6 Jun 2023 Jennifer Evelyn RACKLEY · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 2
Failure to document investigations of incidents View source Failure to identify care staff involved in incidents View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Jennifer Evelyn RACKLEY · 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
Jennifer Evelyn Rackley died at Wexham Park Hospital on 15 January 2022 after a fall at her nursing home on 17 December 2021. Concerns included that her bed may have been in the centre of the room with only one sensor mat despite her high falls risk, and that the care home's reported investigation had no written record and could not identify the carers involved.
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 document investigations of incidents
Wider context from the report “(2) Evidence was given that an investigation was carried out – despite no written document / record of this being made - and the manager being unable even to name the care staff involved in the incident.
” Source location Jennifer Evelyn RACKLEY · 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 identify care staff involved in incidents
Wider context from the report “(2) Evidence was given that an investigation was carried out – despite no written document / record of this being made - and the manager being unable even to name the care staff involved in the incident .
” Source location Jennifer Evelyn RACKLEY · Prevention of Future Deaths report
Open source report
5 Jun 2023 Jonathan “Jonny” Philip Cole [JC] · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 1
Insufficiently robust Trust investigation and review process View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Nottinghamshire Healthcare NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Nottinghamshire Healthcare NHS Foundation Trust
Use a panel sign-off process to review Mental Health Care Group serious-incident investigations.
View source
Nottinghamshire Healthcare NHS Foundation Trust
Share learning from the preventing-future-deaths report through ongoing serious-incident investigation training.
View source
Nottinghamshire Healthcare NHS Foundation Trust
Continue providing two-day systems-based serious-incident investigation training for investigators.
View source
Nottinghamshire Healthcare NHS Foundation Trust
Deliver six serious-incident quality-assurance training events for investigation report reviewers and approvers during 2023–2024.
View source
Nottinghamshire Healthcare NHS Foundation Trust
Use developed neurodiversity guidance to support investigators in considering individual needs and reasonable adjustments.
View source
Nottinghamshire Healthcare NHS Foundation Trust
Conduct a proactive, objective review of active Trust inquests to identify lessons and improvement themes.
View source See 3 more actions
×
AI-generated summary
Jonathan “Jonny” Philip Cole [JC] · 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
Jonny Cole was found hanging at Old Stone Bridge, Butterley Park, on 9 August 2018, after having acted with the intention to end his life. He had PTSD, anxiety and suicidal ideation and was under the care of his local mental health trust. The report raised concerns about inadequate identification and management of his suicide risk, gaps in trauma treatment and veteran services, shortcomings in Ministry of Defence mental-health provision and compensation processes, and the robustness of the Trust’s investigation.
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 Insufficiently robust Trust investigation and review process
Wider context from the report “6. I have a concern as to the quality of the Trust’s Investigation Report and that the process of review is not sufficiently robust
I acknowledge that the Trust recognises that the investigation reports provided in respect of Jonny Cole’s death were unsatisfactory and also and that the review of Rapid Response Liaison Psychiatry involvement in 2022, “was a missed opportunity to retrospectively review the investigation in its entirety”. However, it is of concern that the 2022 review was also insufficient and inadequate .
The concerning information relating to the attempt Jonny made to ligate in a tree was not analysed. ████████ told me that an attempt on life by suicide increases the risk 100-fold that you would die by suicide in the next 12 months and is the most significant risk factor in Jonny’s history that massively elevated the risk until that period of time has lapsed which requires clinical risk assessment.
The Investigation report and the updated report following review failed to identify themes of concern ², and did not reassure me that the Trust had taken an appropriate response to investigate the concerning facts of this case and to ensure lessons were learned and not repeated for other patients and appropriate audit undertaken .
I am told that the Trust is, “committed to continuing our improvement journey in this area”, however, I remain concerned that the Trust’s investigation was insufficient, lacked robustness and did not fully engage with the duty of candour .
