11 Aug 2023 Doris Irene URCH · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to preserve old care plans in their contemporaneous format View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Doris Irene URCH · 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
Doris Irene Urch, aged 90, fell at a care home on 6 February 2023 after support was not offered while she was ambulating. She sustained an acute left frontal intracranial haemorrhage and died on 28 February 2023. Concerns included inadequate fall-risk assessment and care planning, staff unfamiliarity with the care plan, failure to update it after an earlier fall, and inadequate preservation of historical care plans.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to preserve old care plans in their contemporaneous format
Wider context from the report “(5) The system does not preserve old care plans in their contemporaneous format which is a serious shortcoming which has the potential to hinder future investigations. I encourage that system to be reviewed.
” Source location Doris Irene URCH · Prevention of Future Deaths report
Open source report
21 Nov 2022 Celia Lindsey MARSH · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1
Failure to retain hospital blood samples in suspected anaphylaxis cases View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Food Standards Agency UK Health Security Agency
×
AI-generated summary
Celia Lindsey MARSH · 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
Celia Lindsey Marsh died on 27 December 2017 after suffering fatal anaphylaxis caused by milk protein in a wrap she believed was safe to eat. The principal concerns included the investigation and retention of evidence in suspected anaphylaxis deaths, education for doctors and patients, systems for reporting anaphylaxis, and potentially misleading “dairy-free” and other allergen-labelling claims.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to retain hospital blood samples in suspected anaphylaxis cases
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Source location Celia Lindsey MARSH · Prevention of Future Deaths report
Open source report
×
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 Establishing the systems identified by the Coroner falls outside UKHSA’s remit.
Verbatim wording from the response “Whilst we understand the seriousness of the failings leading to the death of Celia Marsh responsibility for establishing systems such as those referred to by the Coroner sit outside of the remit of UKHSA.” Source location Response UK Health Security Agency
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pathology policy responsibility lies with DHSC and the Royal College of Pathologists, rather than the respondent.
Verbatim wording from the response “Your concerns regarding pathology have been noted, however this is not an area where the FSA has policy responsibility. I can see that your report has been directed to the Department for Health and Social Care (DHSC) and the Royal College of Pathologists who may be able to offer a response to these concerns. We are however, open to assisting other government departments where we can.” Source location Response from Food Standards Agency
Open published response
3 Aug 2022 NIGEL JOHN SAUNDERS · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 2
Failure to retain and preserve evidence relevant to learning from deaths in custody View source Insufficient robustness of the local system for retaining and preserving material relevant to deaths View source
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
Serco Limited
Finalise and roll out the updated Death in Custody procedure and checklist across English Serco prisons, with guidance for staff collating relevant documentation.
View source
Serco Limited
Add the Oscar Journal to the Death in Custody checklist so it is preserved when relevant in Serco prisons using an Oscar journal.
View source
×
AI-generated summary
NIGEL JOHN SAUNDERS · 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
Nigel John Saunders was detained at HMP Lowdham Grange and was found suspended by ligature on 17 November 2018. He was pronounced deceased in hospital on 18 November 2018 following hypoxic brain injury sustained during the suspension. The concerns included failings in his admission to the Segregation Unit, care under the ACCT Plan, and searching before entering the shower area, as well as failures to retain and preserve evidence relevant to investigations of deaths in custody.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to retain and preserve evidence relevant to learning from deaths in custody
Wider context from the report “(1) The Prison failed to comply with its obligations pursuant to National Prison policy to retain and preserve evidence likely to assist all agencies to learn from deaths in custody .
(2) The local system in place for the retention and preservation of material likely to be relevant to the circumstances of death is not as robust as it ought to be.
This is not the first time serious disclosure irregularities have undermined the veracity of an Article 2 inquest involving this prison in my corner Area. I consider this to be a local issue of significant importance. If the investigations following a death are repeatedly hindered in their full and frank examination of the facts due to missed opportunities by the prison to have retained and preserved evidence , then lessons cannot be learned, and the risk of further deaths shall persist. The Chief Coroner highlights this specific area of risk at paragraph 42 of the revised Guidance Note 5.
