Concerns raised 1
Lack of a designated lead with oversight and authority over coordinated care View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
NHS England
Continue rolling out Neighbourhood Mental Health Centres across England to provide more joined-up care and oversight.
View source
NHS England
Provide the National Record Locator service to help care professionals locate and retrieve patient information and identify organisations involved in care.
View source
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AI-generated summary
Alex Ganski · 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
Alex Ganski, aged 19, died from fatal injuries after jumping from a bridge while under the influence of ketamine and diazepam, following a relapse in drug misuse and longstanding mental health difficulties. The principal concerns were the absence of a designated lead with oversight and authority across services, fragmented information sharing, and no clear national mechanism to identify and communicate his wider mental health and drug-misuse risks.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a designated lead with oversight and authority over coordinated care
Wider context from the report “The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs:
a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age.
b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence. And then – critically - directing and assuring the right treatment or long-term intervention to follow.
c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented, in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction.
d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information. Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse. As such the situation is ameliorated by local changes but appears to be a wider and national issue.
I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs.
My further concern is that there was no simple mechanism or designation across those patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues, in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken.
This lack of an easily recognised national designator, shown across systems and records,such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved, and creates a risk of further similar deaths.
I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resources grounds, that this report will be acted upon.
I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives.
” Source location Alex Ganski · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue rolling out Neighbourhood Mental Health Centres across England to provide more joined-up care and oversight.
Verbatim wording from the response “As part of a national pilot to transform mental health care, six new neighbourhood mental health hubs are being developed across England.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide the National Record Locator service to help care professionals locate and retrieve patient information and identify organisations involved in care.
Verbatim wording from the response “NHS England’s National Record Locator (NRL) service allows health or social care workers to find and access patient information shared by other health and social care organisations across England, to support the direct care of a patient. It does this by recording the location of digital (and paper) records within the NHS and provides an index of pointers/bookmarks that contain the information required to retrieve key patient information from the source. The vision is to improve cross-border interoperability and help make data sharing possible by allowing healthcare professionals, such as Care Coordinators within a Mental Health Trust to securely and remotely retrieve information from source at the point of need so that they can get a longitudinal view of a patient’s records and an indication of their treatment history.” Source location Response from NHS England
Open published response
Concerns raised 1
Lack of a designated lead with full oversight and authority over coordinated care View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Alex Ganski · 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
Alex Ganski died from fatal injuries after jumping from a bridge while under the influence of ketamine and diazepam, following a relapse in drug misuse and longstanding mental health difficulties. The report identified concerns about fragmented information sharing between services and the absence of a clear lead with overall oversight and authority for his care, creating missed opportunities to address the combined risks of poor mental health, drug misuse and self-harm.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a designated lead with full oversight and authority over coordinated care
Wider context from the report “The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs:
a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age.
b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence. And then – critically – directing and assuring the right treatment or long-term intervention to follow.
c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented, in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction.
d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information. Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse. As such the situation is ameliorated by local changes but appears to be a wider and national issue.
I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs.
My further concern is that there was no simple mechanism or designation across the various patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues, in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken.
This lack of an easily recognised national designator, shown across systems and records, such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved, and creates a risk of further similar deaths.
I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resource grounds, that this report will be acted upon.
I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives.
” Source location Alex Ganski · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the draft Personalised Care Framework with NHS organisations ahead of publication.
Verbatim wording from the response “The Personalised Care Framework also looks to improve continuity, clarity and safety by ensuring people experiencing serious mental illness have a named professional coordinating their care, a care plan that reflects their needs now, quicker re-access to support when things deteriorate, and more consistent standards of good care wherever they live. The Personalised Care Framework has been shared in draft with NHS organisations ahead of its expected publication.” Source location Response from Department of Health and Social Care
Open published response
4 Dec 2025 Lina Piroli · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to provide coordinated care in A&E View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Lina Piroli · 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
Lina Piroli, aged 93, was admitted with an E. coli infection and later suffered an unstable C2 fracture and a stable L1 fracture after a fall down stairs. She remained in A&E for a prolonged period because no elderly care ward bed was available, while experiencing pain, confusion and delirium. The report raises concerns about delayed transfer to a ward and the resulting lack of access to specialist, coordinated care and appropriate symptom management for an elderly, complex patient.