” Source location Jonathan “Jonny” Philip Cole [JC] · Prevention of Future Deaths report
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 Use a panel sign-off process to review Mental Health Care Group serious-incident investigations.
Verbatim wording from the response “The Mental Health Care Group introduced a panel sign off process which collectively reviews the investigation to provide a higher level of quality assurance and triangulation of information. We envisage our reviewed and strengthened governance will mitigate this risk moving forward.” Source location Response from Nottinghamshire Healthcare
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 Share learning from the preventing-future-deaths report through ongoing serious-incident investigation training.
Verbatim wording from the response “The learning from the outcome of this preventing future deaths report will be shared as part of on-going training provided to staff undertaking serious incident investigations and those involved within the approval process of investigations.” Source location Response from Nottinghamshire Healthcare
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 Continue providing two-day systems-based serious-incident investigation training for investigators.
Verbatim wording from the response “We continue to work with external partners to ensure that staff undertaking serious incident investigations are trained and knowledgeable in investigation techniques. We will continue in our commitment to providing a two-day training event for investigators based on a “Systems Based Approach” (SBA). This approach is advocated by the Patient Safety Incident Response Framework (PSIRF) which will be implemented within NHS Organisations during the Autumn of 2023. The role of SBA is to identify the systems-based problems when an incident occurs, rather than focusing on the individuals involved. Our aim is to provide five two-day Serious Incident Investigation training sessions each year, which enables the opportunity for 125 attendees across those sessions.” Source location Response from Nottinghamshire Healthcare
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 six serious-incident quality-assurance training events for investigation report reviewers and approvers during 2023–2024.
Verbatim wording from the response “We also recognised that we needed to strengthen our overall review of our investigation reports and ensure those individuals who are reviewing/approving/authorising the final report have the skills to critically appraise the report and ensure it is fit for purpose.” Source location Response from Nottinghamshire Healthcare
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 developed neurodiversity guidance to support investigators in considering individual needs and reasonable adjustments.
Verbatim wording from the response “The course will provide the attendees with skills to critically assess the investigation report and ensure it concentrates on Systems Based outcomes and SMART actions. Our aim is that within the six sessions we can train approximately 150 individuals. The purpose of this training is to provide senior leaders who have responsibility for approving reports with the skills to analyse the report, ensure fairness, that systems-based learning has been applied and that the report and findings reflect the agreed terms of reference and any questions raised by the patient or family. The Trust recognises the need to consider neurodiversity when undertaking investigations. Guidance has now been developed to support investigators to consider individual need, reasonable adjustments, access to learning development and consultation forums.” Source location Response from Nottinghamshire Healthcare
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 Conduct a proactive, objective review of active Trust inquests to identify lessons and improvement themes.
Verbatim wording from the response “Review of active Investigations & Inquests:” Source location Response from Nottinghamshire Healthcare
Open published response
7 May 2023 Bency Joseph · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2
Failure to involve the deceased patient's family in the Trust investigation View source Failure to involve the senior pharmacist in the Trust investigation View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Bency Joseph · 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
Bency Joseph died instantly on 27 May 2022 from a traumatic head injury after falling headfirst from an upstairs window at home during a severe psychotic episode. The concerns included delays in prescribing and providing therapeutic medication, failure to act on the family’s attempts to escalate the issue, and shortcomings in the Trust’s investigation, including not involving the family or Senior Pharmacist.
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 involve the deceased patient's family in the Trust investigation
Wider context from the report “(2) The Trust investigation did not:
a. Inform or involve the Trust Senior Pharmacist who was unaware of the death and had no opportunity to be involved in the internal investigation.
b. Involve the Family of the deceased
c. Lost an opportunity to understand concerns that the Family had been trying to access additional urgent medication prescribed on 26 May 2022 without success and had been telephoning the Trust to raise an alert .