” Source location NIGEL JOHN SAUNDERS · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient robustness of the local system for retaining and preserving material relevant to deaths
Wider context from the report “(1) The Prison failed to comply with its obligations pursuant to National Prison policy to retain and preserve evidence likely to assist all agencies to learn from deaths in custody.
(2) The local system in place for the retention and preservation of material likely to be relevant to the circumstances of death is not as robust as it ought to be .
This is not the first time serious disclosure irregularities have undermined the veracity of an Article 2 inquest involving this prison in my corner Area. I consider this to be a local issue of significant importance. If the investigations following a death are repeatedly hindered in their full and frank examination of the facts due to missed opportunities by the prison to have retained and preserved evidence, then lessons cannot be learned, and the risk of further deaths shall persist. The Chief Coroner highlights this specific area of risk at paragraph 42 of the revised Guidance Note 5.
” Source location NIGEL JOHN SAUNDERS · 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 Finalise and roll out the updated Death in Custody procedure and checklist across English Serco prisons, with guidance for staff collating relevant documentation.
Verbatim wording from the response “Following this inquest, the DSOP, including the DIC checklist has been reviewed further and an updated version is to be rolled out to the English Serco prison estate by the end of October 2022. The updated version of the DSOP will include a statement that the DIC Checklist is not an exhaustive list, and the Prison should retain any other document that it considers could be of relevance.
The updated DSOP will be rolled out across the prison estate and guidance will be given to all staff responsible for collating relevant documentation following a death in custody.
I understand that a copy of the DIC checklist that was in place at the time of Mr Saunders’ death and a copy of the DIC checklist, as amended in January 2021 were provided to you during the course of the inquest.” Source location Response from HMP Lowdham Grange
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 Add the Oscar Journal to the Death in Custody checklist so it is preserved when relevant in Serco prisons using an Oscar journal.
Verbatim wording from the response “Over the years the Journal has been replaced by incident reports, which are completed and then reported to and discussed by the Director and the Senior Management Team on a daily basis.
It is accepted that Journal entries may have contained relevant information following a DIC and consequently should have been included on the DIC checklist to ensure their preservation following a death. The Journal is now listed in the checklist, to ensure it is produced in Serco prisons that use an Oscars journal.” Source location Response from HMP Lowdham Grange
Open published response
20 Jun 2022 Adele Angel Massoudi · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 1
Failure to retain placentas when required for death investigation View source
This report raised 2 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. 5
RBFT
Store all placentas for 48 hours after birth using designated fridges and automated temperature monitoring.
View source
RBFT
Ratify and implement the placenta-retention Standard Operating Procedure, including histology guidance and 48-hour storage requirements.
View source
RBFT
Train Band 7 midwives and Unit Coordinators on the placenta-retention Standard Operating Procedure.
View source
RBFT
Coordinate with Waste Management so midwifery staff attend placenta disposal and correct procedures are followed.
View source
RBFT
Update electronic safety-huddle templates to identify recent neonatal deterioration or admissions and prevent erroneous placenta disposal.
View source See 2 more actions
×
AI-generated summary
Adele Angel Massoudi · 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
Adele Angel Massoudi was born at home on 26 June 2020, transferred to hospital, and died there on 2 July 2020; the recorded cause of death was severe hypoxic ischaemic encephalopathy. The report identified delays in responding to meconium, inadequate fetal heart-rate monitoring, delayed transfer to hospital, inadequate communication with the family, and destruction of the placenta without retaining it for examination. Concerns focused on midwifery training and the retention of placentas for death investigation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to retain placentas when required for death investigation
Wider context from the report “In terms of learning from these cases, examination of the placenta, either as part of a formal autopsy, or even without an autopsy, is absolutely vital. It is akin to asking a pathologist to
conduct a post-mortem examination without one of the organs, if the placenta is not retained.
