26 Oct 2016 Alfie Rose · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to communicate relevant clinical information between hospitals View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
the Dudley Group NHS Foundation Trust University Hospitals Birmingham 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. 4
the Dudley Group NHS Foundation Trust
Conduct meetings between QEHB and RHH clinical staff to identify communication and referral-system improvements.
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the Dudley Group NHS Foundation Trust
Develop and agree a detailed cross-Trust action plan addressing identified communication, referral and emergency-management concerns.
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the Dudley Group NHS Foundation Trust
Deliver the agreed cross-Trust action plan to address identified safety concerns.
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University Hospitals Birmingham NHS Foundation Trust
Conduct cross-hospital meetings to identify communication and patient-management improvements following the clinical incident.
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Alfie Rose · 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
Alfie Rose, aged 17, died on 09 June 2016 following deterioration from obstructive hydrocephalus, severe brain injury and brain stem death. The report identified poor communication between the two hospitals and inadequate guidance and education for clinicians in outlying hospitals as principal concerns. The inquest concluded that earlier detailed MRI scanning, admission and treatment at the Queen Elizabeth Hospital neurosurgical unit would, on balance, have avoided his death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate relevant clinical information between hospitals
Wider context from the report “1. There was poor communication between both hospitals in relation to Alfie’s condition and care. Details of his neurosurgical review on 16/05/16 were not made available to Russell’s Hall Hospital. His clinical condition was not relayed to QE hospital on 27/05/16 or morning of 06/06/16. These were vital missed opportunities to transfer him back to QE for treatment. Both Trusts need to look at their communication systems and identify areas for improvement and to clarify if the NORSE system is effective. I heard evidence to suggest that all the NORSE system entries cannot always be seen.
” Source location Alfie Rose · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct meetings between QEHB and RHH clinical staff to identify communication and referral-system improvements.
Verbatim wording from the response “It is important to reflect on the effectiveness of any system when there has been a significant clinical incident. To that end the following meetings have been held to identify areas of concern that could be improved:” Source location 2016-0382-Response-by-The-Dudley-Group-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and agree a detailed cross-Trust action plan addressing identified communication, referral and emergency-management concerns.
Verbatim wording from the response “Issues Identified:” Source location 2016-0382-Response-by-The-Dudley-Group-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the agreed cross-Trust action plan to address identified safety concerns.
Verbatim wording from the response “A detailed action plan has been developed (attached to this letter) and the actions have been agreed by both UHB and DGFT. We have commenced on the delivery of these actions and recorded our progress on the action plan for you information.” Source location 2016-0382-Response-by-The-Dudley-Group-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct cross-hospital meetings to identify communication and patient-management improvements following the clinical incident.
Verbatim wording from the response “It is important to reflect on the effectiveness of any system when there has been a significant clinical incident. To that end the following meetings have been held to identify areas of concern that could be improved:” Source location 2016-0382-Response-by-University-Hospitals-Birmingham-NHS-Trust
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25 Oct 2016 Richard Walsh · Prevention of Future Deaths report Inner South London
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Concerns raised 1
Failure of detained organisations to pass risk information consistently between one another View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Richard Walsh · 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
Richard Walsh was detained after being charged with attempted murder and, while experiencing delusions, refused food and drink with the stated intention of dying. He was transferred between HMP Highdown and HMP Belmarsh, where he was isolated in a single cell for 23½ hours a day and later died by hanging. The principal concerns were failures in communication and information-sharing between police, mental health, court and prison services, inadequate mental health assessment, and inadequate assessment of his fitness for segregation and suicide risk.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of detained organisations to pass risk information consistently between one another
Wider context from the report “There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility.
” Source location Richard Walsh · Prevention of Future Deaths report
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5 Sep 2016 John Gerard JONES · Prevention of Future Deaths report Avon
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Concerns raised 1
Delays in notifying GPs of Crisis Team discharge View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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John Gerard JONES · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Gerard JONES had been receiving support because of a perceived risk of suicide, and admission to hospital was recommended but not undertaken. He later took his own life by drowning in the River Avon on or around 1 February 2016. The principal concern was that his GP was not notified of his discharge from the Crisis Team for approximately a week, leaving uncertainty about community support during that period.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in notifying GPs of Crisis Team discharge
Wider context from the report “(1) Mr Jones was initially referred to the Crisis Team because his GP believed that Mr Jones’ suicide risk could not be safely managed within the community.
(2) When Mr Jones was in due course discharged from the Crisis Team's care it was approximately a week before his GP was notified of that discharge. That notification was received by fax.
(3) This meant that during the important period immediately after discharge from the Crisis Team's care there was a period of approximately a week when Mr Jones was (notionally) back under the care of his GP, but his GP was unaware that this was the case: this meant that Mr Jones would have had no support within the community during this period aside from a single follow up / post-discharge call from the Crisis team.
