16 Sep 2021 Irene Ann Esaw · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to adequately assess patients’ mental capacity for care decisions View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Tameside and Glossop Integrated Care NHS Foundation Trust Tameside Borough Council
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 12
Tameside and Glossop Integrated Care NHS Foundation Trust
Maintain and expand the Trust’s Mental Capacity Act improvement programme, led by a dedicated Senior Mental Health Nurse.
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Tameside and Glossop Integrated Care NHS Foundation Trust
Establish a multi-agency Mental Capacity Act group with the local authority to review and benchmark policies, procedures, strategy and training.
View source
Tameside and Glossop Integrated Care NHS Foundation Trust
Review the revised Mental Capacity Act Code of Practice and develop aligned audit processes, audit cycles and training linked to Liberty Protection Safeguards.
View source
Tameside and Glossop Integrated Care NHS Foundation Trust
Deliver a continuing Trust-wide Mental Capacity Act learning and awareness programme using masterclasses, e-learning, briefings, podcasts, animations and related resources.
View source
Tameside and Glossop Integrated Care NHS Foundation Trust
Launch the Trust’s Mental Capacity Act awareness campaign and assess staff knowledge and confidence through surveys and scheduled monitoring.
View source
Tameside and Glossop Integrated Care NHS Foundation Trust
Monitor the Mental Capacity Act improvement project through safeguarding, quality and governance committees and revised multi-agency audit arrangements.
View source
Tameside and Glossop Integrated Care NHS Foundation Trust
Develop and roll out electronic patient-record prompts and alerts to support capacity assessment, vulnerability recognition and safe discharge planning.
View source
Tameside and Glossop Integrated Care NHS Foundation Trust
Include Betty’s Story and its learning in recurrent multi-professional induction and training, and develop a live-play version for organisational dissemination.
View source
Tameside Borough Council
Embed the Mental Capacity Act in adult social care practice through forums, social-work training, quality assurance and workforce-development programmes.
View source
Tameside Borough Council
Update Mental Capacity Assessment and Best Interest documentation and link it with needs and risk assessments in social work practice.
View source
Tameside Borough Council
Implement a quality assurance framework incorporating the Mental Capacity Act Competency Framework and a skills and knowledge audit for social workers and managers.
View source
Tameside Borough Council
Embed multidisciplinary roles and responsibilities in staff induction, clinical supervision, multi-agency procedures and standards, and refresh related capacity procedures and training.
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Irene Ann Esaw · 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
Irene Ann Esaw, who had dementia and was dependent on her grandson for all nutritional, mobility, hygiene and personal care, was discharged from hospital without a formal care package or community referrals. She was later found deceased at home in an emaciated state, with severe untreated pressure sores, tissue damage and widespread sepsis. The principal concerns were failures to assess mental capacity, recognise clinical signs of neglect, and ensure effective multi-agency assessment and working.
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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 adequately assess patients’ mental capacity for care decisions
Wider context from the report “1. Identifying and Assessing Mental Capacity –
My findings in relation to Mrs. Esaw’s death were that there was a fundamental failure by the clinical and nursing staff to adequately consider and assess Mrs. Esaw’s capacity to make decisions about her own care needs whilst she was a patient at Tameside General Hospital between 12ᵗʰ and 28ᵗʰ September 2018. This failure in my view, undermined her discharge planning and was one of the key reasons why the discharge was unsafe. I understand that work is ongoing in this area, but I am concerned having heard the evidence of ████████, the Deputy Director of Nursing and Professional Standards that it is still a “work in progress” identified by this and other incidents reported to the Trust. I am concerned that there are still issues that the Trust aren’t completely compliant with and that this needs to be addressed.
” Source location Irene Ann Esaw · 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 Maintain and expand the Trust’s Mental Capacity Act improvement programme, led by a dedicated Senior Mental Health Nurse.
Verbatim wording from the response “To enhance further our work in relation to Mental Capacity Act awareness and overseen by the Executive Director of Nursing and Integrated Governance and the Deputy Director of Nursing Professional Standards, Safeguarding and Assurance has reprioritised resources for funding for a dedicated Senior Mental Health Nurse to take the lead on a revised improvement project focused on the application of the mental capacity act (MCA) in the Trust, this individual in post. Partnerships have” Source location Response from Tameside and Glossop NHS England
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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 Establish a multi-agency Mental Capacity Act group with the local authority to review and benchmark policies, procedures, strategy and training.