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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 provide coordinated care in A&E
Wider context from the report “When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available. This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not achievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old.
Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses, robust symptom control measures, regular reviews and coordinated care . She remained in a busy, noisy and frightening environment. It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery.
I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require. Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise. This means that patients are not receiving the appropriate level of care.
” Source location Lina Piroli · 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 Introduce clinical operational standards for the first 72 hours of hospital care.
Verbatim wording from the response “• Introducing new clinical operational standards for the first 72 hours of care to support better hospital flow. These set minimum expectations for timely review, availability of advice, and coordinated care when multiple specialist teams are involved.” Source location Response from Department for Health and Social Care
Open published response
11 Nov 2025 Joan Elizabeth Talbot · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1
Failure to maintain continuity of care across admitting teams 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
King'S College Hospital 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. 5
King'S College Hospital NHS Foundation Trust
Produce and use the Problem List Etiquette Guide to standardize problem-list and associated documentation practices.
View source
King'S College Hospital NHS Foundation Trust
Establish a cross-Trust EPIC Documentation Quality Group to assess data quality, oversee documentation enhancements and lead targeted quality-improvement initiatives.
View source
King'S College Hospital NHS Foundation Trust
Agree EPIC documentation metrics and audit standards to establish baseline quality and track improvement.
View source
King'S College Hospital NHS Foundation Trust
Oversee EPIC build changes, including navigators and note templates, to facilitate documentation quality improvement.
View source
King'S College Hospital NHS Foundation Trust
Design and oversee targeted documentation quality-improvement projects before wider rollout.
View source See 2 more actions
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AI-generated summary
Joan Elizabeth Talbot · 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
Joan Talbot had progressive complications from previous radiotherapy, including recurrent urinary tract infections, hydronephrosis and bloody diarrhoea. She was admitted to hospital on 14 August 2022, developed sepsis associated with a dislodged ureteric stent, and died on 24 August 2022 despite treatment. The principal concern was a lack of continuity of care across three earlier admissions, which meant the significance of her diarrhoea was not fully appreciated and delayed investigation.
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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 maintain continuity of care across admitting teams
Wider context from the report “1. Mrs Talbot had been admitted on 3 occasions when a history of diarrhoea, at times bloody, was reported before her final fourth admission. On each occasion she came under a different admitting team. There were gaps in continuity of care such that the significance of her history of diarrhoea was not fully appreciated resulting in delays in this presentation being investigated. Although the Trust has subsequently introduced a new record system that has the potential to assist with continuity of care, it has not asked itself how this system can be used most effectively to ensure continuity of care in this specific scenario, whether further refinements to the existing systems and processes may be required.
” Source location Joan Elizabeth Talbot · 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 Produce and use the Problem List Etiquette Guide to standardize problem-list and associated documentation practices.
Verbatim wording from the response “in October 2023, a number of quality improvement pieces of work have been undertaken to improve patient safety & quality, through an initial ‘stabilisation phase’ of urgent work, followed by an ‘optimisation phase’ of improving functionality across a number of domains. We are conscious that further improvements are required and we are not complacent with regard to pace and scope of this work. Improvements in medical notes documentation commenced over the last few months, in particular a ‘Problem List Etiquette Guide’ has been produced, which outlines expectations for the use of problem lists and associated documentation fields.” Source location Response from Kings College Hospital 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 Establish a cross-Trust EPIC Documentation Quality Group to assess data quality, oversee documentation enhancements and lead targeted quality-improvement initiatives.