” Source location Bency Joseph · 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 involve the senior pharmacist in the Trust investigation
Wider context from the report “(2) The Trust investigation did not:
a. Inform or involve the Trust Senior Pharmacist who was unaware of the death and had no opportunity to be involved in the internal investigation.
b. Involve the Family of the deceased
c. Lost an opportunity to understand concerns that the Family had been trying to access additional urgent medication prescribed on 26 May 2022 without success and had been telephoning the Trust to raise an alert.
” Source location Bency Joseph · Prevention of Future Deaths report
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 Share learning about involving pharmacy expertise in clinical review investigations with the Clinical Review Group chair.
Verbatim wording from the response “Following notification of Mrs Joseph’s death, the Trust’s Clinical Review Group reviewed details of the incident on 14 June 2022 and requested that a Clinical Review be completed. The Group directed that the scope of the review should be from Mrs Joseph’s first contact with the Trust until her death and that any questions from the family should also be answered. At that point in time, it was not evident that involvement from the Trust’s Director of Pharmacy would be required, however the Trust acknowledges that when the report was reviewed by the Clinical Review Group, the Group should have picked up on this point and requested input prior to final approval of the report. This learning has been shared with the Chair of the Clinical Review Group.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
28 Apr 2023 Winbourne Gregory Charles · Prevention of Future Deaths report East London
View report summary
Concerns raised 1
Failure of serious incident investigation to address risk-assessment and reporting deficiencies View source
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Winbourne Gregory Charles · 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
Winbourne Gregory Charles was found unresponsive on 10 April 2021, suspended on a mental health ward, after being admitted under the Mental Health Act following an attempt to take his own life. The principal concerns included failures in risk assessment, observation practices, emergency response, record keeping, and governance processes.
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 serious incident investigation to address risk-assessment and reporting deficiencies
Wider context from the report “6. Governance process failings.
a. A datix incident report created on the evening of 10ᵗʰ April 2021 by a senior nurse and Modern Matron contained misleading information that suggested that emergency response policies were followed when in fact they were not.
b. The Datix failed to mention that observations had been suspended by the shift coordinator, a fact that was understood at that time. This obvious and significant piece of information that should have been escalated through the Trust governance team for action.
c. The Trust 72 hour report was written by the Modern Matron and was signed-off by an integrated care director on 15th April 2021. This document also failed to identify or escalate the significant issue of the suspension of observation at 16.00 on 10th April 2021.
d. The Trust SI report was not prepared to fully address the poor risk assessment or inadequate datix & 72 hr reports.
” Source location Winbourne Gregory Charles · Prevention of Future Deaths report
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 Serious Incident processes and revisit the adequacy of evidence and learning captured in reports.
Verbatim wording from the response “17. Review of SI report and HR processes.” Source location NELFT NHS Foundation Trust Action Plan
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 Concerns about care provision and coordination are mainly for the NHS Trust to address.
Verbatim wording from the response “Your report raises concerns over the provision and coordination of care that Winbourne received at North East London NHS Foundation Trust, which are mainly for the Trust to address. I understand that the Trust has already carefully considered the matters of concern in your report and has provided you with a comprehensive response as well as a copy of its action plan setting out the actions to be taken to improve care quality and patient safety.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 1
Lack of timely completion of internal investigations View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Betsi Cadwaladr University LHB
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Betsi Cadwaladr University LHB
Re-evaluate the incident process and develop a procedure defining roles and responsibilities.
View source
Betsi Cadwaladr University LHB
Address overdue investigations through weekly improvement and scrutiny meetings with clinical directors.
View source
Betsi Cadwaladr University LHB
Strengthen performance and accountability processes to include overdue investigations.
View source
Betsi Cadwaladr University LHB
Provide local quality governance support to services for managing open and overdue investigations and evidencing completed actions.
