9 May 2014 Gary Richards · Prevention of Future Deaths report Inner South London
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Concerns raised 1
Failure to communicate patient risk and vulnerability to relevant agencies 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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AI-generated summary
Gary Richards · 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
Gary Richards had a forensic history and was at increased risk of taking his own life. He deliberately jumped in front of a moving train at Ladywell Station on 10 October 2012 and died at KCH on 16 October 2012. Concerns included inadequate assessment and communication of his self-harm risk, failures in follow-up and reliable communication, and uncompleted actions addressing identified service-delivery problems.
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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 patient risk and vulnerability to relevant agencies
Wider context from the report “(1) Psychiatric staff did not properly assess his risk of self harm, nor communicate his vulnerability to others . At discharge on 10/05 his risk of self harm was not fully measured. On being seen on 14/06 his risk assessment was not recorded and the risk plan not sent to the GP . The consultant explained that the risk was not mitigatable as no mental illness was found. Evidence was heard that his forensic history indicated that he belonged to a group of patients with 80 times the risk of suicide compared with the general population, yet he was considered at low risk. The value of performing a proper risk assessment to demonstrate the risks and vulnerabilities of the patient to other agencies, such as housing and social services , does not seem to have been considered, although it was reluctantly conceded by the consultant to be of value especially as homelessness presented as the primary problem.
” Source location Gary Richards · Prevention of Future Deaths report
Open source report
8 May 2014 Rajesh Parkash · Prevention of Future Deaths report Surrey
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Concerns raised 1
Inadequate communications between the London Ambulance Service and neighbouring ambulance services View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Rajesh Parkash · 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
Rajesh Parkash, a 43-year-old dentist, died after his motorcycle collided with an ambulance parked in lane 3 of the southbound A3. The report identified concerns about the ambulance’s dangerous position, inadequate risk assessment and failure to follow safety guidance, as well as issues involving staff communication, training and supervision.
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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 communications between the London Ambulance Service and neighbouring ambulance services
Wider context from the report “7. Action is required to improve communications between the London Ambulance Service and those ambulance services which border its area , such as the South East Coast Ambulance Service.
” Source location Rajesh Parkash · Prevention of Future Deaths report
Open source report
30 Apr 2014 Miss Samiyo Sahra Shih Farah · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Lack of formal communication and information-transfer protocols between healthcare establishments View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
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AI-generated summary
Miss Samiyo Sahra Shih Farah · 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
Miss Samiyo Sahra Shih Farah, who had depression and a history of self-harm, was found unresponsive with a ligature around her neck on 30 December 2012 and was pronounced dead. The principal concerns were the lack of national guidance on observation of children and adolescents in specialist mental health units, inadequate formal protocols for communication during transfers between private and NHS providers, and inconsistent referral arrangements following her attendances at A&E.
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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 formal communication and information-transfer protocols between healthcare establishments
Wider context from the report “2) Communication/contact between transferring establishments - there is no formal policy/protocol in use/between the private sector and the NHS detailing steps that should be taken (and by whom) upon transfer of patients between sectors , thus risking that not all key information (both verbal and written) is properly communicated before, during and after transfer . Whilst progress is being made in this regard at local level following the death of Miss Farah (and may well be the basis upon which any national policy/protocol might be formulated) there is currently no communication/transfer protocol in existence . This also potentially impacts upon all other healthcare sector providers e.g. the acute sector, hospital to care home, acute to rehabilitation/community services etc.
” Source location Miss Samiyo Sahra Shih Farah · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual NHS Trusts are responsible for developing transfer protocols with private-sector providers, reflecting provider variation and patient factors.
Verbatim wording from the response “With regard to transfer protocols between the NHS and the private sector, each Trust currently develops their own. This is because the private sector is not uniform in its approach and it is necessary to take account of this variance as well as relevant patient factors. In general, Trusts would be expected to establish good working relationships and transfer arrangements with those private sector providers with whom they regularly deal.” Source location 2014-0202-Response-by-Department-of-Health
Open published response
22 Apr 2014 Audrey Wakefield · Prevention of Future Deaths report Staffordshire South
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Concerns raised 1
Failure to ensure effective communication of discharge information to GPs at practices outside the Stoke on Trent area View source
Linked response
University Hospitals of North Midlands NHS 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
University Hospitals of North Midlands NHS Trust
Switch on electronic discharge correspondence for GP practices in Stone, including the deceased’s practice.
View source
University Hospitals of North Midlands NHS Trust
Switch on electronic discharge correspondence for remaining Stafford and Cannock GP practices by the end of July 2014.