Verbatim wording from the response “Although the referenced problem list functionality was not yet deployed at the time of the incident (as the previous electronic patient record system was still in operation), the Trust acknowledges there is scope to enhance both EPIC’s documentation capabilities and the guidance provided to clinicians regarding its use. Therefore, in response to the concerns raised, the Trust has committed to establishing a cross-Trust EPIC Documentation Quality Group (‘DQG’). The DQG will be responsible for developing mechanisms to assess and monitor data quality, overseeing enhancements to documentation functionality, and leading targeted quality improvement initiatives. The drafting of the DQG’s terms of reference has specifically addressed the matters raised within the PFD, ensuring that the DQG’s work programme is both data-driven and aligned with identified risks.” Source location Response from Kings College Hospital 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 Agree EPIC documentation metrics and audit standards to establish baseline quality and track improvement.
Verbatim wording from the response “Although the referenced problem list functionality was not yet deployed at the time of the incident (as the previous electronic patient record system was still in operation), the Trust acknowledges there is scope to enhance both EPIC’s documentation capabilities and the guidance provided to clinicians regarding its use. Therefore, in response to the concerns raised, the Trust has committed to establishing a cross-Trust EPIC Documentation Quality Group (‘DQG’). The DQG will be responsible for developing mechanisms to assess and monitor data quality, overseeing enhancements to documentation functionality, and leading targeted quality improvement initiatives. The drafting of the DQG’s terms of reference has specifically addressed the matters raised within the PFD, ensuring that the DQG’s work programme is both data-driven and aligned with identified risks.” Source location Response from Kings College Hospital NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Oversee EPIC build changes, including navigators and note templates, to facilitate documentation quality improvement.
Verbatim wording from the response “Although the referenced problem list functionality was not yet deployed at the time of the incident (as the previous electronic patient record system was still in operation), the Trust acknowledges there is scope to enhance both EPIC’s documentation capabilities and the guidance provided to clinicians regarding its use. Therefore, in response to the concerns raised, the Trust has committed to establishing a cross-Trust EPIC Documentation Quality Group (‘DQG’). The DQG will be responsible for developing mechanisms to assess and monitor data quality, overseeing enhancements to documentation functionality, and leading targeted quality improvement initiatives. The drafting of the DQG’s terms of reference has specifically addressed the matters raised within the PFD, ensuring that the DQG’s work programme is both data-driven and aligned with identified risks.” Source location Response from Kings College Hospital NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Design and oversee targeted documentation quality-improvement projects before wider rollout.
Verbatim wording from the response “Although the referenced problem list functionality was not yet deployed at the time of the incident (as the previous electronic patient record system was still in operation), the Trust acknowledges there is scope to enhance both EPIC’s documentation capabilities and the guidance provided to clinicians regarding its use. Therefore, in response to the concerns raised, the Trust has committed to establishing a cross-Trust EPIC Documentation Quality Group (‘DQG’). The DQG will be responsible for developing mechanisms to assess and monitor data quality, overseeing enhancements to documentation functionality, and leading targeted quality improvement initiatives. The drafting of the DQG’s terms of reference has specifically addressed the matters raised within the PFD, ensuring that the DQG’s work programme is both data-driven and aligned with identified risks.” Source location Response from Kings College Hospital NHS Trust
Open published response
30 Jun 2025 Thomas Raymond Mallinson · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 1
Lack of clear responsibility for care of patients during illness 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
Carlisle Central Practice Cumbria Health Limited Department of Health and Social Care North West Ambulance Service 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
North West Ambulance Service NHS Trust
Maintain established pathways for circumstances in which a receiving provider passes a referral back to NWAS.
View source
Cumbria Health Limited
Implement an overnight process for breached response times, including welfare calls and priority clinical escalation where deterioration is suspected.
View source
Cumbria Health Limited
Continue discussions with the ICB, practices and primary-care representatives on formal arrangements for safely handing cases between daytime and out-of-hours services.