(4) In evidence the GP indicated that it would have been helpful to have been contacted by telephone at the time of Mr Jones’ discharge and notified of it.
(5) It did not appear to me that there was any clear provision within the Crisis Team’s training / structure / protocols for the sort of communication envisaged by Mr Jones’ GP.
” Source location John Gerard JONES · Prevention of Future Deaths report
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10 Aug 2016 Thomas George Jordan · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Breakdown in communication between hospital and prison at discharge View source
This report raised 3 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
Care UK
Create an electronic pathway to share hospital discharge summaries with HMP Leeds.
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Thomas George Jordan · 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
Thomas George Jordan, a remand prisoner at Her Majesty’s Prison, Leeds, became unwell with cardiac symptoms and was admitted to hospital on 6 August 2015. His condition deteriorated, and he died following cardiac arrest at 1955 hours that day; the inquest recorded natural causes. The concerns included continued administration of Digoxin after hospital clinicians requested its discontinuation and a breakdown in communication when he was discharged from hospital, although the report stated there was no evidence that the drug error materially caused or contributed to his death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Breakdown in communication between hospital and prison at discharge
Wider context from the report “(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued.
(2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged .
(3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them.
(4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan's death.
” Source location Thomas George Jordan · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create an electronic pathway to share hospital discharge summaries with HMP Leeds.
Verbatim wording from the response “Further to that correspondence, the Head of Healthcare at HMP Leeds has discussed the above with the Clinical Director for Urgent Care at Leeds Teaching Hospital. The Director has agreed that an electronic summary can be issued with all patients who transfer back to HMP Leeds following discharge from a hospital admission. The Hospital currently send an electronic summary to the registered GP and the process for sending the same to the prison can be incorporated within their system. IT personnel from both the Hospital and Care UK will create a pathway that ensures all summaries are appropriately shared. In the meantime, the Director will ensure that written summaries are provided in a sealed envelope for all hospital discharges and these will accompany the patient back to the prison.” Source location Response from Care UK
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24 Jun 2016 Kirsty Childs · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 1
Failure of agencies to obtain information from previously involved agencies View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Kirsty Childs · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kirsty Childs, aged 20, developed severe abdominal symptoms and repeatedly sought advice from NHS Direct and other services between 31 December 2012 and 2 January 2013. She was not admitted to hospital and was later found dead at home; the inquest recorded septic shock caused by an undiagnosed and untreated mesenteric venous thrombosis. The principal concerns included incorrect telephone triage, failure to review earlier calls, medically unqualified staff selecting questionnaires, the ability to override recommended outcomes, and poor information-sharing between agencies.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of agencies to obtain information from previously involved agencies
Wider context from the report “7. All the different agencies operated in isolation , and despite computerised systems and phone facilities being available, there was no attempt to gain information from previous agencies which they had been involved
” Source location Kirsty Childs · Prevention of Future Deaths report
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29 Dec 2015 Imran DOUGLAS · Prevention of Future Deaths report Inner South London
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Concerns raised 1
Failure of social workers to communicate directly with secure estate staff View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
London Borough of Tower Hamlets Ministry of Justice Youth Justice Board for England and Wales
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Ministry of Justice
Review the Transitions Protocol and develop it into a Prison Service Instruction defining mandatory transition, safeguarding, assessment, information-sharing and collaborative-working procedures.
View source
Youth Justice Board for England and Wales
Reminded Tower Hamlets’ Director of Children’s Services of social-care expectations and sought assurance about future practice.
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London Borough of Tower Hamlets
Participate in the London Independent Reviewing Officer Managers Forum project to improve communication and partnership working with the secure estate.
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London Borough of Tower Hamlets
Update and recirculate guidance on transition planning, professional communication, information sharing, and detention placement plans by 31 March 2016.
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London Borough of Tower Hamlets
Deliver cross-service training for line managers, social workers and Youth Offending Service officers on remand, transition, risk management and secure-estate communication.
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Imran DOUGLAS · 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
Imran Douglas died by suicide on 13 November 2013, on the fifth day of his detention at HMP Belmarsh, after being sentenced to 18 years. The report identified concerns about transition and placement arrangements, communication and information-sharing between agencies, access to electronic records, and the adequacy of a medical assessment and response to suicide risk.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of social workers to communicate directly with secure estate staff
Wider context from the report “Evidence pointed to a disconnection between Looked After Child pathway planning and Transition Planning. A social worker said that the LAC plan was “potentially informative” but did not matter if it was not completed, but that now it is regarded as key and should be shared. One social worker said she did not know what a Transition Plan was. The current Head of Children's Social Care at LB Tower Hamlets said that staff pressures at the time had eased somewhat, but that under her leadership the interface with the secure estate was through the YJB and so social workers do not directly talk to the secure estate staff . This was despite the requirement for the two to work together in the Youth to Adult Transitions Framework. Given the lack of documented communications of the risks and concerns between YOT and Feltham in 2013, this evidence throws doubt on the reported improvements in training and changes in interagency communication have been put into operation since.
