its criteria cannot be followed.
  Stated by Barts Health NHS TrustStated in progress
Respondent positions 1
1. Position
  The primarily local concerns are for Barts Health NHS Foundation Trust to address.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Elvon Paul Randolph Morton · 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

Elvon Paul Randolph Morton, a 38-year-old man with extensive co-morbidity, was admitted to hospital on 6 December 2022 with abdominal pain, vomiting, diarrhoea, dizziness and shortness of breath. He deteriorated and went into cardiac arrest while awaiting a CT scan under sedation; the inquest concluded that his death was caused by the combined effects of septic shock, oxycodone and lorazepam. Concerns included poor documentation of critical decisions, a flawed decision to sedate him, failures to manage workload pressures safely, and inadequate Trust processes for identifying and reviewing serious incidents.

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 make and evidence a reasoned decision on rapid tranquilisation
Wider context from the report
“3. The decision to sedate Mr Morton was flawed. The lack of contemporary documentation impeded an effective coronary investigation and review of that clinical decision. In the absence of clear and reasoned evidence of decision making, weight must be attached to evidence heard that Elvon’s; size, sex and race triggered a heightened response by hospital staff to his agitation, leading to security officers being called. It was in this febrile atmosphere that the decision to utilise rapid tranquilisation, a simpler and faster process than anaesthesia and intubation, was made. ”
Source location
Elvon Paul Randolph Morton · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Deliver an A&E induction programme covering mental capacity, contemporaneous documentation, emergency medicines, sedation and escalation.

Verbatim wording from the response
“A specific induction programme has been formulated for the A&E which specifically covers themes such as the mental capacity act, contemporaneous documentation including emergency administered drugs with rationale, sedation and also escalation. The induction programme will be delivered and evidenced retained. A specific presentation relating to the Mental Capacity Act (MCA) its implementation in practice and the wider considerations will be delivered within the teaching programmes for all grades within A&E.”

Source location
Response from Barts Health
Page 2 · response
Published 14 May 2024
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
Arrange consultant attendance for specified emergency procedures in line with professional guidance.

Verbatim wording from the response
“The Trust are supportive of staff that are increasingly managing high numbers of complex and acutely unwell patients. In this case, doctors sought and were provided with advice from a consultant on call. The consultant on call will attend to perform certain procedures (in line with the Royal College of Emergency Medicine guidance). With the benefit of hindsight, consultant presence would have provided support for the trainees.”

Source location
Response from Barts Health
Page 2 · response
Published 14 May 2024
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
Update rapid-tranquilisation guidance to require senior, clearly documented decision-making when its criteria cannot be followed.

Verbatim wording from the response
“For assurance and complete clarity, the new rapid tranquilisation guidance which in the process of being recently updated is applicable to the whole of Barts Health has a very clear wording at the top “This guidance is not to be used in the hypoxic, hypovolemic or septic patient or in one in which intubation as opposed to rapid tranquilisation is required”. This will ensure decision making is senior and clearly documented if and when the guidance cannot be followed in cases where there is sound clinical justification to do so.”

Source location
Response from Barts Health
Page 3 · response
Published 14 May 2024
Open published response
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 primarily local concerns are for Barts Health NHS Foundation Trust to address.

Verbatim wording from the response
“In preparing this response, Departmental officials have made enquiries with NHS England. The department is advised that the matters of concern raised are primarily local and for Barts Health NHS Foundation Trust to address, who confirm they are in receipt of this report. The report provides a further opportunity for the Trust to reflect and assure itself that it has acted on all the learnings to be taken from Mr Morton’s death. It is vital that lessons are learnt collectively, and changes are made to reflect where things have gone wrong, which is essential to ensure the NHS provides safe, high-quality care.”