Verbatim wording from the response “In partnership with the Local authority we have taken the lead in establishing a multi-agency group focused on the application of the MCA with a view to a collective review and benchmarking of our policies and procedures in order to develop a multi-agency strategy, policy and training on the application of the Mental Capacity Act across the multiagency system, to promote a shared approach and understanding.” Source location Response from Tameside and Glossop NHS England
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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 revised Mental Capacity Act Code of Practice and develop aligned audit processes, audit cycles and training linked to Liberty Protection Safeguards.
Verbatim wording from the response “- Legislation
Whilst the Trust has a current Mental Capacity Act Policy which is in line with the required statutory requirements and meets regulatory requirements, the Trust is cognisant that the new Mental Capacity Act Code of Practice is due to be published in 2022. In line with this the Trust will review the revised Code to ensure that its policies are aligned. As part of the Trust’s response to this the Trust, will develop an audit process and clear audit cycles, this will be aligned to the national implementation of Liberty Protection Safeguards. Our training will be aligned with this.” Source location Response from Tameside and Glossop NHS England
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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 a continuing Trust-wide Mental Capacity Act learning and awareness programme using masterclasses, e-learning, briefings, podcasts, animations and related resources.
Verbatim wording from the response “- Training and development
The Trust has a focused month on safeguarding throughout the month of November 2021. As part of this whole month of focus there is a Mental Capacity Act Masterclass entitled “back to basics” which will work in parallel with our community and social care partners as a multi-agency plan. In addition to this, a proposal for the inaugural integrated safeguarding conference has also been approved to be held in Spring 2022, hosted by the Trust, with invitations to multi-agency colleagues to promote a culture in which teams collaborate work and learn together.” Source location Response from Tameside and Glossop NHS England
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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 Launch the Trust’s Mental Capacity Act awareness campaign and assess staff knowledge and confidence through surveys and scheduled monitoring.
Verbatim wording from the response “- Communications
As part of the Trust’s broader communications project in which specific topics receive focused exposure during a calendar month, November is ‘Spotlight on Safeguarding’ month, to coincide with Adult Safeguarding week. This will incorporate the launch of a Mental Capacity Act campaign and encouraged all staff to ‘think family’ by raising awareness and providing opportunities for learning to support and promote a culture and organisational approach, that safeguarding is ‘Our Everyday Business’. The Trust have also developing multimedia resources such as short animations, screensavers, MCA aide memoire cards and coverings to the lift doors to maintain a high profile throughout the organisation. To establish the positive impact upon staff awareness of MCA a short online survey has been developed for use across the Trust.” Source location Response from Tameside and Glossop NHS England
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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 Monitor the Mental Capacity Act improvement project through safeguarding, quality and governance committees and revised multi-agency audit arrangements.
Verbatim wording from the response “The oversight and scrutiny of the MCA Quality Improvement Programme will be by the Trust’s Integrated Safeguarding Committee which is chaired by the Executive Lead for Safeguarding. Regular update reports and oversight of the Trust’s improvement project will also report to the newly formed Multi Agency Monitoring Group, established to monitor the significant learning and actions from this case.” Source location Response from Tameside and Glossop NHS England
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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 roll out electronic patient-record prompts and alerts to support capacity assessment, vulnerability recognition and safe discharge planning.
Verbatim wording from the response “The Trust is in the process of transitioning towards electronic patient records in accordance with the NHS commitment to use all electronic patient records. Working closely with our Chief Clinical Information officer in relation to the transition to electronic notes work has progressed with clinical colleagues which has considered the potential to include prompts in relation to mental capacity assessments, in particular when preparing the discharge letter.” Source location Response from Tameside and Glossop NHS England
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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 Include Betty’s Story and its learning in recurrent multi-professional induction and training, and develop a live-play version for organisational dissemination.
Verbatim wording from the response “We have liaised with teams who coordinate multi-professional inductions for staff across the Trust, all have committed to including Betty’s story and the learning from this to develop a recurrent programme of training.” Source location Response from Tameside and Glossop NHS England
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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 Embed the Mental Capacity Act in adult social care practice through forums, social-work training, quality assurance and workforce-development programmes.
Verbatim wording from the response “Identifying and Assessing Mental Capacity
Since 2019, one of Adult Social Care work force development priorities has been to improve our staff knowledge and application of the Mental Capacity Act.” Source location Response from Tameside and Glossop NHS England
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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 Mental Capacity Assessment and Best Interest documentation and link it with needs and risk assessments in social work practice.
Verbatim wording from the response “On the 22 July 2020, a 12 month improvement plan was launched, which incorporates standards of practice, themed audits and themed Continuing Professional Development. The Individual Management Report (IMR) recommendations and action plan are annexed to this report as Appendix A.” Source location Response from Tameside and Glossop NHS England
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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 Implement a quality assurance framework incorporating the Mental Capacity Act Competency Framework and a skills and knowledge audit for social workers and managers.