View source
Department of Health and Social Care
Introduce outcomes-based funding, integrated digital records and personalised care plans.
View source See 1 more action
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AI-generated summary
Thomas Raymond Mallinson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Thomas Raymond Mallinson became unwell with vomiting and diarrhoea and, after repeated contacts with health services over four days, was admitted to hospital gravely ill. He developed cardiogenic shock and acute kidney failure and died on 23 November 2024. The report raised concerns about delays and gaps in responsibility and communication across general practice, out-of-hours care, and ambulance services, and described the delay as amounting to neglect.
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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 clear responsibility for care of patients during illness
Wider context from the report “(1) To SSP Health, owners and operators of Carlisle Central Practice, 65 Warwick Road, Carlisle.
I wish to thank ████████ for his attendance and and assistance at the hearing. It was acknowledged that on 18th the advice "to call back tomorrow" should never have been given and that the telephone appointment the following day really ought to have been a face to face assessment either in surgery or at Thomas's home. I am concerned that no body or organization has taken responsibility for Thomas, an elderly man with significant co-morbidities, during his illness. Should this responsibility ultimately rest with a patients general practitioner, if not where does it rest?
” Source location Thomas Raymond Mallinson · 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 Maintain established pathways for circumstances in which a receiving provider passes a referral back to NWAS.
Verbatim wording from the response “There was no subsequent pass back to NWAS in Mr Mallinson's case, but if there had been NWAS also have established pathways for these circumstances.” Source location Response from North West Ambulance Services
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 an overnight process for breached response times, including welfare calls and priority clinical escalation where deterioration is suspected.
Verbatim wording from the response “In terms of the updated policy, we have put in place a clear process for managing calls that we cannot deal with overnight to reduce the risk of simply handing them all back to the daytime GP practices (page 13 in Clinical Operational Policy). We now provide a welfare call to patients in the overnight period in whom we have breached their response times. If there are concerns of deterioration then the case is escalated to a Clinician as priority. As discussed at inquest we will be adopting an automated text system to do the welfare checks with Adastra (our patient record software provider) when it becomes available which we understand will be by the end of the year.” Source location Response from Cumbria Health
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 discussions with the ICB, practices and primary-care representatives on formal arrangements for safely handing cases between daytime and out-of-hours services.
Verbatim wording from the response “2. The ICB have been informed of the receipt of the Regulation 28. I have had meetings with their quality team looking at how we manage the “shoulder time” at the daytime practice/Out of Hours interface. These discussions are ongoing as currently there is no formal agreement on how cases are managed and I have raised the possibility with the ICB about an MOU with all practices that would” Source location Response from Cumbria Health
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 Introduce outcomes-based funding, integrated digital records and personalised care plans.
Verbatim wording from the response “The plan also commits to a whole-system reform by creating a new NHS operating model, outcomes-based funding, integrated digital records, and personalised care plans, ensuring services work together rather than in isolation. It aims to reduce overcomplexity through system-wide working and joined-up pathways. With respect to clinical neglect, the plan outlines a commitment to a new era of transparency, improved quality of care for all, and stronger inclusion of patient and staff voices. This effort aims to address and prevent unnecessary suffering caused by healthcare failures and broader issues within the NHS.” Source location Response from Department for Health and Social Care
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 Wider risks from fragmented responsibility across NHS services should be addressed by national stakeholders through national guidance and structural changes.
Verbatim wording from the response “We also recognise your wider concerns about fragmented care across the NHS services. During the inquest, we noted that Mr Mallinson's case involved repeated transfers between 111, 999, Out-of-Hours and the GP surgery. In our view, this case exemplifies the complexity and lack of clarity that can occur when multiple providers share responsibility without a single clear point of accountability. We therefore support your decision to address this Regulation 28 to national stakeholders and would welcome further national guidance and structural changes to reduce these risks for vulnerable patients in future.” Source location Response from NHS Services
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 Contractual arrangements with partner organisations are considered sufficient to ensure continuity after NWAS transfers care.