Source location
Response from DHSC
Page 1 · response
Published 14 May 2024
Open published response
4 Oct2023
Nottinghamshire
Concerns raised4
1. Failure of Rapid Tranquilisation policy to specify vital-sign observations and recording for sleeping patients
2. Failure to embed Rapid Tranquilisation monitoring requirements through staff learning and development
3. Failure of Rapid Tranquilisation policy to specify action for suspected unconsciousness
1. Rapid Tranquilisation policy departing from national guidance without supported clinical rationale
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.
Actions described in response 9
1. Action
  Amend Rapid Tranquilisation training to reflect revised monitoring requirements.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
2. Action
  Support wards and services to embed Rapid Tranquilisation standards through case reviews and staff case-based learning.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progress
3. Action
  Deliver bite-sized inpatient teaching on post-Rapid Tranquilisation observations, NEWS2 and escalation.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progress
1. Action
  Amend the Rapid Tranquilisation policy to require NEWS2 monitoring, consciousness assessment, escalation and enhanced observation for sleeping or higher-risk patients.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
2. Action
  Use amended RiO NEWS2 and non-contact observation templates to alert staff to Rapid Tranquilisation observation-frequency requirements.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
3. Action
  Undertake a full Rapid Tranquilisation training review informed by inquest learning, including competency assessment for healthcare support workers.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
4. Action
  Use the junior doctor learning space to share Rapid Tranquilisation policy learning and changes.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
5. Action
  Communicate revised Rapid Tranquilisation policy requirements Trustwide and cascade them through leadership, team meetings and supervision.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
6. Action
  Strengthen Hospital Life Support training to distinguish sleep from reduced consciousness using the ACVPU scale.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
AI-generated summary

Michelle Louise WHITEHEAD · 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

Michelle Louise Whitehead died on 7 May 2021 while an inpatient, after acute hyponatraemia caused by psychogenic polydipsia. The report identified failures to follow the Rapid Tranquilisation policy, including inadequate monitoring of consciousness and delays in responding to her deterioration, and raised concerns about staff training, policy clarity, monitoring guidance, and the detection and management of psychogenic polydipsia.

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 of Rapid Tranquilisation policy to specify vital-sign observations and recording for sleeping patients
Wider context from the report
“2. The Trust’s Rapid Tranquilisation policy is not sufficiently clear on what action should be taken if a patient is considered to be unconscious during the period of monitoring, or is felt to be asleep. The current iteration of the policy (revised after Michelle’s death) does not make it clear that any suspected unconsciousness should result in the immediate summoning of a doctor and alerting the ambulance service via 999. Further, the revised policy does not make it clear which vital sign observations should be undertaken and recorded if a patient is thought to be asleep in the period post rapidly tranquilisation and until the patient is ambulatory. This is despite the policy listing reduced consciousness and respiratory depression as known risks of sedative use, which can lead to death. ”
Source location
Michelle Louise WHITEHEAD · Prevention of Future Deaths report
Page 3 · concerns
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 embed Rapid Tranquilisation monitoring requirements through staff learning and development
Wider context from the report
“1. The Trust’s Rapid Tranquilisation policy has not been sufficiently embedded through learning and development to ensure that all staff have a good working knowledge of the requirements for safely monitoring patients following the use of sedative medications I heard evidence that ward staff had all received training on the policy as part of their initial induction, but all staff in this case had conscientiously failed to follow the policy, including senior ward leaders and medical staff, who informed the court that they were simply not aware of the necessary safeguards to monitor a patient’s consciousness level after administering tranquilisation medications, or how to do so when the patient was thought to be sleeping. ”
Source location
Michelle Louise WHITEHEAD · Prevention of Future Deaths report
Page 2 · concerns
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 of Rapid Tranquilisation policy to specify action for suspected unconsciousness
Wider context from the report
“2. The Trust’s Rapid Tranquilisation policy is not sufficiently clear on what action should be taken if a patient is considered to be unconscious during the period of monitoring, or is felt to be asleep. The current iteration of the policy (revised after Michelle’s death) does not make it clear that any suspected unconsciousness should result in the immediate summoning of a doctor and alerting the ambulance service via 999. Further, the revised policy does not make it clear which vital sign observations should be undertaken and recorded if a patient is thought to be asleep in the period post rapidly tranquilisation and until the patient is ambulatory. This is despite the policy listing reduced consciousness and respiratory depression as known risks of sedative use, which can lead to death. ”
Source location
Michelle Louise WHITEHEAD · Prevention of Future Deaths report
Page 3 · concerns
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
Rapid Tranquilisation policy departing from national guidance without supported clinical rationale
Wider context from the report
“3. The Trust’s current policy appears to depart from National guidance – NICE issued Rapid Tranquillisation Guidance in Notice NG10 in May 2015 The Trust advised me in the course of the inquest that their policy was in line with other local mental health Trusts. However, a review of NICE guidance and other Mental Health Trust policies, available via a brief internet search, demonstrates differences in the advised monitoring protocols. I have shared with the Trust both the NICE guideline and a copy of the publicly available policy issued by a London Trust in February 2022 for comparison. ”
Source location
Michelle Louise WHITEHEAD · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Amend Rapid Tranquilisation training to reflect revised monitoring requirements.