Verbatim wording from the response “The Principal Social Worker is currently reviewing the implementation of the quality assurance framework for social work practice, the application of the Mental Capacity Act will feature in this work. The aim is that a new framework will be in place from January 2022. Part of this work will include implementing the National Mental Capacity Act Competency Framework, developed by Bournemouth University. A skills and knowledge audit will take place of social workers and managers and the outcome will inform the ongoing training programme.” Source location Response from Tameside and Glossop NHS England
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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 Embed multidisciplinary roles and responsibilities in staff induction, clinical supervision, multi-agency procedures and standards, and refresh related capacity procedures and training.
Verbatim wording from the response “Integral to this, is ensuring that the multidisciplinary team have a good understanding of one another’s roles and responsibilities. Work will take place to ensure that this is embedded in practice. This will include ensuring that roles and responsibilities feature in the induction of all staff, in ongoing clinical supervision and in multiagency procedures and standards. A multiagency review and refresh of the Mental Capacity Act procedures and training regarding adults with care needs on discharge, will take place.” Source location Response from Tameside and Glossop NHS England
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9 Aug 2021 Terence Robert TUTTLE · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Failure to adequately assess under the Mental Capacity Act View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Norfolk and Suffolk NHS Foundation Trust
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Terence Robert TUTTLE · 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
Terence Robert Tuttle, who lived in a care home, was admitted to hospital after testing positive for Covid-19 and was treated for acute kidney injury, pneumonia and a bleeding duodenal ulcer. His recorded poor oral intake was not acted on promptly, and he lost significant weight before being transferred to another nursing home, where he died three days later. The concerns included delayed dietetic and mental health assessments, inadequate action on weight loss, difficulties applying the Mental Capacity Act, insufficient care for a mentally unwell patient refusing food, exclusion of family from involvement in his care, and lack of recognition of serious harm.
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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 adequately assess under the Mental Capacity Act
Wider context from the report “3.Ability to assess Mr Tuttle adequately under the Mental Capacity Act .
” Source location Terence Robert TUTTLE · Prevention of Future Deaths report
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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 Queen Elizabeth Hospital should respond to the concerns outside the second part of the first concern.
Verbatim wording from the response “Out of the concerns listed below I would advise that NSFT are able to respond to the second part, in italics, of the first point only. The other points would be for the QEH to respond to:” Source location 2021-0265-Response-from-Hellesdon-Hospital_Published-1
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How this respondent position was interpreted
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PFD Monitor interpretation For physical health decisions requiring capacity assessment, the physical health expert is the decision maker.
Verbatim wording from the response “Where a capacity assessment is required for a decision on a physical health issue or intervention, the team may assist in respect of mental illness symptomology and the potential impact on a persons capacity. However the decision maker will be the physical health expert.” Source location 2021-0265-Response-from-Hellesdon-Hospital_Published-1
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28 May 2021 KEVIN JOHN FITTON · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 1
Lack of capacity assessments View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
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KEVIN JOHN FITTON · Prevention of Future Deaths report
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Report summary
Kevin Fitton suffered a catastrophic stroke in 2010 and died after a cardiac arrest following fluid overload during his final hospital admission on 12 July 2019. The report identified longstanding concerns about inadequate assessment and support for his acquired brain injury, poor coordination and communication, ineffective implementation of care assessments, and failures to recognise and respond to his substance use, self-neglect and deteriorating health. The inquest concluded that a failure to obtain an urgent echocardiogram represented a missed opportunity to diagnose and treat his cardiac condition, and that the outcome may have been different with a correct diagnosis and more controlled fluid administration.
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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 capacity assessments
Wider context from the report “(1) There was an almost complete reliance of assumption of capacity. The lack of capacity assessments resulted in failure to identify the area and support needed by Mr Fitton and a failure to use best interests policy appropriately.
” Source location KEVIN JOHN FITTON · 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 Explore joint commissioning with health to establish specialist access for capacity assessments involving acquired brain injury.
Verbatim wording from the response “• We will take forward the area of Social Work practitioner access to specialists when undertaking capacity assessments with people with new or historic ABI and/or when the specific brain impairment necessitates a specialist. We will explore a joint commissioning arrangement with health to agree a pathway for our health and adult social care practitioners to access.” Source location 2021-0169-Responses-from-Sussex-NHS-Commissioners-and-Brighton-and-Hove-City-Council_Published
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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 standalone training on mental capacity assessments and executive functioning.