View source See 1 more action
×
AI-generated summary
Nancy Carolyn 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
Nancy Carolyn Price, aged 62, presented with sudden loss of movement and sensation in both lower limbs and was diagnosed with limb ischaemia. There were delays in assessing and transferring her for vascular surgery, after which she developed multi-organ failure and died on 1 January 2021. The principal concerns were the delayed Health Board investigation, delayed sharing of learning, and unrealistic or incomplete action plans, which limited the timely identification of learning and training needs.
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 timely completion of internal investigations
Wider context from the report “An investigation was commenced by the Health Board into the death of Nancy Carolyn Price, a significant time after her death and was completed only on 9 June 2022, some 17 months after her death . At inquest it was identified that not all actions arising have been fully completed and the dates by when actions ought to have been completed (according to the investigation report) not adhered to. For example, the investigation report was due to be shared with vascular services to share learning by June 2022 (once approved) and yet the Report was only shared with vascular services in January 2023.
The actions arising from the investigation report are not always realistic. For example, one action was to identify any gaps in knowledge with regards to assessment and management of vascular emergencies, including recording of limb colour, sensation and movement, by the end of June 2022, approximately 3-4 weeks after the final report.
I have previously issued Prevention of Future Death Reports to the Health Board pertaining to the lack of timeliness of their investigations .
I remain significantly concerned that the strategic management of internal Health Board investigations is lacking leading to investigations that are too slow , actions are not always realistic and, as a result, identification of areas for learning and training are not understood quickly enough, such that deaths will occur or will continue to occur into the future unless rapid action is taken.
” Source location Nancy Carolyn Price · Prevention of Future Deaths report
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 Re-evaluate the incident process and develop a procedure defining roles and responsibilities.
Verbatim wording from the response “• We are re-evaluating the incident process to identify how it can be streamlined and a new procedure document will be developed setting out roles and responsibilities. This will be complete by the end of August 2023.” Source location Response from Betsi Cadwaladr University Local Health Board
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 Address overdue investigations through weekly improvement and scrutiny meetings with clinical directors.
Verbatim wording from the response “• We are working to address those investigations currently overdue. A weekly improvement and scrutiny meeting, chaired by the Deputy Directors of Nursing, is held with clinical directors from our services to monitor, track and support the completion of serious incidents.” Source location Response from Betsi Cadwaladr University Local Health Board
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 performance and accountability processes to include overdue investigations.
Verbatim wording from the response “• We will be strengthening the performance and accountability process with our services to include overdue investigations.” Source location Response from Betsi Cadwaladr University Local Health Board
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 Provide local quality governance support to services for managing open and overdue investigations and evidencing completed actions.
Verbatim wording from the response “• Our divisionally-based Quality Governance Teams will support our services locally with understanding their open and overdue investigations and actions, and will support services to collate evidence of action completion. The Patient Safety Team have the role of monitoring performance and assuring the completion of actions.” Source location Response from Betsi Cadwaladr University Local Health Board
Open published response
19 Apr 2023 DAVID ERNEST MASON · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1
Failure of internal investigation coordination and learning from patient-safety incidents View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
DAVID ERNEST MASON · 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 Ernest Mason, aged 82, fell at home on 5 March 2022, fractured his hip and was taken to hospital after an ambulance delay. He had Addison’s disease and died in the early hours of 7 March 2022 after developing an acute adrenal crisis. The principal concerns were that clinicians and ambulance staff did not recognise the need for additional steroid replacement after trauma and physiological stress, and that relevant clinical guidance, call-handler pathways and documentation prompts did not sufficiently address this risk.
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 internal investigation coordination and learning from patient-safety incidents
Wider context from the report “4) Evidence heard at the inquest confirmed that the investigation lead at WMAS had not been shown the inquest disclosure bundle , which had been disclosed to the legal department at WMAS a number of months prior to the inquest. This bundle contained relevant evidence from a different internal investigation (by WAHT), suggesting that the likely cause of Mr Mason’s deterioration and death was an acute adrenal crisis and not, as had been considered when a coronial referral had initially been made, hyperkalaemia and rhabdomyolysis (following a fall and long lie). This lack of internal co-ordination within WMAS prevented full internal investigation and learning in respect of the care given to Mr Mason by WMAS.