Verbatim wording from the response
“The policy changes that have since been made will be reflected within the training offer to ensure all staff are aware of the additional monitoring requirements. We recognise that staff did not understand the policy standards as necessary and whilst training will be amended to reflect the subsequent changes relating to monitoring, a full training review in line with the learning from the inquest will be undertaken in relation to Rapid Tranquilisation to ensure we have the correct approaches in place post induction. For example, a review of the e-learning package to Health Care Support workers to ensure competency assessment features as part of this process.”

Source location
Response from Nottinghamshire Healthcare NHS Foundation Trust
Page 2 · response
Published 18 October 2023
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
Support wards and services to embed Rapid Tranquilisation standards through case reviews and staff case-based learning.

Verbatim wording from the response
“To ensure training is embedded into practice, as an immediate action we have shared resource across our Forensics and Adult Mental Health care groups of the expertise of a Quality Improvement lead role who will be supporting the Trust is working with wards and services to embed the standards within the policy and ensuring that staff are familiar with this policy and expectations. This will include review of individual cases of RT post observation and staff case-based discussion learning. This is now in place and will remain under review with the learning and improvements monitored through Quality Oversight group.”

Source location
Response from Nottinghamshire Healthcare NHS Foundation Trust
Page 2 · response
Published 18 October 2023
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
Deliver bite-sized inpatient teaching on post-Rapid Tranquilisation observations, NEWS2 and escalation.

Verbatim wording from the response
“The above resource will additionally be delivering bite-size teaching across the In-Patient units with a focus on post Rapid Tranquilisation Observations including NEWS2 and escalation.”

Source location
Response from Nottinghamshire Healthcare NHS Foundation Trust
Page 2 · response
Published 18 October 2023
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
Amend the Rapid Tranquilisation policy to require NEWS2 monitoring, consciousness assessment, escalation and enhanced observation for sleeping or higher-risk patients.

Verbatim wording from the response
“Immediate actions The Trust have responded to the concerns raised regarding the clarity within the Rapid Tranquilisation policy about the escalation requirements relating to known risks associated with the use of medication with Rapid Tranquilisation. The relevant section within the policy concerning escalation of a deteriorating patient has been amended to specifically respond to the risks of reduced consciousness, monitoring when a patient is asleep post rapid tranquilisation and the use of NEWS2 escalation.”

Source location
Response from Nottinghamshire Healthcare NHS Foundation Trust
Page 3 · response
Published 18 October 2023
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
Use amended RiO NEWS2 and non-contact observation templates to alert staff to Rapid Tranquilisation observation-frequency requirements.

Verbatim wording from the response
“The NEWS2 and Non-Contact Observations templates on RiO have been amended to create an alert for ward staff when these observations are carried out due to Rapid Tranquilisation there is a mandatory requirement to change the frequency of observations as per the policy. This change will support the changes in practice and act as a reminder to clinicians as to the monitoring requirements.”

Source location
Response from Nottinghamshire Healthcare NHS Foundation Trust
Page 5 · response
Published 18 October 2023
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 full Rapid Tranquilisation training review informed by inquest learning, including competency assessment for healthcare support workers.

Verbatim wording from the response
“The policy changes that have since been made will be reflected within the training offer to ensure all staff are aware of the additional monitoring requirements. We recognise that staff did not understand the policy standards as necessary and whilst training will be amended to reflect the subsequent changes relating to monitoring, a full training review in line with the learning from the inquest will be undertaken in relation to Rapid Tranquilisation to ensure we have the correct approaches in place post induction. For example, a review of the e-learning package to Health Care Support workers to ensure competency assessment features as part of this process.”