I am concerned about the response from the hospital trust on this point. I am told that the guideline for placenta examination is being reviewed and I quote from the statement sent by the Director of Midwifery, dated 6 June 2022:
We continue to explore opportunities that may extend placental storage.
It does not go far enough simply to state “we are looking into it” at this stage, or that the trust does not have the space to store placentas for longer. I appreciate that the Human Tissue Act and other considerations have to be taken into account. It is not insurmountable, and I believe the trust must now be given a deadline for responding to this concern, in the format of a Regulation 28 Report, in order to ensure that a decision has been made. There are cases where keeping the placenta is clearly required - such as this case - because Adele was born in a poor condition. The practical realities have to be taken into account, and a line drawn as to when placentas should be kept for longer than usual. Currently, placentas in uncomplicated cases are being disposed of daily.
” Source location Adele Angel Massoudi · 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 Store all placentas for 48 hours after birth using designated fridges and automated temperature monitoring.
Verbatim wording from the response “Previously, placentas in uncomplicated cases were being disposed of on a daily basis but I can confirm that the Trust have implemented processes to ensure that all placentas are stored for 48 hours from the time of birth. We are advised by the Pathology team that retaining placentas beyond this time would not provide reliable histology findings.” Source location Response from Royal Berkshire NHS Foundation 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 Ratify and implement the placenta-retention Standard Operating Procedure, including histology guidance and 48-hour storage requirements.
Verbatim wording from the response “The Standard Operating Procedure (SOP) for placenta retention will be ratified at the Maternity Clinical Governance Meeting in October 2022 and will go live on 10 October 2022; it provides guidance on which placentas need to be sent to histology for pathological examination, as well as storing and retaining all placentas for 48 hours before disposal in uncomplicated cases. In order to disseminate this information, all of the Trust’s Band 7 midwives and Unit Coordinators will be trained on the new SOP to ensure compliance throughout maternity, and in particular the midwives and maternity support workers. We are also working with Waste Management to ensure that their team are fully aware of the new process, as they now need to request that a member of the midwifery team attends with them to ensure that the correct procedures are followed.” Source location Response from Royal Berkshire NHS Foundation 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 Train Band 7 midwives and Unit Coordinators on the placenta-retention Standard Operating Procedure.
Verbatim wording from the response “The Standard Operating Procedure (SOP) for placenta retention will be ratified at the Maternity Clinical Governance Meeting in October 2022 and will go live on 10 October 2022; it provides guidance on which placentas need to be sent to histology for pathological examination, as well as storing and retaining all placentas for 48 hours before disposal in uncomplicated cases. In order to disseminate this information, all of the Trust’s Band 7 midwives and Unit Coordinators will be trained on the new SOP to ensure compliance throughout maternity, and in particular the midwives and maternity support workers. We are also working with Waste Management to ensure that their team are fully aware of the new process, as they now need to request that a member of the midwifery team attends with them to ensure that the correct procedures are followed.” Source location Response from Royal Berkshire NHS Foundation 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 Coordinate with Waste Management so midwifery staff attend placenta disposal and correct procedures are followed.
Verbatim wording from the response “The Standard Operating Procedure (SOP) for placenta retention will be ratified at the Maternity Clinical Governance Meeting in October 2022 and will go live on 10 October 2022; it provides guidance on which placentas need to be sent to histology for pathological examination, as well as storing and retaining all placentas for 48 hours before disposal in uncomplicated cases. In order to disseminate this information, all of the Trust’s Band 7 midwives and Unit Coordinators will be trained on the new SOP to ensure compliance throughout maternity, and in particular the midwives and maternity support workers. We are also working with Waste Management to ensure that their team are fully aware of the new process, as they now need to request that a member of the midwifery team attends with them to ensure that the correct procedures are followed.” Source location Response from Royal Berkshire NHS Foundation 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 Update electronic safety-huddle templates to identify recent neonatal deterioration or admissions and prevent erroneous placenta disposal.