Verbatim wording from the response “• We will develop a stand-alone training course on Mental Capacity Assessments and executive functioning/capacity” Source location 2021-0169-Responses-from-Sussex-NHS-Commissioners-and-Brighton-and-Hove-City-Council_Published
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3 Feb 2021 CHRISTOPHER SMITH · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 2
Failure to reassess fluctuating mental capacity View source Failure to establish capacity before decisions about care and treatment View source
This report raised 11 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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CHRISTOPHER SMITH · 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
Christopher Smith was admitted to hospital with peripheral vascular disease, extensive leg ulcers, epilepsy and infections, and died on 4 March 2019 after deterioration following discharge home. Principal concerns included inadequate discharge planning and capacity reassessment, failure to arrange home and district nursing support, unsafe home conditions and an unacted-on safeguarding alert, and inadequate nutritional care.
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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 reassess fluctuating mental capacity
Wider context from the report “(3) Mr Smith remained on a discharge ward from 2nd February until his discharge on 10th February even though he suffered a deterioration in his medical condition. Mr Smith’s capacity fluctuated during his admission, he was noted by nurses to be confused and his capacity was not reassessed .
” Source location CHRISTOPHER SMITH · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to establish capacity before decisions about care and treatment
Wider context from the report “(4) Nursing notes in respect of Mr Smith’s discharge were incomplete, incorrect, and led to assumptions being made that Mr Smith
a. had capacity to make decisions about his care and treatment
b. was being cared for in the community.
” Source location CHRISTOPHER SMITH · Prevention of Future Deaths report
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4 May 2020 Barry Wayne Preston · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to recognise lack of decision-making capacity View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Bolton NHS Foundation Trust Department of Health and Social Care Greater Manchester Mental Health 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. 7
Bolton NHS Foundation Trust
Strengthen and ratify the Mental Capacity Act policy to clarify assessment responsibilities, decision makers and Independent Mental Capacity Advocate referrals.
View source
Bolton NHS Foundation Trust
Review and revise Mental Capacity Act training provision to clarify roles and responsibilities for relevant clinical staff.
View source
Bolton NHS Foundation Trust
Provide bespoke Mental Capacity Act training to designated staff cohorts.
View source
Bolton NHS Foundation Trust
Make Mental Capacity Act forms available for completion by all staff designations on the Electronic Patient Record.
View source
Greater Manchester Mental Health NHS Foundation Trust
Communicate expectations to staff that significant changes require consideration and recording of capacity assessments and Best Interest meetings, with care-plan liaison monitored through supervision.
View source
Greater Manchester Mental Health NHS Foundation Trust
Have Team Managers proactively review cases involving admission to other care settings during supervision to check care coordination and consideration of capacity and Best Interest meetings.
View source
Greater Manchester Mental Health NHS Foundation Trust
Share inquest learning with senior management and leadership teams and put an action plan in place to keep staff current with Best Interest, Capacity and CPA training.
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Barry Wayne Preston · 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
Barry Wayne Preston, who lacked capacity and lived in supported accommodation, suffered a series of falls and traumatic brain injuries before developing urosepsis associated with a catheter that was not replaced within the guidance period, followed by bronchopneumonia. The report identified concerns about inaccurate documentation, unsuitable placement and wards, inadequate coordination and ownership of care, failures to hold best interests meetings, and insufficient understanding of his lack of capacity.
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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 recognise lack of decision-making capacity
Wider context from the report “5. The inquest was told that for a long period of time whilst in the care of the NHS there was not a clear understanding of his lack of capacity to make decisions about his care . Acquiescence by him was seen as him understanding and having capacity .
” Source location Barry Wayne Preston · 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 Strengthen and ratify the Mental Capacity Act policy to clarify assessment responsibilities, decision makers and Independent Mental Capacity Advocate referrals.
Verbatim wording from the response “In response to the concern raised of poor appreciation of the gentleman’s lack of capacity to make decisions about his care, BFT has completed a review of the ‘Mental Capacity Act 2005’ policy. The narrative in the policy has been strengthened in respect of defining roles and responsibilities in the application of mental capacity assessments and there is clarity as to whom should be ‘The Decision Maker’ and the legal requirement for referral and involvement of Independent Mental Capacity Advocates in the absence of a relevant representative. The revised policy has been ratified by the Safeguarding Committee on 16th June 2020.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and revise Mental Capacity Act training provision to clarify roles and responsibilities for relevant clinical staff.
Verbatim wording from the response “In conjunction with the review, Bolton NHS Foundation Trust is revising mandatory and non-mandatory training provision in respect of the Mental Capacity Act which Medical Staff, Nurses and Allied Health Care Professionals undertake, ensuring clarification of roles and responsibilities.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
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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 bespoke Mental Capacity Act training to designated staff cohorts.