View source
University Hospitals of North Midlands NHS Trust
Develop a supplier solution enabling electronic discharge correspondence for GP practices beyond Stoke and North Staffordshire.
View source
University Hospitals of North Midlands NHS Trust
Continue negotiating annual funding arrangements with external GP practices and request confirmation of payment for electronic correspondence.
View source See 1 more action
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AI-generated summary
Audrey Wakefield · 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
Audrey Wakefield suffered a stroke, later fell at a care home, deteriorated after hospital admission, and died at a hospice on 11 April 2013. The principal concern was inadequate communication of discharge information from the hospital to her GP, particularly for practices outside the usual local communication system.
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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 ensure effective communication of discharge information to GPs at practices outside the Stoke on Trent area
Wider context from the report “(1) At the Inquest I was greatly assisted by ████████ Consultant Stroke Physician at your hospital. He indicated that when Mrs Wakefield was discharged from UHNS on 16 January 2013 the communication of relevant discharge information to Mrs Wakefield’s GP was not good . The reason was that there is a good communication system from the hospital and GPs in the Stoke on Trent area but this did not apply to more distant practices (Mrs Wakefield’s practice was in Stone). ████████ indicated that steps were being taken to improve this. With Stafford Hospital moving to come under the control of your Trust the situation could be quite serious as a number of GPs practices are likely to be involved. It may be that this is being addressed in any event but I should be grateful if you could check that an effective system of discharge information will apply wherever a patient’s GP’s practice may be situated .
” Source location Audrey Wakefield · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Switch on electronic discharge correspondence for GP practices in Stone, including the deceased’s practice.
Verbatim wording from the response “The GP practices in Stone were ‘switched on’ by 12 June 2014, including the GP practice which provided care to Mrs Wakefield. All of the remaining Stafford and Cannock GP practices (South Staffs) have committed to being switched on by the end of July; this allows some time prior to UHNS and Mid Staffs Hospital acquisition which is due to occur on 1 November 2014.” Source location 2014-0186-Response-by-University-Hospital-of-North-Staffordshire
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Switch on electronic discharge correspondence for remaining Stafford and Cannock GP practices by the end of July 2014.
Verbatim wording from the response “The GP practices in Stone were ‘switched on’ by 12 June 2014, including the GP practice which provided care to Mrs Wakefield. All of the remaining Stafford and Cannock GP practices (South Staffs) have committed to being switched on by the end of July; this allows some time prior to UHNS and Mid Staffs Hospital acquisition which is due to occur on 1 November 2014.” Source location 2014-0186-Response-by-University-Hospital-of-North-Staffordshire
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a supplier solution enabling electronic discharge correspondence for GP practices beyond Stoke and North Staffordshire.
Verbatim wording from the response “In order to facilitate the timely electronic distribution of discharge letters beyond Stoke on Trent and North Staffs Clinical Commissioning Groups, a solution has been developed with the system supplier to ‘switch on’ GP practices in South Staffordshire, Shropshire and Cheshire. UHNS funded the one-off development of the solution with the supplier however there is a requirement for each GP practice to pay an annual fee for the on-going delivery of electronic correspondence. This is a matter requiring on-going negotiation although it is common practice nationally, for Clinical Commissioning Groups to fund this within their local area.” Source location 2014-0186-Response-by-University-Hospital-of-North-Staffordshire
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue negotiating annual funding arrangements with external GP practices and request confirmation of payment for electronic correspondence.
Verbatim wording from the response “In order to facilitate the timely electronic distribution of discharge letters beyond Stoke on Trent and North Staffs Clinical Commissioning Groups, a solution has been developed with the system supplier to ‘switch on’ GP practices in South Staffordshire, Shropshire and Cheshire. UHNS funded the one-off development of the solution with the supplier however there is a requirement for each GP practice to pay an annual fee for the on-going delivery of electronic correspondence. This is a matter requiring on-going negotiation although it is common practice nationally, for Clinical Commissioning Groups to fund this within their local area.” Source location 2014-0186-Response-by-University-Hospital-of-North-Staffordshire
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Delivery of discharge-information improvements is a shared responsibility involving the Local Health Economy IM&T Group and Clinical Commissioning Groups.