Verbatim wording from the response “In Mr Mallinson's case NWAS handed over the episode of care to Cumbria Health on Call (CHOC) in line with the established clinical pathway. It is not possible for NWAS to follow up on every call once care has been transferred, and the service relies on the contractual arrangements that are in place with partner organisations to ensure appropriate continuity of care.” Source location Response from North West Ambulance Services
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 Once a referral is accepted, responsibility for the patient's care rests with the receiving provider rather than NWAS.
Verbatim wording from the response “In this case, Mr Mallinson was referred to community-based care and CHOC accepted responsibility for the referral. I understand this was confirmed by CHOC during the inquest, and there was no dispute regarding the transfer of care. Once a referral has been accepted, the duty of care then rests with the receiving provider, and NWAS' responsibility appropriately ends at that point.” Source location Response from North West Ambulance Services
Open published response
Concerns raised 1
Failure to establish clear responsibility for patient care View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Andrew James Tizard-Varcoe · 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 James Tizard-Varcoe died at home on 11 May 2022 due to the progression of an ear infection, later described at inquest as complications of necrotising otitis externa. Concerns included fragmented care across three hospital trusts, difficulties accessing medical records and establishing responsibility, delayed outpatient follow-up, and discharge without oral antibiotics despite microbiology advice.
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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 establish clear responsibility for patient care
Wider context from the report “(1) The evidence shows that Mr Tizard-Varcoe’s overall treatment for the ear infections between April 2021 and May 2022 was provided across three different health trusts and hospitals, Musgrove Park in Taunton, North Devon District Hospital in Barnstaple and Exeter Hospital; it is acknowledged that this was as a consequence of Mr Tizard- Varcoe’s vascular disease (being treated at Musgrove Park) and the locations of specialist doctors. Whilst being treated at Musgrove Park for a vascular problem, Mr Tizard-Varcoe consulted with ear nose and throat specialists for ear pain; subsequently between April 2021 and May 2022 he was seen on a number of occasions by clinicians in all three locations; this led to occasions when Mr Tizard -Varcoe was reviewed by clinicians without the full clinical picture due to the inability of separate hospital trusts to access each other’s medical records. The evidence revealed that on occasions it was difficult for Mr Tizard-Varcoe’s GP to work out who had responsibility for his care . It is my judgement that on occasions this led to less than optimal treatment for Mr Tizard Varcoe.
” Source location Andrew James Tizard-Varcoe · 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 Continue collaborating with neighbouring NHS partners to coordinate care, treatment and information sharing for patients receiving cross-organisation care.
Verbatim wording from the response “It would be unusual to undertake shared care between two neighbouring departments unless specifically requested. It is normally best practice for the same clinical consultant and team to manage care and treatment of a patient (where possible) for continuity. ENT and other specialties often work closely and collaboratively with colleagues from other NHS bodies, including teams in neighbouring hospitals and GPs in respect of patient treatment and this generally works well. Where SFT input is needed, we have and will continue to work with partners to ensure coordination, collaboration and optimal treatment in the best interests of the patients and their families.” Source location Response from NHS Somerset
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 Existing cross-organisational clinical collaboration generally provides sufficient coordination, with shared care used where specifically requested.