Verbatim wording from the response “• There has been a review of training provision in respect of the Mental Capacity Act (MCA). Bespoke training is now provided to designated cohorts and will be completed by 30th September 2020.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
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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 Make Mental Capacity Act forms available for completion by all staff designations on the Electronic Patient Record.
Verbatim wording from the response “• MCA forms are now available for completion by all designations of staff on the Electronic Patient Record.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
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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 Communicate expectations to staff that significant changes require consideration and recording of capacity assessments and Best Interest meetings, with care-plan liaison monitored through supervision.
Verbatim wording from the response “• Team Managers have discussed the expectations with all staff, that every time there is a significant change in an individual's circumstance, that capacity assessments & Best Interest Meetings are considered and clearly recorded, and that care coordinators ensure they proactively liaise with other care providers to ensure any changes to the care plan can be reviewed and updated appropriately, and this is being monitored via supervision.” Source location 2020-0110-Response-from-Greater-Manchester-Mental-Health-Trust_Redacted.pdf
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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 Have Team Managers proactively review cases involving admission to other care settings during supervision to check care coordination and consideration of capacity and Best Interest meetings.
Verbatim wording from the response “Through supervision and team meetings, all staff have been informed of the expectations of a care coordinator when patients are admitted to alternative care settings, such as acute trusts, and informed that they must consider support from advocacy / IMCA. Team Managers will proactively review cases where individuals have been admitted to other care settings in supervision to ensure that care coordinator are proactively coordinating the individuals care, and consideration has been given to Capacity and Best Interest meetings, where appropriate.” Source location 2020-0110-Response-from-Greater-Manchester-Mental-Health-Trust_Redacted.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share inquest learning with senior management and leadership teams and put an action plan in place to keep staff current with Best Interest, Capacity and CPA training.
Verbatim wording from the response “Learning form the inquest has been shared with the Senior Management Teams, over both Adult and Older Adult Services and with the Senior Leadership Teams, which has an overarching responsibility within Bolton Mental Health Services and an action plan put in place to ensure that all staff are up to date with Best Interest & Capacity Training and Care Programme Approach (CPA) training, which is monitored by team managers. Learning from the inquest will be shared trust wide, via the trust wide Care Programme Approach (CPA) meeting.” Source location 2020-0110-Response-from-Greater-Manchester-Mental-Health-Trust_Redacted.pdf
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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 GMMHFT will provide a further response concerning mental capacity assessment and advocacy arrangements.
Verbatim wording from the response “Section 5 (5): The inquest was told that for a long period of time whilst in the care of the NHS there was not a clear understanding of his lack of capacity to make decisions about his care. Acquiescence by him was seen as him understanding and having capacity.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
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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 Bolton NHS Foundation Trust, Greater Manchester Mental Health NHS Foundation Trust and Bolton Council are responsible for responding to the report’s specific concerns.
Verbatim wording from the response “I expect the Bolton NHS Foundation Trust, the Greater Manchester Mental Health NHS Foundation Trust and Bolton Council to carefully consider and respond to the specific concerns highlighted by your report. I am advised that Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust have apologised for the lack of co-ordination in Mr Preston’s care while he was in hospital and the failure to conduct a formal assessment of Mr Preston’s mental capacity. You will know from the responses of the NHS trusts and Bolton Council to your report that they have worked together to resolve the matters of concern highlighted, with several actions taken to improve the co-ordination and quality of care for people with physical and mental health problems. I am pleased to see that learnings are being taken from the circumstances around Mr Preston’s care.” Source location 2020-0110-Response-from-Department-of-Health-and-Social-Care.pdf
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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 Local authorities, service providers and the Care Quality Commission are responsible for acting on allegations of poor care, neglect or abuse.
Verbatim wording from the response “The Government is committed to preventing and reducing the risk of harm to adults in vulnerable situations. Under the Care Act 2014, we expect local authorities to ensure that the services they commission are safe, effective and of high quality. We also expect those providing the service, local authorities and the Care Quality Commission (CQC) to take swift action where anyone alleges poor care, neglect or abuse.” Source location 2020-0110-Response-from-Department-of-Health-and-Social-Care.pdf
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7 Nov 2019 Charlotte Elizabeth Jacobs · Prevention of Future Deaths report Manchester City
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Concerns raised 1
Failure of clinicians treating physical illness to undertake required capacity assessments 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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Charlotte Elizabeth Jacobs · 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
Charlotte Jacobs suffered an accidental fall at home on 11 October 2016, developed a deep tissue injury and sacral ulcer, later suffered a stroke, and died from heart failure and related disease on 31 October 2016. Concerns included the failure to assess her capacity to refuse treatment, fluids and nutrition, an inappropriate transfer to a psychiatric ward while she was physically unwell, continuing uncertainty about the appropriateness of such transfers, and incomplete transfer guidance.