Source location
Response from Nottinghamshire Healthcare NHS Foundation Trust
Page 2 · response
Published 18 October 2023
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
Use the junior doctor learning space to share Rapid Tranquilisation policy learning and changes.

Verbatim wording from the response
“There is a learning space for Junior Doctors within the Organisation which will be utilised to share the learning related to the use of Rapid Tranquilisation, ensuring those are sighted on the policy and the related changes.”

Source location
Response from Nottinghamshire Healthcare NHS Foundation Trust
Page 3 · response
Published 18 October 2023
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
Communicate revised Rapid Tranquilisation policy requirements Trustwide and cascade them through leadership, team meetings and supervision.

Verbatim wording from the response
“Amendments to the policy as outlined further in this letter will be communicated Trust Wide in our Chief Executive briefing. Leaders will be tasked with cascading through team meetings, through supervision and overseeing the changes in practice. Associated monitoring tools are also in the process of being updated to understand compliance in practice.”

Source location
Response from Nottinghamshire Healthcare NHS Foundation Trust
Page 3 · response
Published 18 October 2023
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
Strengthen Hospital Life Support training to distinguish sleep from reduced consciousness using the ACVPU scale.

Verbatim wording from the response
“The above changes are to be reflected, with immediate effect, within the training offer provided for Rapid Tranquilisation as outlined in above section. In addition, Within the Trust Hospital Life Support training, the use of ACVPU scale for assessment of reduced consciousness is included, this has been strengthened to include the considerations and ability to differentiate a patient that is asleep versus a patient with reduced consciousness.”

Source location
Response from Nottinghamshire Healthcare NHS Foundation Trust
Page 4 · response
Published 18 October 2023
Open published response
30 Apr2021
East London
Concerns raised2
1. Failure to complete relevant documentation after rapid tranquillisation
2. Failure to monitor patients following rapid tranquillisation
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.
Actions described in response 5
1. Action
  Review and update the rapid-tranquilisation policy to clarify definitions, health limits, monitoring terminology, paper charts and a ward grab pack.
  Stated by East London NHS Foundation TrustStated planned
2. Action
  Use a RIO rapid-tranquilisation monitoring pack as an interim standardised guide and documentation tool for pre-, during- and post-administration monitoring.
  Stated by East London NHS Foundation TrustStated completed
3. Action
  Require rapid-tranquilisation monitoring by Registered Nurses and place recipients on Registered Nurse eyesight observations during the first post-administration hour.
  Stated by East London NHS Foundation TrustStated completed
1. Action
  Overhaul rapid-tranquilisation training, including interim policy-change content and a standalone annual module for Registered Nurses and Nursing Associates.
  Stated by East London NHS Foundation TrustStated in progress
2. Action
  Make a rapid-tranquilisation e-learning package available on ESR and monitor uptake in real time.
  Stated by East London NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Professional concerns about nurses’ conduct and registration are for the NMC to investigate and sanction.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Rohan Dayal Singh · 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

Rohan Dayal Singh died on a mental health ward on 13 December 2018 after being found unresponsive following rapid tranquillisation. He had retained dangerous contraband, including controlled drugs and a bracelet concealing a blade, despite searches. Fifteen-minute observation records were falsified, and required monitoring and documentation after rapid tranquillisation were not completed; the jury found that the failure to monitor contributed to his death.

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 complete relevant documentation after rapid tranquillisation
Wider context from the report
“3. Mr Singh was subject to rapid tranquillisation, following administration of this medication, staff failed to follow the Trust’s monitoring process or complete relevant documentation. The failure to monitor Rohan was found by the jury to have contributed to his death. Trust evidence demonstrates that beyond this incident, throughout the organisation the processes are not being universally followed. ”
Source location
Rohan Dayal Singh · Prevention of Future Deaths report
Page 3 · concerns
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 monitor patients following rapid tranquillisation
Wider context from the report
“3. Mr Singh was subject to rapid tranquillisation, following administration of this medication, staff failed to follow the Trust’s monitoring process or complete relevant documentation. The failure to monitor Rohan was found by the jury to have contributed to his death. Trust evidence demonstrates that beyond this incident, throughout the organisation the processes are not being universally followed. ”
Source location
Rohan Dayal Singh · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review and update the rapid-tranquilisation policy to clarify definitions, health limits, monitoring terminology, paper charts and a ward grab pack.