” Source location DAVID ERNEST MASON · Prevention of Future Deaths report
Open source report
6 Apr 2023 Alexandra Briess · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 1
Inadequate immediate investigation of suspected anaphylaxis deaths View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
NHS England
Consider the report’s concerns about investigating and following up perioperative anaphylaxis when developing specialised allergy service specifications and commissioning policies.
View source
×
AI-generated summary
Alexandra Briess · 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
Alexandra Briess underwent tonsillectomy, later required surgery for post-operative bleeding, and suffered sudden deterioration and cardiac arrest during anaesthesia on 30 May 2021. She died on 31 May 2021, with the most likely cause identified as an anaphylactic reaction to Rocuronium; there were no concerns about her clinical management. The principal concerns were the lack of national leadership and funding for anaphylaxis work, mandatory reporting of fatal anaphylaxis, and improved national data gathering, research and information sharing.
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 Inadequate immediate investigation of suspected anaphylaxis deaths
Wider context from the report ““Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis , that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths , but that to achieve this, changes are required .
In relation to the Food Standards Agency, the UK Health Security Agency, and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxes, and specifically, fatal and near-fatal anaphylaxis…
• Such a system could involve, mandatory reporting of anaphylaxis presenting to hospital analogous to the current system for notifiable diseases… by registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the State of Victoria in Australia, and allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate public health risk.”
” Source location Alexandra Briess · Prevention of Future Deaths report
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 Consider the report’s concerns about investigating and following up perioperative anaphylaxis when developing specialised allergy service specifications and commissioning policies.
Verbatim wording from the response “NHS England’s NSA for Specialised Immunology and Allergy and the CRG has provided assurances that they recognise the importance of the issues relating to investigation and follow up of perioperative anaphylaxis as highlighted in your Report and will be taking points raised into consideration in the development of the specialised allergy service specifications and commissioning policies.” Source location Response from NHS England
Open published response
27 Feb 2023 Sharon Elizabeth Langley · Prevention of Future Deaths report Essex
View report summary
Concerns raised 4
Failure to investigate bath plug storage and control issues View source Failure to maintain reliable investigation conclusions when presented with unrequested and uncertain evidence View source Failure to scrutinise staff movements and available door logs during investigations View source
Failure to investigate emergency response and information-sharing concerns View source See 1 more concern
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Sharon Elizabeth Langley · 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
Sharon Elizabeth Langley, an inpatient with Severe Depressive Disorder and Psychosis, died by immersion in water while unsupervised in an assisted bathroom at Princess Alexandra Hospital on 10 August 2019. The principal concerns included failures in the immediate emergency response, inadequate communication and coordination, shortcomings in bathroom and high-risk-area safety measures, confusion about bath-plug controls, unreliable investigation and learning processes, and inadequate record keeping and risk documentation.
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 investigate bath plug storage and control issues
Wider context from the report “(6) There is concern about the reliability of the Trust investigation and how the Trust learns lessons. The investigation report did not:
a. scrutinise the movements of staff even though the door logs were available or raise any issues for further investigation
b. raise any issues around the bath plug or where it should be kept
c. investigate concerns raised around the Trust staff emergency response or failure to provide basic information on the incident to paramedics
” Source location Sharon Elizabeth Langley · 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 maintain reliable investigation conclusions when presented with unrequested and uncertain evidence
Wider context from the report “(7) The Trust investigation author changed the conclusion of his report during the inquest when he received statements provided by staff that were not requested and contained timing information that in evidence staff stated they did not know .