” Source location Imran DOUGLAS · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Transitions Protocol and develop it into a Prison Service Instruction defining mandatory transition, safeguarding, assessment, information-sharing and collaborative-working procedures.
Verbatim wording from the response “NOMS is currently reviewing the transitions protocol with a view to developing it into a Prison Service Instruction (PSI) which will define the national and local procedures which governors must implement to meet the specific needs of young people who will transition to adult custody, with a particular focus on supporting effective assessments and information sharing as well as promoting collaborative working between the” Source location 2015-0446-Response-by-NOMS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reminded Tower Hamlets’ Director of Children’s Services of social-care expectations and sought assurance about future practice.
Verbatim wording from the response “We know that looked after children are disproportionately represented amongst children in the youth justice system. Whilst the YJB recognise that there is still more that can be done to better support the interface between children’s social care and the secure estate, we are clear that the evidence provided by the Head of Children’s Services for Tower Hamlets on the way in which communication between their staff and the secure estate is facilitated was inaccurate and in contradiction to the evidence of YOT staff and National Standards for Youth Justice. We have written to the Director of Children’s Services at Tower Hamlets to remind them of expectations and assure ourselves of their practice in the future.” Source location 2015-0446-Response-by-Youth-Justice-Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate in the London Independent Reviewing Officer Managers Forum project to improve communication and partnership working with the secure estate.
Verbatim wording from the response “12. Additionally, Tower Hamlets is currently engaged in a project through the London Independent Reviewing Officer Managers Forum to improve communication and partnership working with the secure estate. ████████ Group Manager for the Independent Reviewing Officer (IRO) Service has visited Feltham Young Offenders Institute three times, and met with the Governor to discuss proposals to promote the welfare needs of young people in custody. Due to the success of this programme, similar meetings have now been scheduled with Cookham Wood YOI.” Source location 2015-0446-Response-by-London-Borough-Tower-Hamlets
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and recirculate guidance on transition planning, professional communication, information sharing, and detention placement plans by 31 March 2016.
Verbatim wording from the response “16. This is now being updated in light of the issues raised during the course of the request and will be recirculated by 31 March 2016 to all YOS and CSC teams, to specifically address the following issues:” Source location 2015-0446-Response-by-London-Borough-Tower-Hamlets
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver cross-service training for line managers, social workers and Youth Offending Service officers on remand, transition, risk management and secure-estate communication.
Verbatim wording from the response “17. A training session was provided on 8 February 2016 for line managers, social workers and YOS officers, which was well attended. In addition to giving an overview of the Legal Aid, Sentencing and Punishment of Offender Act 2012, the following topics were addressed:” Source location 2015-0446-Response-by-London-Borough-Tower-Hamlets
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The reported account of Tower Hamlets communication with the secure estate was inaccurate and contradicted other evidence and national standards.
Verbatim wording from the response “We know that looked after children are disproportionately represented amongst children in the youth justice system. Whilst the YJB recognise that there is still more that can be done to better support the interface between children’s social care and the secure estate, we are clear that the evidence provided by the Head of Children’s Services for Tower Hamlets on the way in which communication between their staff and the secure estate is facilitated was inaccurate and in contradiction to the evidence of YOT staff and National Standards for Youth Justice. We have written to the Director of Children’s Services at Tower Hamlets to remind them of expectations and assure ourselves of their practice in the future.” Source location 2015-0446-Response-by-Youth-Justice-Board
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1 Dec 2015 Bryan Arnold CATANACH · Prevention of Future Deaths report Worcestershire
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Concerns raised 1
Failure of communication during inter-hospital transfers View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Bryan Arnold CATANACH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Bryan Arnold Catanach sustained a fractured odontoid peg and cervical injury after a fall, and died in hospital on 8 February 2015 after his condition deteriorated. The report identified concerns about communication and delays in transfer and senior review, inpatient falls prevention, and the availability and use of appropriate traction equipment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of communication during inter-hospital transfers
Wider context from the report “(1) There were a number of difficulties with communication between the various clinicians and hospital Trusts. This led to a delay in the initial transfer of the patient, a delay in his subsequent review by a senior clinician and confusion on the part of nursing staff as to whether Mr Catanach was to be kept nil by mouth and/or given his prescribed medication. While it is a matter for you it may be that the Trust will want to reflect on whether there is a need to standardize its inter-hospital transfer process so that nursing as well as medical staff are fully engaged with the process.
” Source location Bryan Arnold CATANACH · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refresh and reaffirm emergency patient receiving and first-line management processes, including a ring-fenced spinal emergency bed and HDU escalation route.