Verbatim wording from the response “It would be unusual to undertake shared care between two neighbouring departments unless specifically requested. It is normally best practice for the same clinical consultant and team to manage care and treatment of a patient (where possible) for continuity. ENT and other specialties often work closely and collaboratively with colleagues from other NHS bodies, including teams in neighbouring hospitals and GPs in respect of patient treatment and this generally works well. Where SFT input is needed, we have and will continue to work with partners to ensure coordination, collaboration and optimal treatment in the best interests of the patients and their families.” Source location Response from NHS Somerset
Open published response
20 Feb 2025 Duncan HOLLOWAY · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to provide joined-up care between different agencies View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
British Association For Counselling And Psychotherapy North London NHS Foundation Trust
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AI-generated summary
Duncan HOLLOWAY · 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
Duncan Holloway died after jumping from a bridge at approximately 5am on 18 July 2024, being killed by the impact with the railway tracks below. The concerns included psychotherapy note-keeping, training and response to suicidality, whether psychotherapists unable to manage suicidality should practise with at-risk clients, and a lack of joined-up care between agencies.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide joined-up care between different agencies
Wider context from the report “5. Mr Holloway was seen and fully assessed by North West London clinicians when he was taken to hospital by police following an episode of self harm on 30 June 2024. Police attendance had been prompted by Mr Holloway’s brother, calling from abroad.
Mr Holloway’s brother was particularly disappointed that it seemed as if Mr Holloway’s care was not joined up between the different agencies .
” Source location Duncan HOLLOWAY · 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 Existing processes require enquiries about support networks and promptly sending mental health assessment summaries to service users’ GPs.
Verbatim wording from the response “The Trust entirely recognises the importance of communication between its services and service users’ professional and personal support networks to support joined up care and manage risks. Service users are vital partners in their own care. However, with the exception of key support networks (such as those offered by a service user’s GP or next of kin), and although we enquire, the Trust relies on service users to expressly alert it to the involvement of any other networks. In accordance with our standard process when anyone is brought to A&E and a mental health assessment is carried out, a summary was promptly sent to Mr Holloway’s GP.” Source location Response from North London NHS
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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 Trust cannot involve other relevant parties without the service user’s consent and relies on the service user identifying those parties.
Verbatim wording from the response “The Trust was not aware that Mr Holloway had sought the support of a private therapist and was only made aware of this involvement during the inquest hearing. It appears that the therapist’s involvement postdates the Trust’s assessment of Mr Holloway at A&E. The Trust always seeks to involve all relevant parties in a patient’s care. However, this only possible with their consent and, although we enquire, the Trust is reliant on service users making it aware of who the relevant parties are. It is therefore difficult to see what the Trust could have done differently in this case. Notwithstanding this, the Trust will continue to reflect on this incident, which it will share through its various governance forums as part of its commitment to learning and improvement.” Source location Response from North London NHS
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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 A private psychotherapist cannot currently be included in integrated care planning, limiting the ability to coordinate care across agencies.
Verbatim wording from the response “As the psychotherapist contracted was a private practitioner there is currently no ability for them to be included in any integrated care planning that may have been available. Mr Holloway was under no obligation to inform his GP or any other care provider that he was seeking private psychotherapy. Consequently, it may have been that other agencies were unaware of this. BACP has no knowledge as to whether Mr Holloway did share this information or not.” Source location Response from BACP
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25 Nov 2024 Jai · Prevention of Future Deaths report Berkshire
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Concerns raised 1
Failure to provide a care co-ordinator or key worker after hospital discharge 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
Jai · 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
Jai was a 36-year-old GP who was found deceased on 27 April 2023 and had taken her own life. She had previously received mental health support, but after discharge from hospital no medium- or long-term plan was put in place and she was not under secondary mental health services at the time of her death. The concerns include the absence of a care co-ordinator or key worker after discharge and the continuing inability of teams using different electronic records systems to access each other’s clinical notes.
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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 provide a care co-ordinator or key worker after hospital discharge
Wider context from the report “1. The Trust’s own internal investigation highlighted the fact that no care co-ordinator or key worker was provided to Jai after her discharge from hospital on 7th of September 2022. The Trust’s initial plan was to review this by June 2024, and the aim now is for January 2025, almost two years from Jai’s death.
” Source location Jai · 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 Progress the Quality Improvement project to make care-transfer changes sustainable, Trust-wide and effective in mitigating recurrence risk.