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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 clinicians treating physical illness to undertake required capacity assessments
Wider context from the report “1. The Consultant in charge of Ms Jacobs’ care (who authorised Ms Jacobs’ discharge on the 28th October 2016 to Maple Ward) indicated that – if similar circumstances arose again – he would make the same decision to transfer a patient to the Psychiatric Unit, despite the findings of the internal trust investigation that the discharge/transfer to Maple Ward should not have taken place.
2. The Consultant in charge of Ms Jacobs’ care still did not appear to understand that it was his role (and the role of those involved in treatment of Ms Jacobs’ physical illness) to consider whether a capacity assessment was required and to carry that out . This was not the role of the Psychiatric team .
3. The Consultant in charge of Ms Jacobs’ care and the Ward Manager for Ward 46 (at the time in 2016) did not appear to be aware of the findings of the Trust’s internal investigation.
4. Whilst I was informed that steps were being taken to put together guidance and a protocol for transfers of patients from Manchester Royal Infirmary to Park House, this had not been completed (despite Ms Jacobs’ death occurring some time ago in 2016).
In light of this evidence, I am concerned that there could be further inappropriate discharges/transfers from Ward 46 and/or from Manchester Royal Infirmary generally, leading to a risk of future deaths.
” Source location Charlotte Elizabeth Jacobs · Prevention of Future Deaths report
Open source report
6 Nov 2019 Hazel Maureen Lewis · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Failure to correctly apply Mental Capacity Act capacity requirements to decisions about investigations 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.
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AI-generated summary
Hazel Maureen Lewis · 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
Hazel Maureen Lewis died in hospital on 28 November 2018 after an unwitnessed fall caused a hip fracture; the medical cause of death was metastatic breast cancer, with the fracture contributing. Concerns were raised about the best-interest decision-making process, including inadequate consultation, failure to formally instruct an IMCA, insufficient exploration of support to help her engage with investigations, and uncertainty about the advocate’s role.
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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 correctly apply Mental Capacity Act capacity requirements to decisions about investigations
Wider context from the report “Whilst evidence was given that all witnesses had undergone mandatory Mental Capacity Act 2005 (MCA) training, the Court was left with some concerns about the adequacy of that training as it relates to decisions concerning life-sustaining treatment.
It would appear that those involved in the Deceased’s care did not fully understand the order in which steps are to be taken under the MCA, the nature of consultation and the role of consultees, when an IMCA is to be instructed and the need to explore all available options before a best interest decision is reached.
The best interest decision not to proceed with investigations in this case was taken prior to consultation with those involved in the Deceased’s care. Neither the social worker or community learning disability nurse appreciated that they were being consulted when spoken to by the GP. The carers who provided daily care to the Deceased and who had been able to foster her engagement with social care were not consulted. An IMCA was not formally instructed. There was no exploration of or advice given in relation to the options available to support the Deceased in engaging with medical investigations or medical care such as desensitisation or 1:1 care. The community learning disability nurse’s understanding was that the Deceased had the capacity to decline investigations . A best interest meeting was not convened and whilst this was not mandatory under these circumstances, it would have afforded an opportunity to ensure that agencies applied their minds to the possibility that the Deceased may engage with investigations if additional support was offered. It would also have facilitated more effective communication between the agencies and on-going management of the consequences of the best interest decision.
” Source location Hazel Maureen Lewis · Prevention of Future Deaths report
Open source report
19 Feb 2019 Janice Andrea Keelan · Prevention of Future Deaths report Manchester City
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Concerns raised 1
Failure to account for impaired cognition and probable lack of mental capacity in care and welfare decisions View source
This report raised 7 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
Manchester City Council
Review mental capacity awareness training to clarify complex decision-making.
View source
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AI-generated summary
Janice Andrea Keelan · 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
Janice Andrea Keelan, who had chronic and complex health conditions and was at risk of falling asleep or having a seizure in the bath, died by drowning on 14 November 2017. A referral for a walk-in shower was not approved until ten days after her death. Concerns included inadequate consideration of her impaired cognition and mental capacity, failure to prioritise the urgent risk, and insufficient action to involve mental health services to reduce the risk of 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 account for impaired cognition and probable lack of mental capacity in care and welfare decisions
Wider context from the report “1. It must have been apparent that the deceased suffered from fluctuating and impaired cognition and probably lacked ‘mental capacity’ to make decisions about her own care and welfare . The initial assessment on 21 July 2017 clearly demonstrated that she was at significant risk of having an event when using the bath which could prove fatal. Suggesting to a person with the deceased’s mental health conditions that they should not use the bath is completely unrealistic. Her daughter had been struggling to cope with her mother over some years. No apparent thought was given to obtaining authority from the deceased to obtain information from the mental health team to give a fuller picture and a more detailed explanation of the effects of her medication. This also could have produced evidence as to the manifestation of her psychiatric conditions and how, for example, she might have felt the bath was a safe place and a sanctuary from recurring symptoms. There was also clear evidence that the deceased had scalded herself in the bath. She may not have appreciated how hot the water was and people can and do die from scalding burn injuries when using a bath. This added to the risks to the deceased.