Verbatim wording from the response “Action Taken
The University Hospital of North Staffordshire NHS Trust has considered the Coroner’s concerns and has outlined below the actions taken in conjunction with the wider Local Health Economy (LHE). UHNS does not have a unilateral obligation to resolve the issues and the Trust therefore continues to work in partnership with the LHE IM&T Group and the local Clinical Commissioning Groups.” Source location 2014-0186-Response-by-University-Hospital-of-North-Staffordshire
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ongoing electronic correspondence costs are expected to be funded by GP practices or their local Clinical Commissioning Groups.
Verbatim wording from the response “In order to facilitate the timely electronic distribution of discharge letters beyond Stoke on Trent and North Staffs Clinical Commissioning Groups, a solution has been developed with the system supplier to ‘switch on’ GP practices in South Staffordshire, Shropshire and Cheshire. UHNS funded the one-off development of the solution with the supplier however there is a requirement for each GP practice to pay an annual fee for the on-going delivery of electronic correspondence. This is a matter requiring on-going negotiation although it is common practice nationally, for Clinical Commissioning Groups to fund this within their local area.” Source location 2014-0186-Response-by-University-Hospital-of-North-Staffordshire
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Electronic rollout beyond existing areas cannot be completed until participating areas confirm funding for annual practice charges.
Verbatim wording from the response “A total solution for all areas is proposed to be delivered in three separate phases based on geographical area; South Staffordshire, Shropshire and Cheshire and I wrote to them on 29 April 2014. This will include remote implementation and training where possible, and GP practices will also be supported by a dedicated IT trainer, telephone support during implementation and Standard Operating Procedures. We are still awaiting confirmation from Western Cheshire, South East Staffs and Seisdon, Shropshire and Vale Royal and South Cheshire who have not yet confirmed that they will pay the annual practice charge. I will write to them again to ask them to do this however it may be helpful for you to do the same given that the request came from you.” Source location 2014-0186-Response-by-University-Hospital-of-North-Staffordshire
Open published response
8 Apr 2014 Andrew Michael Horgan · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 1
Failure of the communication pathway for engaging mental health professionals to be clear and effective View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Andrew Michael Horgan · 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 Michael Horgan died on 16 September 2013 from acute cardiac failure following a Colchicine overdose, with coronary artery atherosclerosis, myocardial fibrosis and focal incomplete hepatic cirrhosis also identified. The principal concern was that hospital staff lacked a clear understanding of referral procedures for mental health assessment following discharge, creating a risk that similar communication failures could contribute to a future 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 of the communication pathway for engaging mental health professionals to be clear and effective
Wider context from the report “1. Training for Doctors and other medical staff in relation to referring patients for assessment both within the hospital and externally following discharge. – During the course of the Inquest ████████ gave evidence and it was quite clear that he did not have a clear understanding of the referral procedure to involve professionals from the Avon and Wiltshire Mental Health Partnership. He believed his telephone conversation with the Swindon Intensive Services with CPN ████████ would result in the outreach team assessing Andrew in the community. He thought that a telephone call alone would be sufficient in that respect to engage the Mental Healthcare professionals.
The importance of a clear and effective communication pathway following recognised and agreed practices and procedures cannot be ignored and I am concerned following the evidence I heard there were knowledge gaps as regards practice and procedures to be followed when engaging Mental Health Partnership personnel .
I would be grateful if you could please review the appropriateness and the effectiveness of training in this respect not only for current GWH personnel but also how effective training in this area can be given to personnel in the future. Whilst I was satisfied that this did not contribute to Andrew’s death in this instance my concern is that an issue could arise in the future whereby that may not be the case.
” Source location Andrew Michael Horgan · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the mental health referral process and current staff training provision, identifying resulting actions in collaboration with AWP.
Verbatim wording from the response “Your letter raised concerns about this case, around the lack of understanding by medical staff about the procedure to engage our mental health provider, the Avon and Wiltshire Mental Health Partnership (AWP). Regulation 28 was issued because during the Inquest ████████ did not provide a clear understanding of the referral procedure needed to initiate an assessment by the community outreach team following Mr Horgan’s self-discharge from hospital. You requested that the Trust should review the appropriateness and effectiveness of training currently provided to all staff.” Source location 2014-0163-Response-by-Great-Western-Hospital-NHS-Foundation-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include community crisis-intervention access information in the patient leaflet, Mental Health Act training programme and Trust intranet.