Verbatim wording from the response “In relation to your first concern, I acknowledge that a delay in the completion of an action that arises from a patient safety incident investigation is a concern. I have asked to receive a report from the Oxford Healthcare Improvement Manager by the end of January 2025. In the meantime, I am satisfied that the Quality Improvement project has been progressing well. The purpose of this project is for us to ensure that the changes made are sustainable and Trust wide and that they do indeed mitigate against the risk of a similar event. I have been informed that a meeting takes place every fortnight in order to review progress (the most recent meeting was on 17th December 2024). The Trust is clear about the critical importance of the process by which a patient’s care is transferred from a ward to community teams.” Source location Response from Oxford Health NHS Foundation Trust
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15 Oct 2024 Stephen Charles Stringer · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to maintain holistic oversight of patients receiving care from multiple practitioners View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Stephen Charles Stringer · 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
Stephen Charles Stringer developed a hoarse voice from January 2023, but its persistence and deterioration were not recognised as a potential cancer warning sign until October 2023. He was diagnosed in January 2024 with stage 4 squamous cell carcinoma of the glottis and treated palliatively. The report identified concerns about delayed referral, gaps in electronic patient enquiry systems, fragmented oversight of his care, and limited awareness of persistent hoarseness as a possible cancer symptom.
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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 maintain holistic oversight of patients receiving care from multiple practitioners
Wider context from the report “3. A number of different health professionals had input into his care. This meant that there was no one health professional who had a good insight into his overall deterioration and symptoms. Where multiple practitioners were involved one person needed to maintain oversight or the electronic patient record needed to have easily accessible clear action plans and notes were required so that a patient and their symptoms could be seen holistically rather than a one off.
” Source location Stephen Charles Stringer · 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 Discuss adding record-keeping resources to the Hub Plus online information and support suite.
Verbatim wording from the response “The DDICB will also liaise with HUB+ to discuss the possibility of Record Keeping being added to their suite of online information and support for general practice.” Source location Response from Derby and Derbyshire Integrated Care Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss high-quality patient-record and medical-record guidance at a Clinical Governance Leads patient-safety agenda item.
Verbatim wording from the response “At the Clinical Governance Leads meeting with general practice the below documents will be discussed as part of the Patient safety standard agenda item.” Source location Response from Derby and Derbyshire Integrated Care Board
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2 Oct 2024 Michael Sean Heath · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Lack of connectivity between overseas and UK mental health services during repatriation of an ill patient View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission Department of Health and Social Care Greater Manchester Mental Health NHS Foundation Trust NHS England North West Ambulance Service NHS Trust Trafford 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. 4
Greater Manchester Mental Health NHS Foundation Trust
Revise the repatriation procedure to support communication and continuity of care for international patients.
View source
Greater Manchester Mental Health NHS Foundation Trust
Share the revised community mental health policy’s final draft with the Trafford Strategic Safeguarding Partnership.
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Greater Manchester Mental Health NHS Foundation Trust
Share learning with the overseas hospital consultant and reinforce proactive communication before discharge.
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Care Quality Commission
Continue monitoring how providers work with other agencies during service transitions to prevent gaps in care.
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AI-generated summary
Michael Sean Heath · 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 Sean Heath died on 25 August 2023 in an apartment from injuries involving his pericardial sac. The inquest jury determined that he died by taking his own life while suffering an acute mental health crisis. Principal concerns included police and mental health service responses, inter-agency communication, continuity of care after his return from Gibraltar, and access to appropriate mental health support.
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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 connectivity between overseas and UK mental health services during repatriation of an ill patient
Wider context from the report “The apparent lack of connectivity between mental health services abroad and the UK upon repatriation whilst the patient remains ill ;
” Source location Michael Sean Heath · 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 Revise the repatriation procedure to support communication and continuity of care for international patients.