” Source location Janice Andrea Keelan · 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 mental capacity awareness training to clarify complex decision-making.
Verbatim wording from the response “Action:” Source location 2019-0057-Response-by-Manchester-City-Council
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1 Apr 2018 Julia Jane MacPherson · Prevention of Future Deaths report South London
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Concerns raised 1
Failure to formally review mental capacity to consent to treatment View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission Oxleas 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
Oxleas NHS Foundation Trust
Implement an MDT meeting template to record family concerns, review capacity and consent, incorporate multidisciplinary information, and document agreed actions.
View source
Oxleas NHS Foundation Trust
Continue auditing MDT template use, capacity assessments, and responses to family concerns.
View source
Oxleas NHS Foundation Trust
Set expectations that doctors regularly assess and document informal patients’ capacity and consent during weekly MDT reviews.
View source
Oxleas NHS Foundation Trust
Require ward pharmacists to review off-license medication processes, including discussions, capacity, efficacy, risks and benefits, and share concerns with prescribers and Clinical Directors.
View source
Care Quality Commission
Conducted a follow-up inspection of Oxleas NHS Foundation Trust’s acute wards to assess whether specific improvements had been made.
View source
Care Quality Commission
Return to inspect Oxleas NHS Foundation Trust and follow up the identified concerns to check that necessary improvements have been made.
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AI-generated summary
Julia Jane MacPherson · 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
Julia Jane MacPherson, an informal patient of Oxleas NHS Foundation Trust, suffered swallowing difficulties and collapsed in the community with food bolus and vomitus in her throat; resuscitation was unsuccessful. Concerns included failure to arrange or undertake a timely medical review, failure to assess her mental capacity after concerns about confusion, incomplete clinical records, and prescribing and consent processes for off-licence medication. The inquest recorded the medical cause of death as upper airway obstruction associated with swallowing difficulties secondary to medication-related extrapyramidal symptoms.
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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 formally review mental capacity to consent to treatment
Wider context from the report “(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however:
(a) This review did not take place and her Responsible Clinician did not see this note until the inquest.
(b) Julia was not reviewed on 16th May.
(c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May.
(2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records.
(3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised.
(4) NICE guidelines for the prescription of off licenced medicines was not followed.
(5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients.
” Source location Julia Jane MacPherson · 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 Implement an MDT meeting template to record family concerns, review capacity and consent, incorporate multidisciplinary information, and document agreed actions.
Verbatim wording from the response “The Trust has developed a Multidisciplinary Team (MDT) meeting template following a quality improvement project to enable every member of the MDT to contribute to the review. There is a section for families, carers and significant people in a service user’s life in which any concerns raised are documented to ensure these are discussed in the meeting and agreed actions to address these outlined.” Source location 2018-0298-Oxleas-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 Continue auditing MDT template use, capacity assessments, and responses to family concerns.
Verbatim wording from the response “A recent audit of the use of the MDT template and capacity assessments have shown that it is being used and that views and concerns of families are being addressed. These audits will be carried out on a regular basis to give assurance to the trust.” Source location 2018-0298-Oxleas-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 Set expectations that doctors regularly assess and document informal patients’ capacity and consent during weekly MDT reviews.
Verbatim wording from the response “The Trust will make clear its expectations of all doctors to regularly assess and document capacity and consent to treatment for informal patients. This should be done as part of the weekly MDT review process and where there are concerns about a patient’s capacity to understand the treatment then the patient’s informal status must be reviewed and detention sought. This will ensure that such patients come under the statutory process described above. For patients prescribed off-license medication, the ward pharmacist will review the medications and ensure that all processes: discussion with patient and relatives, on-going capacity assessments and efficacy of treatment and risk/ benefits have been checked and are documented. If there are any concerns these will be shared with the consultant prescribing the medication and their Clinical Director.” Source location 2018-0298-Oxleas-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 Require ward pharmacists to review off-license medication processes, including discussions, capacity, efficacy, risks and benefits, and share concerns with prescribers and Clinical Directors.