Verbatim wording from the response “In Mr Horgan’s case, there was a miscommunication as to whether the contact with the out of hours intensive team was for advice or referral to mental health community services upon Mr Horgan’s self discharge. The Trust and AWP both agreed that this area of practice should be made clearer to all staff. The AWP documentation record has now been updated to include a question making it clear that the telephone call from GWH staff is either for referral, advice or both. In addition, the Trust is advised that community crisis intervention as, in the case of Mr Horgan, is only accessible by the patient contacting the out of hours General Practitioners’ service. The patients’ General Practitioner will normally be informed about their admission or attendance to hospital through the Trust Patient Electronic Discharge Summary system.” Source location 2014-0163-Response-by-Great-Western-Hospital-NHS-Foundation-Trust
Open published response
Concerns raised 1
Failure to exchange prescription information between treatment services and the GP View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Leicestershire Partnership NHS 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
Leicestershire Partnership NHS Trust
Publish the Leicester Recovery Partnership standard operating protocol defining GP communication requirements for structured treatment and open access services.
View source
Leicestershire Partnership NHS Trust
Upload reviewed GP letter templates with prompts for detailed updates into SystmOne.
View source
Leicestershire Partnership NHS Trust
Implement SystmOne prompts and reminders to alert practitioners when GP updates are due.
View source
Leicestershire Partnership NHS Trust
Audit case notes for GP correspondence within 14 days and repeat the audit every six months.
View source See 1 more action
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AI-generated summary
Michael Anthony Tarratt · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Anthony Tarratt, who had a history of poly-drug and alcohol abuse and was receiving methadone treatment, was found deceased at home from multiple drug toxicity. The concerns included a lack of contact between drug and alcohol services and his GP for 18 months, and the prescription of tramadol to an opioid-dependent patient without routine information-sharing between services.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to exchange prescription information between treatment services and the GP
Wider context from the report “(2) Despite Evidence that the GP prescription of tramadol (for knee pain) was inappropriate for an opiate dependent patient, no contact was made with the GP surgery and it was left to the patient to tell his GP. There was no evidence to suggest that Mr Tarratt did this. Consideration should be given to routine exchange of information regarding prescriptions between services , to avoid one agency counter-acting the treatment of the other. Consideration should be given to the appropriateness of asking the patient to be responsible for this communication.
” Source location Michael Anthony Tarratt · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the Leicester Recovery Partnership standard operating protocol defining GP communication requirements for structured treatment and open access services.
Verbatim wording from the response “The Leicester Recovery Partnership’s working draft Standard Operating Protocol (SOP) is under review and due for publication within the next few weeks. In relation to GP communication the SOP will state:” Source location 2014-0115-Response-by-Leicestershire-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Upload reviewed GP letter templates with prompts for detailed updates into SystmOne.
Verbatim wording from the response “I enclose a copy of the standard GP letter templates which have been reviewed and now include prompts to ensure detailed updates are sent. These are due to be uploaded as part of the configuration with SystmOne within the next 14 days. The subsequent phase of work that will be completed by June 30th 2014 at the latest will include prompts and reminders to practitioners when GP updates are due.” Source location 2014-0115-Response-by-Leicestershire-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement SystmOne prompts and reminders to alert practitioners when GP updates are due.
Verbatim wording from the response “I enclose a copy of the standard GP letter templates which have been reviewed and now include prompts to ensure detailed updates are sent. These are due to be uploaded as part of the configuration with SystmOne within the next 14 days. The subsequent phase of work that will be completed by June 30th 2014 at the latest will include prompts and reminders to practitioners when GP updates are due.” Source location 2014-0115-Response-by-Leicestershire-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit case notes for GP correspondence within 14 days and repeat the audit every six months.
Verbatim wording from the response “A case note audit is due to take place within the next 14 days and will include a review of GP correspondence. Audits will be completed every 6 months thereafter.” Source location 2014-0115-Response-by-Leicestershire-Partnership-NHS-Trust
Open published response
13 Feb 2014 Lisa Marie Inkin · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 1
Failures in communication between local services and out-of-area psychiatric care providers View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Lisa Marie Inkin · 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
Lisa Marie Inkin, who had severe anorexia nervosa and was on home leave from an eating disorders unit, took her own life by diving in front of a train at Victoria Station on 9 April 2013. The report raised concerns about the lack of local specialist inpatient eating disorder services, communication between local and out-of-area providers, inadequate escalation of information about suicidal intent, possible failures to record or answer calls, and the proposed lack of overnight supervision and transport difficulties in Kent.
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 Failures in communication between local services and out-of-area psychiatric care providers
Wider context from the report “3. The communication between local services and out of area providers of psychiatric care .