Verbatim wording from the response “Following this incident, the Trust has revised its Repatriation Procedure, as part of the newly developed Community Mental Health Transformation policy which outlines the steps necessary to ensure seamless communication and care for international patients. This policy is currently a working draft, and it is anticipated a final draft will be shared with the Trafford Strategic Safeguarding Partnership in early 2025.” Source location Response from Great Manchester Mental Health NHS
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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 the revised community mental health policy’s final draft with the Trafford Strategic Safeguarding Partnership.
Verbatim wording from the response “Following this incident, the Trust has revised its Repatriation Procedure, as part of the newly developed Community Mental Health Transformation policy which outlines the steps necessary to ensure seamless communication and care for international patients. This policy is currently a working draft, and it is anticipated a final draft will be shared with the Trafford Strategic Safeguarding Partnership in early 2025.” Source location Response from Great Manchester Mental Health NHS
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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 learning with the overseas hospital consultant and reinforce proactive communication before discharge.
Verbatim wording from the response “In response to our learning from Mr Heath’s death, the Trust contacted the Consultant Psychiatrist at Oceanview Hospital in Gibraltar to share learning and reinforce the importance of proactive communication upon discharge. Going forward, this procedure will ensure that overseas providers understand the need to engage with the Trust prior to repatriation.” Source location Response from Great Manchester Mental Health NHS
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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 Continue monitoring how providers work with other agencies during service transitions to prevent gaps in care.
Verbatim wording from the response “Our assessment of services includes how providers respond to patients transitioning between services. We will continue to work with providers to monitor how they are working effectively with other agencies to prevent gaps in a person’s care.” Source location Response from CQC
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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 Policing, mental health management, cross-service collaboration and GP decision-making do not concern Trafford Council’s actions or decisions, so it cannot address them.
Verbatim wording from the response “Within your listed matters, you have raised over-arching concerns regarding Policing, the management of mental health patients, the quality of collaboration between mental health services both abroad and in the UK upon repatriation whilst the patient remains ill and GP decision-making – and I note that there is no specific reference to the actions of Trafford Council within those listed concerns. As these concerns do not relate to the actions nor decision-making of Trafford Council, you will appreciate that I am unable to specifically address these with a respective timetable for action.” Source location Response from Trafford Council
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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 Overseas healthcare providers cannot be mandated to share clinical information when patients are medically repatriated.
Verbatim wording from the response “Regarding your concern over the apparent lack of connectivity between mental health services abroad and the UK, whilst it would be NHS England’s hope that, in the patient’s best interests, when a patient is medically repatriated there will be appropriate sharing of clinical information between the discharging and receiving healthcare providers, this cannot be mandated for overseas healthcare providers.” Source location Response from NHSE
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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 A provider cannot reasonably be expected to know about a patient’s return when the patient independently arranged travel and gave no notification.
Verbatim wording from the response “Further, where a patient makes their own arrangements to return to the UK independent of an overseas healthcare provider, there can be no expectation that a provider would be aware of the patient’s travel arrangements unless the patient themselves notifies the relevant provider of their return. In this case, it is our understanding that Michael made his own travel arrangements independent of an overseas healthcare provider, and did not notify a provider in England of his return.” Source location Response from NHSE
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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 Concerns about police training, family notification, international mental health connectivity and GP list removals relate to other organisations and fall outside NWAS’s remit.
Verbatim wording from the response “Unfortunately, as the matters of concern raised at points (1) – (4) relate to other organisations, I will not be able to provide any assistance with those concerns.” Source location Response from NWAS
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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 Mental-health repatriation is not provided for by the Mental Health Act and presents infeasible data-protection, language and logistical challenges.
Verbatim wording from the response “You have also raised concerns around a lack of connectivity between mental health services abroad and the UK upon repatriation to the UK. I should explain that the Mental Health Act does not include provision for repatriation of individuals back to the UK (other than in certain cases where individuals have been diverted from the justice system to the hospital system by an order of a court following a criminal offence). This would present a number of challenges in terms of data protection, language and logistical practicalities which would not be feasible.” Source location Response from DHSC
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.