Verbatim wording from the response
“Additionally, the following areas of the Trust’s policy are scheduled to be reviewed by a Subject Matter Expert Group led by Director of Nursing. It will be updated on 19 July 2021 with a specific focus on:”

Source location
2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
Page 5 · response
Published 5 May 2021
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
Use a RIO rapid-tranquilisation monitoring pack as an interim standardised guide and documentation tool for pre-, during- and post-administration monitoring.

Verbatim wording from the response
“Finally, since the e-obs platform outlined above will only be available later this year, as of June 2021 a RIO RT monitoring pack is being used as an interim measure to reinforce the Trust’s RT policy.”

Source location
2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
Page 6 · response
Published 5 May 2021
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
Require rapid-tranquilisation monitoring by Registered Nurses and place recipients on Registered Nurse eyesight observations during the first post-administration hour.

Verbatim wording from the response
“Given the serious implications of the above findings, the Chief Nurse made immediate changes to the substance of the Trust’s RT policy. On 10 May 2021 (via email), she instructed all Lead Borough Nurses that as of 17 May 2021, RT Monitoring will only be undertaken by Registered Nurses. Further, patients receiving RT medicines will be placed on eyesight observations with a Registered Nurse, only for the first hour, post-administration.”

Source location
2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
Page 5 · response
Published 5 May 2021
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
Overhaul rapid-tranquilisation training, including interim policy-change content and a standalone annual module for Registered Nurses and Nursing Associates.

Verbatim wording from the response
“In order to ensure that Nurses are fully aware of both the importance and the content of the Trust’s RT policy, processes and procedures the Trust is overhauling its program of training.”

Source location
2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
Page 5 · response
Published 5 May 2021
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
Make a rapid-tranquilisation e-learning package available on ESR and monitor uptake in real time.

Verbatim wording from the response
“The more substantial stand-alone training module in relation to the administration and post-administration monitoring of RT is expected to be completed by 31 August 2021. It will be undertaken alongside the SAME training annually.”

Source location
2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
Page 6 · response
Published 5 May 2021
Open published response
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
Professional concerns about nurses’ conduct and registration are for the NMC to investigate and sanction.

Verbatim wording from the response
“The Nursing and Midwifery Council (NMC) have informed the Department it will be providing a separate response to you in relation to this case. The NMC code of practice² sets out the professional standards that nurses, midwives and nursing associates must uphold in order to be registered to practise in the UK.”

Source location
2021-0134-Response-from-Department-of-Health-Social-Care_Published
Page 2 · response
Published 5 May 2021
Open published response
27 Mar2015
Leicester City and South Leicestershire
Concerns raised2
1. Failure to apply the NICE guidance that diazepam was not recommended
2. Failure to identify and pursue appropriate quick-acting medication alternatives for rapid tranquilisation
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.
Actions described in response 2
1. Action
  Develop a shared rapid tranquillisation guideline with the Leicestershire Partnership Trust, including appropriate consideration of relevant NICE guidance.
  Stated by University Hospitals of Leicester NHS TrustStated in progress
2. Action
  Put the shared rapid tranquillisation guideline in place in the Emergency Department.
  Stated by University Hospitals of Leicester NHS TrustStated planned
AI-generated summary

Rafal Delezuch · 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

Rafal Delezuch was seen behaving bizarrely and showing paranoia in Leicester before being restrained by police under section 136 of the Mental Health Act and taken to hospital. The inquest concluded that he died from amphetamine-induced delirium in association with prolonged struggle. Concerns included staff awareness and training on restraint, lack of familiarity with the dangers of prolonged prone restraint, difficulties obtaining and selecting medication for rapid tranquillisation, and an overlooked warning about diazepam in NICE guidance.