” Source location Sharon Elizabeth Langley · 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 scrutinise staff movements and available door logs during investigations
Wider context from the report “(6) There is concern about the reliability of the Trust investigation and how the Trust learns lessons. The investigation report did not:
a. scrutinise the movements of staff even though the door logs were available or raise any issues for further investigation
b. raise any issues around the bath plug or where it should be kept
c. investigate concerns raised around the Trust staff emergency response or failure to provide basic information on the incident to paramedics
” Source location Sharon Elizabeth Langley · 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 investigate emergency response and information-sharing concerns
Wider context from the report “(6) There is concern about the reliability of the Trust investigation and how the Trust learns lessons. The investigation report did not:
a. scrutinise the movements of staff even though the door logs were available or raise any issues for further investigation
b. raise any issues around the bath plug or where it should be kept
c. investigate concerns raised around the Trust staff emergency response or failure to provide basic information on the incident to paramedics
” Source location Sharon Elizabeth Langley · Prevention of Future Deaths report
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 Use the Patient Safety Incident Response Framework and current response plan to investigate incidents with revised methodology and fuller chronology and triangulation.
Verbatim wording from the response “- The weaknesses of the Serious Incident Framework have been nationally recognised, which has led to the implementation of the Patient Safety Incident Response Framework (PSIRF, 2022). EPUT were an early adopter of PSIRF having formally implemented on 1st May 2021, and have helped shape the national implementation expectations. With this in mind, under the Trust’s current Patient Safety Incident Response Plan (PSIRP), an incident of this nature would have been investigated using a revised and recognised methodology and the data in which the investigation would have been set out would allow for a longer period of time to scrutinise the logs against other information to support with a chronology of events, triangulation of events and identification of learning.” Source location Response from Essex Partnership University NHS Foundation Trust
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 investigation could not analyse access logs in depth because they arrived after the chronology and the applicable framework required completion within 60 days.
Verbatim wording from the response “- The Lead Investigator and author of the Root Cause Analysis report reviewed the door access control logs as part of the investigation process. The Root Cause Analysis report was completed under the Serious Incidents Framework (SIF, 2015) whereby the expectation at the time was for the report to be completed within 60 days of the date of commissioning. The Lead Investigator has stated that the logs were received after the chronology had been completed and were not analysed in depth due to the timeline above.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
25 Jan 2023 Andrew Mark Largin · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure of serious incident investigations to interview relevant decision makers and provide feedback View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Andrew Mark Largin · 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
Andrew Mark Largin died by suicide after asphyxiating himself in the early hours of 6 February 2022 at the home where he lived. Concerns included delays in allocation to the neighbourhood rehabilitation team, failure by the crisis team to reassess him after being told he remained very depressed, inadequate recording and investigation of decision-making, and a lack of clarity about referral pathways and response times between teams.
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 serious incident investigations to interview relevant decision makers and provide feedback
Wider context from the report “4. The SI reviewer giving evidence in court said that the SI reviewing team had not even spoken to that crisis team member as part of their investigation, let alone fed back to her .
5. He said they did not at the time realise that she still worked for ELFT, though he accepted that it would have been an extremely straightforward matter to find out. The crisis team member’s manager gave evidence that she thought the relevant decision maker had left the team before Mr Largin’s death, so between 3 and 6 February 2022. When I invited that manager to make a call while the inquest was ongoing to check, she later told me that the team member had not left the crisis team until 29 April 2022.
” Source location Andrew Mark Largin · Prevention of Future Deaths report
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 the Serious Incident reviewer responsibilities document to require relevant staff to be contacted through Human Resources for review involvement.
Verbatim wording from the response “I was troubled that the Trust’s SI review did not highlight that the relevant crisis team member did not record their rationale explaining why Mr Largin should remain with WWNT. I asked the Trust’s Associate Director of Governance and Risk to explore this further.” Source location Response from East London NHS Foundation Trust
Open published response
17 Jan 2023 Teegan Marie Barnard · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 2
Failure to investigate potential anaesthetic-related causes of unexpected deaths View source Lack of a robust system to trigger investigations into unexpected deaths View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Association Of Anaesthetists (Great Britain & Ireland) NHS England Royal College of Anaesthetists University Hospitals Sussex NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
University Hospitals Sussex NHS Foundation Trust
Develop and ratify a standard operating procedure defining actions for HSIB investigations and considering parallel local investigation.