Verbatim wording from the response “As an additional assurance, the safety huddle templates on our electronic patient record system will be updated to prompt the team to ask whether any babies have deteriorated or been admitted from other areas in the last 24 hours to the paediatric ward, who are less than 48 hours of age and require ventilation, cooling or neonatal death. This measure will be introduced to ensure that placentas are not erroneously disposed of due to any lack of communication between the maternity unit and paediatric ward.” Source location Response from Royal Berkshire NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Retention of placentas beyond 48 hours would not provide reliable histology findings, so longer storage is not undertaken.
Verbatim wording from the response “Previously, placentas in uncomplicated cases were being disposed of on a daily basis but I can confirm that the Trust have implemented processes to ensure that all placentas are stored for 48 hours from the time of birth. We are advised by the Pathology team that retaining placentas beyond this time would not provide reliable histology findings.” Source location Response from Royal Berkshire NHS Foundation Trust
Open published response
15 May 2022 Connor Samuel Timothy Wellsted · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Failure to retain medical records after sudden unexpected deaths View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Connor Samuel Timothy Wellsted · 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
Connor Samuel Timothy Wellsted, a five-year-old boy with significant neuro-disabilities, was found deceased in his cot on 17 May 2017 during a residential neuro-rehabilitation stay. The investigation determined that he died following entrapment by a loose cot bumper causing airway obstruction. Concerns included inadequate cot maintenance and securing, lack of regular direct visual night-time supervision, and failures to preserve the scene, inform relevant bodies, and investigate the circumstances openly and transparently.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to retain medical records after sudden unexpected deaths
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns . Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death.
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death.
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” Source location Connor Samuel Timothy Wellsted · 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 Carry out a comprehensive review of the Report’s concerns at the Children’s Trust through South East regional representatives.
Verbatim wording from the response “I note that you also sent your Report to the Chief Executive and Medical Director of the Children’s Trust, Tadworth, and I have had sight of their response as referred to above. On 15 July 2022, representatives from the South East Region attended upon the Trust and carried out a comprehensive review of all of the points that you made in your Report. They concluded that there were no current quality concerns, however there was room for improvement. The outstanding actions for improvement will continue to be monitored by NHS England South East. I am assured that the Children’s Trust, Tadworth, have addressed all of the concerns raised in your Report.” 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 Develop clear protocols and training for unexpected child deaths using relevant national and local guidance.
Verbatim wording from the response “In addition to this, we have reviewed The Royal College of Pathologists guidelines on ‘Sudden unexpected death in infancy and childhood: Multi-agency guidelines for care and investigation’, 2016, and guidance produced by the Surrey Child Death Review Partnership. We are further developing a clear protocol and training for our nursing and medical staff in the event of an unexpected child death. We accept that our training has historically focussed on basic life support and actively assessing and supporting children who we do not anticipate will die unexpectedly. Whilst our staff will continue to receive their basic life support training, we will have clear guidelines on processes and actions to be taken in the event of a sudden unexpected death. We are also planning to expand our existing simulation training beyond medical emergencies and basic life support, to cover unexpected deaths.” Source location Response from The Children's Trust
Open published response
28 Jan 2022 Mark Anthony Athias · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1
Failure to preserve handover records View source
This report raised 6 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
Exemplar Health Care
Preserve handover records through electronic monthly files, printed management-office copies, archiving and monthly completeness checks.
View source
×
AI-generated summary
Mark Anthony Athias · 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
Mark Anthony Athias had multiple physical and mental health issues, including recurring urinary infections and problems with a long-term catheter. After difficulties with his catheter on 2 July 2021, he was admitted to hospital, where his condition deteriorated and he died on 6 July 2021. Concerns included a lack of sterile replacement catheters, inadequate monitoring records, and a missing handover record, with risks arising from deficient record keeping.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to preserve handover records
Wider context from the report “3. The handover record for 2 July 2021 was missing, having allegedly been overwritten . The managers in the nursing home did not appreciate this until an Adult Safeguarding Investigation was underway.