” Source location Lisa Marie Inkin · Prevention of Future Deaths report
Open source report
22 Jan 2014 Paul Alan Rogerson · Prevention of Future Deaths report York City
View report summary
Concerns raised 1
Insufficient police communication of detailed information during river rescues View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Paul Alan Rogerson · 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 Alan Rogerson, aged 26, fell into the River Ouse in York on 26 March 2011 after consuming several pints of beer and drowned. The report raised concerns about inadequate life-buoy and throwing-line provision and maintenance, a lack of warning signs, and shortcomings in river-rescue training, communication and procedures.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient police communication of detailed information during river rescues
Wider context from the report “(4) North Yorkshire Police work with the Fire and Rescue Service in river rescues. The Fire and Rescue Service need to receive detailed information from Police Control ; mutual assistance can be given during rescues; there may be a lack of sufficient communication from the Police on these occasions and a need for the Police to familiarise themselves with current Fire and Rescue methods of water rescue.
” Source location Paul Alan Rogerson · Prevention of Future Deaths report
Open source report
21 Jan 2014 Mrs Nutbeam · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 1
Lack of a procedure for transferring patient information between different Trusts View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Mrs Nutbeam · 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 Nutbeam was struck by a car and later underwent debridement surgery for an infected leg wound. She vomited and aspirated during the procedure and subsequently died; the principal concerns were failures to transfer information about her vomiting between hospitals and to record or communicate vomiting symptoms before surgery, together with whether pre-operative questioning should routinely address recent vomiting.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a procedure for transferring patient information between different Trusts
Wider context from the report “(1) Staff at St. Peter’s Hospital did not contact Wexham Park Hospital to advise of the recent admission, treatment and symptoms even though they were once aware that Mrs Nutbeam had a follow up appointment at Wexham Park Hospital some two days later because they arranged that appointment. Concern is the apparent lack of any procedure to allow information to be transferred between different Trusts in different Counties. There was no letter given to Mrs Nutbeam to accompany her to the subsequent appointment.
” Source location Mrs Nutbeam · Prevention of Future Deaths report
Open source report
Concerns raised 1
Delays and limitations in liaison and communication between prison and hospital health care staff View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
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AI-generated summary
Zeeyad Hamadi · 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
Zeeyad Hamadi was a prisoner at HMP Frankland who became unwell, was diagnosed with Hodgkins Lymphoma, and deteriorated while arrangements were made to transfer him to a London hospital for private chemotherapy. Concerns included inadequate weighing and medical record keeping, limited communication between prison and hospital staff, unclear funding and transfer arrangements, and the absence of a system or responsible point of contact to manage the transfer, contributing to delay.
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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 and limitations in liaison and communication between prison and hospital health care staff
Wider context from the report “(3) There was limited liaison between health care staff in HMP Frankland and medical staff at UHND to monitor the deceased’s medical condition once he had left the prison . When a decision was made by the deceased to seek treatment in London on a private paying basis this information was not speedily communicated to those responsible for health care in HMP Frankland and contact was made by a hospital doctor with a duty governor at the prison who in turn had to refer to the health care manager. Confusion developed as to the basis of the proposed move to Bart’s from UHND; whether this was a prison to prison transfer or whether it was a relocation of the deceased from one hospital to another whilst remaining the responsibility of HMP Frankland. There was confusion over the funding arrangements for this proposal; whether the local NHS would be responsible for the medical treatment or the costs of transport, the form of such transport and/or the costs of bed watch. The brother of the deceased confirmed to different people at different times that he would undertake to be responsible for the costs incurred (subject to a challenge by Judicial review) and it took some time for the issues of funding to be identified before being addressed and resolved. There was a lack of clarity of understanding who would be responsible for what and when, so far as money was concerned and who would have the responsibility for payment in the first place prior to reimbursement by the deceased’s brother. There was no formal policy in place to deal with the situation. There was lack of clarity in the rules that were referred to in evidence as to how and when a convicted prisoner is entitled to private health care as opposed to a prisoner on remand.
” Source location Zeeyad Hamadi · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record keeping, prison-hospital liaison, bed-watch security and prison ownership issues are not for the Department of Health to respond to.
Verbatim wording from the response “I consider that several of the issues you have raised regarding record keeping, liaison between prison and hospital medical staff, security issues such as bed-watch and ownership of the situation at the prison, are not for my Department to respond.” Source location 2014-0014-Response-by-Department-of-Health
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The National Offender Management Service is expected to address record keeping, liaison, bed-watch security and ownership issues.
Verbatim wording from the response “I note that you have sent a copy of this Regulation 28 report to the National Offender Management Service (NOMS) and I would expect them to properly address these issues.” Source location 2014-0014-Response-by-Department-of-Health
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.