View source
Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists
Amend guidance to require a standardised investigation process automatically triggered immediately after a catastrophic event.
View source
Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists
Promote the amended catastrophic-event investigation process to the anaesthesia specialty.
View source
Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists
Embed the amended catastrophic-event investigation process through the Royal College of Anaesthetists’ Anaesthesia Clinical Services Accreditation scheme.
View source
Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists
Review guidance to identify the need for a standardised investigation process automatically triggered after catastrophic events.
View source
Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists
Amend guidance to specify a standardised investigation process automatically triggered immediately after catastrophic events.
View source
Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists
Promote the amended catastrophic-event investigation process to the anaesthesia specialty.
View source
Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists
Embed the amended catastrophic-event investigation process through the Royal College of Anaesthetists’ Anaesthesia Clinical Services Accreditation scheme.
View source
NHS England
Launch the Patient Safety Incident Response Framework for developing and maintaining systems to respond to incidents and improve patient safety.
View source See 6 more actions
×
AI-generated summary
Teegan Marie Barnard · 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
Teegan Marie Barnard suffered a prolonged PEA cardiac arrest during emergence from general anaesthesia after an emergency caesarean section, following significant postpartum haemorrhage and bilateral tension pneumothoraces. She sustained a non-survivable hypoxic brain injury and died at home six weeks later. Concerns included failure to consider and promptly recognise tension pneumothoraces during resuscitation, and inadequate investigation, clinical governance and learning after her 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 investigate potential anaesthetic-related causes of unexpected deaths
Wider context from the report “3. Investigation after Teegan’s death
Following this incident, and despite Teegan being intubated and ventilated at the time, with a real possibility of this being an anaesthetic related event, no steps were taken by the anaesthetic department at St Richard’s Hospital, Chichester, either before or after the publication of the HSIB report, to explore potential iatrogenic or other anaesthetic related causes (such as exposure of Teegan’s lungs to excessive volume or pressure ) as a possible or probable cause of Teegan’s death.
Furthermore, the anaesthetic machine/ventilator was not taken out of service and assessed to see if there was a fault. Neither was the data from the anaesthetic machine downloaded and interrogated, which may have assisted in establishing how Teegan came to develop bilateral tension pneumothoraces during her emergence from general anaesthesia.
The failure of the anaesthetic department to undertake any morbidity or mortality review/meeting following Teegan’s death led to a lost opportunity to share any possible learning opportunities both within and outside their department to prevent future deaths, and as a corollary to have been in a position to fully assist both the investigation by the HSIB and the inquest hearing.
” Source location Teegan Marie Barnard · 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 Lack of a robust system to trigger investigations into unexpected deaths
Wider context from the report “4. Trust Clinical Governance procedures
The senior management team within the Trust have not acknowledged that there was a lack of a proper and robust system in place to trigger an investigation into all the circumstances of the death of a 17-year-old patient, with no steps taken by them to do so either before or after the publication of the HSIB report or at any time prior to the Inquest hearing.
This gives rise to a concern of a lack of insight within the senior management team of the importance of undertaking a comprehensive investigation into unexpected deaths within their organisation and for there to be wider dissemination of any institutional learning with the aim of preventing future deaths.
The failure of the Trust to fully investigate how Teegan came by her death also gives rise to a concern regarding the Trust’s obligation to comply with the Statutory Duty of Candour and their requirement to share their findings with both the regulators and Teegan’s family as well as to indicate the steps, if any, they have taken to prevent future deaths.