Verbatim wording from the response “The Trust will make clear its expectations of all doctors to regularly assess and document capacity and consent to treatment for informal patients. This should be done as part of the weekly MDT review process and where there are concerns about a patient’s capacity to understand the treatment then the patient’s informal status must be reviewed and detention sought. This will ensure that such patients come under the statutory process described above. For patients prescribed off-license medication, the ward pharmacist will review the medications and ensure that all processes: discussion with patient and relatives, on-going capacity assessments and efficacy of treatment and risk/ benefits have been checked and are documented. If there are any concerns these will be shared with the consultant prescribing the medication and their Clinical Director.” Source location 2018-0298-Oxleas-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 Conducted a follow-up inspection of Oxleas NHS Foundation Trust’s acute wards to assess whether specific improvements had been made.
Verbatim wording from the response “Since Julia Jane MacPherson's death in May 2016, we have inspected Oxleas NHS Foundation Trust once. This was a follow up inspection of the acute wards in the Trust, including Norman Ward, in February 2017 to see if some specific improvements had taken place since the comprehensive inspection in April 2016. We also carried out regular visits by our Mental Health Act reviewers, and the last one took place on Norman Ward in March 2017.” Source location 2018-0298-Response-by-CQC
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 Return to inspect Oxleas NHS Foundation Trust and follow up the identified concerns to check that necessary improvements have been made.
Verbatim wording from the response “We will be returning to inspect Oxleas NHS Foundation Trust later in the year. We intend to follow through some of the areas of concern in more detail. This will be to ensure the trust has learnt from this and made the necessary improvements.” Source location 2018-0298-Response-by-CQC
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 Specific circumstances of Julia MacPherson’s individual care and treatment fall outside the regulator’s remit for comment.
Verbatim wording from the response “We note our legal responsibility to submit a written response to you, however some of the matters of concern relate to the very specific circumstances of Julia MacPherson's individual care and treatment, so we are unable as a regulator to comment on this.” Source location 2018-0298-Response-by-CQC
Open published response
26 May 2017 Doreen Helen MILLER · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 1
Failure to undertake a mental capacity assessment for a serious and complex decision 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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AI-generated summary
Doreen Helen MILLER · 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
Doreen Helen MILLER, a vulnerable and housebound adult, was discharged home after an intermediate-care placement despite concerns about unusual toileting behaviour, possible cognitive impairment, self-neglect and limited provisions. She was found severely hypothermic in her cold, dark flat the next morning and died at hospital on 13 January 2016. The principal concerns included safeguarding referrals not being properly investigated, important cognitive information not being communicated, poor record-keeping and decision-making, insufficient assessment of mental capacity, and inadequate systems for reviewing serious incidents and learning from them.
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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 undertake a mental capacity assessment for a serious and complex decision
Wider context from the report “d) (Wiltshire Health & Care) As part of the evidence I heard that Doreen in the opinion of an Expert Geriatric Psychiatrist, not only had a mental impairment (cognitive impairment more likely with underlying dementia) but also more importantly that in relation to a serious and complex decision to return home she was of the view, in respect of which I accepted, that more likely than not Doreen could not understand her needs and was unable to recognise the risk of refusing the safeguarding recommendations and that in relation to her decision to return home and those associated decisions that she did not have mental capacity. I indicated in my summing up that this was a difficult case but I feel that the training given especially to the Therapy led members of the team did not sufficiently prepare them to deal with very complicated cases such as Doreen’s although that having been said if the advice that had been given had been followed the outcome possibly would have been different. I was however satisfied that had the advice been followed and a capacity test undertaken that Doreen would not have returned home when she did and therefore would not have died when she did. It was also readily apparent to me that members of the Therapy led Team and particularly ███████ was unaware that the safeguarding measures, part of the Mental Capacity Act and in particular the ability to secure either and urgent or standard authorisation for the deprivation of somebody’s liberty was not available where the individual concerned lives in the community and where their care is paid for privately. One witness said those cases can be extremely challenging and essentially those trying to do their best for the individual essentially have to wait for the next crisis to occur before they may be given an opportunity to introduce safeguarding measures. Had the mental impairment been recognised and the mental capacity assessment been carried out revealing that she did not have mental capacity in relation to the serious and complex decision to return home and associated decisions concerning additional safeguarding measures and if Doreen still wished to return home then it may have been in her best interests to have considered Deprivation of Liberty Safeguarding Order. I would hope that this particular case in particular could be used as a specific training case by all organisations involved but I have concerns that there were material gaps in individuals’ knowledge bases.
” Source location Doreen Helen MILLER · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.