” Source location Mark Anthony Athias · 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 Preserve handover records through electronic monthly files, printed management-office copies, archiving and monthly completeness checks.
Verbatim wording from the response “You heard evidence from Ms ████████ that Exemplar Health Care had changed its system to use word templates across the entire organisation. It is therefore no longer possible for documents such as handovers to be overwritten. In addition, each handover is now saved electronically in a specific month document file and a copy is printed off and retained in the management office at Copperfields in paper form with a date tracker.” Source location 2022-0024-Response-from-Exemplar-Health-Care_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Electronic storage, printed copies and monthly checks ensure handovers cannot be overwritten and remain accessible.
Verbatim wording from the response “You heard evidence from Ms ████████ that Exemplar Health Care had changed its system to use word templates across the entire organisation. It is therefore no longer possible for documents such as handovers to be overwritten. In addition, each handover is now saved electronically in a specific month document file and a copy is printed off and retained in the management office at Copperfields in paper form with a date tracker.” Source location 2022-0024-Response-from-Exemplar-Health-Care_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing management oversight, quality assurance and governance processes are considered sufficient to ensure records are kept, retained and reviewed for trends.
Verbatim wording from the response “I have detailed above the relevant management structure changes and quality assurance systems in place to ensure that all record keeping is appropriate and accurate. In summary:” Source location 2022-0024-Response-from-Exemplar-Health-Care_Published
Open published response
21 Oct 2021 Quinn Lias Parker · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1
Failure to retain the placenta for full paediatric post mortem examination before coronial reporting View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Quinn Lias Parker · 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
Quinn Lias Parker was born in very poor condition and died two days later, after remaining extremely unwell from shortly after birth. The placenta was cut into or dissected after his death without discussion with the Coroner, limiting the paediatric post-mortem examination and the investigation into the circumstances and likely cause of death. The report also identifies repeated cases in which placental examination was compromised following early neonatal deaths in Nottingham.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to retain the placenta for full paediatric post mortem examination before coronial reporting
Wider context from the report “1. The placenta, a key organ required for a full paediatric post mortem in an early neonatal death, has been interfered with such that the Paediatric Pathologist, is limited in his conclusion as to the likely cause of death.
In some ways the placenta is akin to an organ for the purposes of a paediatric post mortem- Loss of an organ at any post mortem examination, may well undermine the ability of the pathologist to carry out a full and proper examination. Decisions surrounding interference with, or disposal of, the placenta should be made in a careful and considered manner, with thought given to an early discussion with the coroner as would happen if organ donation is being considered. This did not happen in this case.
2. Unfortunately, there have been a number of cases in Nottingham where the death of a baby shortly after the birth was anticipated, but the placenta was disposed of and/or interfered with prior to the death being reported to the coroner . This undermines the coronial investigation resulting in limited findings and therefore limited conclusions at inquest. This will likely lead to a lack of learning from such deaths, and therefore a risk that similar deaths will occur in the future. It may also deprive the parents of significant information when considering whether future pregnancies may be at greater risk with the consequent need for appropriate management and planning.
3. The Nottinghamshire Coronial service has to date worked collaboratively with all local Trusts, but particularly with NUH NHS Trust, to ensure key staff understand the importance of retaining the placenta in an early neonatal death. This has not led to the actions necessary to achieve a full and proper examination of the placenta in repeated paediatric post mortems in this jurisdiction.
” Source location Quinn Lias Parker · 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 Maintain a 96-hour stop on dissecting placentas sent to Pathology, allowing fixation during the period without dissection.