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 apply the NICE guidance that diazepam was not recommended
Wider context from the report
“(1) Although the Trust had a policy for Restraint for dealing with aggressive patients, it became clear from the witnesses from the Trust who gave evidence, that many of the staff in the Emergency Department (including the Senior Registrar in charge of the case) were either wholly unaware of the Policy or unaware of, and had no training in, the application of the policy. (2) It also became clear that the Senior Registrar was not familiar with the dangers of prolonged restraint of a patient in the prone (face-down) position (3) When it was decided that the patient was in need of rapid tranquilisation then: a) A supply of Lorazepam from the manufacturer was apparently not available and no policy appeared to have been devised for the priority use of any limited supply of Lorazepam within the Trust and there was no awareness amongst the clinicians of the availability of alternative medications b)The possibility of a licensed product or of the alternative of Promethazine does not appear to have been pursued. The importance of quick-acting drugs, for the purpose of rapid tranquilisation did not appear to have been fully appreciated. (4) Although the NICE guidelines were printed off and consulted in dealing with the rapid tranquilisation, a reference there to the fact that diazepam was “not recommended” was overlooked. ”
Source location
Rafal Delezuch · Prevention of Future Deaths report
Page 2 · concerns
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 identify and pursue appropriate quick-acting medication alternatives for rapid tranquilisation
Wider context from the report
“(1) Although the Trust had a policy for Restraint for dealing with aggressive patients, it became clear from the witnesses from the Trust who gave evidence, that many of the staff in the Emergency Department (including the Senior Registrar in charge of the case) were either wholly unaware of the Policy or unaware of, and had no training in, the application of the policy. (2) It also became clear that the Senior Registrar was not familiar with the dangers of prolonged restraint of a patient in the prone (face-down) position (3) When it was decided that the patient was in need of rapid tranquilisation then: a) A supply of Lorazepam from the manufacturer was apparently not available and no policy appeared to have been devised for the priority use of any limited supply of Lorazepam within the Trust and there was no awareness amongst the clinicians of the availability of alternative medications b)The possibility of a licensed product or of the alternative of Promethazine does not appear to have been pursued. The importance of quick-acting drugs, for the purpose of rapid tranquilisation did not appear to have been fully appreciated. (4) Although the NICE guidelines were printed off and consulted in dealing with the rapid tranquilisation, a reference there to the fact that diazepam was “not recommended” was overlooked. ”
Source location
Rafal Delezuch · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 a shared rapid tranquillisation guideline with the Leicestershire Partnership Trust, including appropriate consideration of relevant NICE guidance.

Verbatim wording from the response
“In addition, our Chief Pharmacist has met with the Leicestershire Partnership Trust to develop a shared rapid tranquillisation guideline; our Clinical Director will ensure that this guideline is in place by the end of May 2015. This Guideline will also deal with appropriate consideration of the relevant NICE Guidelines.”

Source location
2015-0024-Response-by-University-Hospitals-of-Leicester
Page 2 · response
Published 27 January 2015
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
Put the shared rapid tranquillisation guideline in place in the Emergency Department.

Verbatim wording from the response
“In addition, our Chief Pharmacist has met with the Leicestershire Partnership Trust to develop a shared rapid tranquillisation guideline; our Clinical Director will ensure that this guideline is in place by the end of May 2015. This Guideline will also deal with appropriate consideration of the relevant NICE Guidelines.”

Source location
2015-0024-Response-by-University-Hospitals-of-Leicester
Page 2 · response
Published 27 January 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of national guidance and timelines for administering medication in Mental Health agitation or Mental Health crisis

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to make and evidence a reasoned decision on rapid tranquilisation

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised4

Failure of Rapid Tranquilisation policy to specify vital-sign observations and recording for sleeping patients

Failure to embed Rapid Tranquilisation monitoring requirements through staff learning and development

Failure of Rapid Tranquilisation policy to specify action for suspected unconsciousness

Rapid Tranquilisation policy departing from national guidance without supported clinical rationale

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9

Concerns raised2

Failure to complete relevant documentation after rapid tranquillisation

Failure to monitor patients following rapid tranquillisation

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Respondent positions 1

Actions described in response 3

Respondent positions 1

Actions described in response 9

Actions described in response 5

Respondent positions 1