Verbatim wording from the response “Difficulties with communication between various clinicians and hospital Trusts.
The Trust has looked to progress improved communication routes and systems in preparedness for the receipt of an emergency/unscheduled patient. As was explained within your Court, ROH acts as a regional centre for a range of spinal emergencies. Broadly speaking two to three spinal emergencies are transferred into the ROH each week for emergency elective care. Following this court hearing, the Trust has refreshed and reaffirmed its receiving and first line management processes in preparedness for the arrival of such patients. The Trust robustly pursues the ring fencing of a single spinal emergency bed and this provides a guaranteed safe point of arrival for any inbound emergency patient.” Source location Bryan-Catanach-Response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refresh and simplify proforma-based documentation for nursing and medical multidisciplinary teams.
Verbatim wording from the response “Additional concerns over communications
Following apparent communication and messaging issues identified in this case, Mr Newton-Ede has led a piece of work to refresh and simplify proforma based documentation. Both nursing and medical members of the multi-disciplinary team have been involved in delivering this change. There is a clearly held view from clinical colleagues that these developments have already been seen to be positively impacting on improved communication flow and necessary escalation.” Source location Bryan-Catanach-Response
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Concerns raised 1
Inadequate communication about anticoagulation monitoring and potential therapy adjustment View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Mrs. Mary Patricia James · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs. Mary Patricia James had a prosthetic heart valve requiring anticoagulation, but INR monitoring was inadequate and there was uncertainty about whether she was taking Warfarin. Concerns included failures in communication between the INR Unit, care home and GP, and that she was not admitted to hospital on 15 May 2015 despite concern about a possible ischaemic leg. The inquest concluded: “Ischaemic leg contributed to by inadequate Warfarin monitoring and dosing”.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate communication about anticoagulation monitoring and potential therapy adjustment
Wider context from the report “(3) Inadequate communication between the INR Unit, the Care Home and the GP regarding this patient’s anticoagulation monitoring and the potential need for therapy adjustment ;
” Source location Mrs. Mary Patricia James · Prevention of Future Deaths report
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12 May 2015 Paul Mc Guigan · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure of agencies to check and share available information before multi-agency meetings View source
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
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Paul Mc Guigan · 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
Paul Mc Guigan was shot and unlawfully killed by a close protection work colleague on 9 August 2009 while both were working as armed private security contractors in Baghdad. The report identified missed opportunities and failings in managing the offender’s escalating offending behaviour and risk, and stated that G4S had not adequately vetted him before deployment. Concerns also included failures in information sharing, recording bail conditions, police disclosure processes, and the supervision and risk assessment of offenders.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of agencies to check and share available information before multi-agency meetings
Wider context from the report “It is important irrespective of who is the lead agency at a Multi Agency Meeting that each agency invited to attend checks information held on systems and records to which they have access and provides all this information to a multi agency meeting to ensure that a full and informed assessment of risk takes place and the fullest possible informed information sharing.
” Source location Paul Mc Guigan · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide clinical staff attending multi-agency meetings with adequate time to review case information and contribute to discussions and action planning.
Verbatim wording from the response “Clinical staff who are required to attend multi-agency meetings now have adequate time to access and assimilate pertinent information from case notes to be able to effectively contribute to the discussion and any subsequent action planning.” Source location 2015-0185-Response-by-Pennine-Care-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue guidance to MAPPA agencies on preparing for meetings and fully recording agreed actions, completed actions and communications.
Verbatim wording from the response “A major lesson from the inquest is the need for more effective inter-agency working, particularly between the police and the probation service, in the context of the MAPP arrangements. Work to address the issues you have highlighted is being taken forward by the National MAPPA team, which will issue guidance to all MAPPA agencies shortly. This will cover the need to prepare for MAPPA meetings carefully, including obtaining full case details, and to record in full all actions agreed and taken and all communications in individual cases.” Source location 2015-0185-Response-by-Greater-Manchester-Police-NOMS-SIA
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1 May 2015 Jayne Jowett · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Lack of clear guidance for communicating patients’ physical condition to GPs View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Jayne Jowett · 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
Jayne Jowett, who was resident in a low secure and locked rehabilitation mental health facility, became unwell with intermittent respiratory difficulties, low oxygen saturations, dizziness, breathlessness and episodes of collapse before she died of a pulmonary embolus on 23 September 2014. The report identified concerns about staff training and response to National Early Warning Scores, understanding of significant clinical signs, and the lack of clear arrangements for sharing physical-health information between the facility and the GP surgery.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clear guidance for communicating patients’ physical condition to GPs
Wider context from the report “3. There remains no clear current service level agreement regarding how best for PIC to work with the local GP surgery to provide high quality joint care. There is no clear guidance that ensures all information regarding a patient’s physical condition is communicated to a GP when seeing a patient .
” Source location Jayne Jowett · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.