Verbatim wording from the response “Last year, in the light of your PFD report, an immediate 48 hour stop was put on the dissection of all placentas. However we have since reviewed the proposed processes and the length of that stop has been extended and is now set at 96 hours (ie 4 days) for all placentas that are sent to Pathology. A placenta may be fixed during that period, to prevent its deterioration, but it will not be dissected.” Source location Response from NUH (3)
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review whether placental examination processes need adaptation after receiving further information about the examination.
Verbatim wording from the response “In response to this Report the Trust will develop a standard procedure such that in the case of any neonatal death within 48 hours of birth the medical examiner team will inform the pathology laboratory of this at the very earliest opportunity. Once further information is gained in relation to the placental examination the Pathology Department will review whether there needs to be any adaptation to current examination processes.” Source location Response from NUH
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust considers a process to identify very unwell neonates for pre-death Coroner discussions impractical and unreliable because deaths are not predictable.
Verbatim wording from the response “After consultation with Obstetricians, Neonatologists, Pathologists and Digital Lead, it is the view of the Trust that it is not proportionate nor practically achievable to devise a process that would reliably allow for this given that all of the 975 admissions to NICU each year are, by the very nature of NICU, neonates who are very unwell and may go on to die. The death of a neonate on NICU is not predictable in a way that could reliably allow us to identify the 25 or so neonates who do actually die each year. This is why we have determined that extending the Pathology stop period across the board for all placentas, and having discussions with your office where a death occurs within 96 hours, is a preferable and more realistically achievable approach.” Source location Response from NUH (3)
Open published response
28 Jul 2021 Carl Lee Walters · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 1
Failure to preserve key evidence View source
×
AI-generated summary
Carl Lee Walters · 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
Carl Lee Walters died suddenly and unexpectedly in his prison cell from a ruptured splenic pseudoaneurysm, with the evidence unable to establish whether it was naturally occurring or trauma related. CCTV footage had not been preserved and only limited cell bell records were kept, meaning key evidence was unavailable and the inquest could not be as full as it otherwise would have been.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to preserve key evidence
Wider context from the report “The failure to preserve key evidence meant that the inquest could not be as full as it would otherwise have been. If key evidence is not preserved there is an ongoing risk that dangerous conditions or circumstances go undiscovered raising the prospect that appropriate steps to avoid a similar tragedy are overlooked.
” Source location Carl Lee Walters · 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 Create and implement a local operating policy requiring retention of essential documents, including cell bell records, CCTV and body-worn video footage.
Verbatim wording from the response “As a consequence of Mr Walters’ death and the discovery of HMP Exeter’s deficiencies with regard to the preservation of key evidence, new measures and processes have been put in place to prevent similar circumstances in the future. In particular, HMP Exeter have created a local operating policy for deaths in custody, which contains a list of essential documents that must be retained and the required actions. Included within the list is the collation of relevant cell bell records, CCTV and Body Worn Video Camera footage of any incident. Also, since Mr Walters’ death a new CCTV system has been installed which provides a more reliable source of footage.” Source location 2021-0256-Response-from-HMPPS_Published
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 Install a new CCTV system providing a more reliable source of incident footage.
Verbatim wording from the response “As a consequence of Mr Walters’ death and the discovery of HMP Exeter’s deficiencies with regard to the preservation of key evidence, new measures and processes have been put in place to prevent similar circumstances in the future. In particular, HMP Exeter have created a local operating policy for deaths in custody, which contains a list of essential documents that must be retained and the required actions. Included within the list is the collation of relevant cell bell records, CCTV and Body Worn Video Camera footage of any incident. Also, since Mr Walters’ death a new CCTV system has been installed which provides a more reliable source of footage.” Source location 2021-0256-Response-from-HMPPS_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a rapid learning review of every death in custody within 72 hours, ensuring pertinent information is made available and reviewed.