” Source location Teegan Marie Barnard · Prevention of Future Deaths report
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 and ratify a standard operating procedure defining actions for HSIB investigations and considering parallel local investigation.
Verbatim wording from the response “Although the Trust followed existing national guidance, additional safeguards have been put in place to ensure our processes for investigating maternal deaths are robust. In the Regulation 28 notice, the Trust’s decision not to undertake a local investigation alongside the one initiated by HSIB is highlighted. At the inquest the Trust presented evidence demonstrating the very clear national guidance indicating that the HSIB investigation should replace the need for local scrutiny as described above. However, in response to the coroner’s concerns, the Trust has developed a draft SOP that defines the actions required when an HSIB investigation takes place” Source location Response from St Richards Hospital
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 guidance to require a standardised investigation process automatically triggered immediately after a catastrophic event.
Verbatim wording from the response “We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.” Source location Response from Royal College of Anaesthetists
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 Promote the amended catastrophic-event investigation process to the anaesthesia specialty.
Verbatim wording from the response “We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.” Source location Response from Royal College of Anaesthetists
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 Embed the amended catastrophic-event investigation process through the Royal College of Anaesthetists’ Anaesthesia Clinical Services Accreditation scheme.
Verbatim wording from the response “We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.” Source location Response from Royal College of Anaesthetists
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 Review guidance to identify the need for a standardised investigation process automatically triggered after catastrophic events.
Verbatim wording from the response “We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.” Source location Response from Royal College of Anaesthetists
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 guidance to specify a standardised investigation process automatically triggered immediately after catastrophic events.
Verbatim wording from the response “We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.” Source location Response from Royal College of Anaesthetists
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 Promote the amended catastrophic-event investigation process to the anaesthesia specialty.
Verbatim wording from the response “We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.” Source location Response from Royal College of Anaesthetists
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 Embed the amended catastrophic-event investigation process through the Royal College of Anaesthetists’ Anaesthesia Clinical Services Accreditation scheme.
Verbatim wording from the response “We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.” Source location Response from Royal College of Anaesthetists
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 Launch the Patient Safety Incident Response Framework for developing and maintaining systems to respond to incidents and improve patient safety.
Verbatim wording from the response “With regard to the concerns around the subsequent investigation into Teegan’s death, and the fact that there was no local investigation run in parallel to the Healthcare Safety Investigation Branch’s (HSIB’s) investigation, the NHS England National Patient Safety Team has recently launched a new Patient Safety Incident Response Framework (PSIRF), which ‘sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety’.” Source location Response from NHS England
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 HSIB investigation replaced the need for a parallel local investigation under national guidance, so no concurrent local investigation was required.
Verbatim wording from the response “The coroner raises the concern that there was no local investigation by the anaesthetic team before or after the HSIB report. However, initiating a local investigation in parallel to the HSIB investigation would have been contrary to national guidance.” Source location Response from St Richards Hospital
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 identified care, evidence-handling, Duty of Candour and investigation concerns fall outside HEE’s current role and statutory responsibilities.
Verbatim wording from the response “I write in response to your report of 17 January 2023, made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. I have been asked to respond on behalf of Health Education England. Please may I start by offering my sincere condolences to the family of Teegan Marie Bernard, following her tragic death. However, having carefully considered the report, together with the facts of the case, we believe that whilst there are valuable lessons to be learned; Unfortunately, these do not come within the scope of HEE’s current role and statutory responsibilities.” Source location Response from Health Education England
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 Where HSIB undertakes a maternity investigation, a separate local patient safety learning response is not required under PSIRF.
Verbatim wording from the response “With regard to the concerns around the subsequent investigation into Teegan’s death, and the fact that there was no local investigation run in parallel to the Healthcare Safety Investigation Branch’s (HSIB’s) investigation, the NHS England National Patient Safety Team has recently launched a new Patient Safety Incident Response Framework (PSIRF), which ‘sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety’.” Source location Response from NHS England
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.