Verbatim wording from the response “In addition to the above, all deaths in custody at HMP Exeter are subject to a quick time learning review conducted by the Head of Safety and Regional Groups Safety Lead. This occurs within 72 hours of any apparent self-inflicted death taking place and as a result requires all pertinent information, including CCTV footage and cell bell records, to be made available and reviewed.” Source location 2021-0256-Response-from-HMPPS_Published
Open published response
14 Aug 2020 Brenda Elmer · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 1
Failure of private laboratories to retain Listeria isolates 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
Brenda Elmer · 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
Brenda Elmer acquired a Listeria infection after consuming a contaminated sandwich while attending St Richard’s Hospital and died on 17 July 2019 after becoming seriously ill. Concerns included inadequate communication with patients who had left the area during the outbreak, which delayed recognition and appropriate treatment, and the absence of requirements for laboratories and hospital trusts to retain or share Listeria isolates, hindering the identification of connected outbreaks.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of private laboratories to retain Listeria isolates
Wider context from the report “1. During the course of the Inquest evidence was given by the representative of Public Health England that there was no legal requirement for Private Laboratories who identify Listeria in food to share the Listeria isolate with PHE or indeed keep this isolate for any period of time . If a problem is subsequently identified by PHE then it makes it particularly difficult to check if particular products have been implicated.
2. Similarly there is no legal requirement of Hospital Trusts to send in Listeria isolates when Listeria has been identified. This therefore does not allow PHE to match particular strains and identify outbreaks which are connected earlier.
3. In both these circumstances this leads to missed opportunities to deal with any outbreak.
” Source location Brenda Elmer · Prevention of Future Deaths report
Open source report
×
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 PHE has no legislative power to implement actions in NHS organisations or impose food safety measures.
Verbatim wording from the response “PHE is an executive agency and is not directly involved with patient care. The role of PHE is to provide guidance on the implementations to be taken, based on best scientific practices in order to retain good health and prevent deaths. PHE has a mandate to investigate an incident but has no legislative power to implement action on NHS or to implement food safety measures. The latter of which is an FSA mandate.” Source location 2020-0159-Response-from-Public-Health-England_Redacted.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Food Standards Agency is responsible for implementing food safety measures.
Verbatim wording from the response “PHE is an executive agency and is not directly involved with patient care. The role of PHE is to provide guidance on the implementations to be taken, based on best scientific practices in order to retain good health and prevent deaths. PHE has a mandate to investigate an incident but has no legislative power to implement action on NHS or to implement food safety measures. The latter of which is an FSA mandate.” Source location 2020-0159-Response-from-Public-Health-England_Redacted.pdf
Open published response
19 Nov 2019 Katie Croft · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Delays in seizing key digital evidence View source
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Katie Croft · 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
Katie Croft was a vulnerable child who had reported abuse and later disclosed thoughts of self-harm. She was found suspended from a ligature at home, sustained catastrophic brain damage, and died in hospital on 15 January 2019. Concerns included shortcomings in the police and social-care responses, failures to fully hear Katie’s voice and share relevant information, and uncertainty about guidance for schools teaching material involving suicide to vulnerable pupils.
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 Delays in seizing key digital evidence
Wider context from the report “1. The inquest was told that GMP followed their own guidance which accorded with that of the College of Policing into the level of expertise of the officer allocated to investigate Katie’s allegations. As a result of this the case was not dealt with by an experienced Public Protection or specialist sexual offences trained officer. It was allocated to a probationary police constable with approximately 6 months experience. The officer did not seize the phone which contained key social media contents until her third visit on the initial evening the offence was disclosed . The allocated officer was not experienced in joint working with social services or familiar with the concept of the voice of the child and what it would mean in such a case. At the time the decision was made by police to NFA matters there was no discussion about whether there could be a victimless prosecution; it was not established if the initial account was recorded on body worn footage or the extent of the social media contact by the suspect and the nature of any offences that could be revealed by those messages. No attempt was made to have a further face to face conversation with Katie;
” Source location Katie Croft · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.