20 Aug 2025 Masood Hamid · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Lack of coordinated planning for least-distressing patient transport 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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Masood Hamid · 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
Masood Hamid, who had dementia and multiple physical health conditions, died on 24 December 2024 shortly after being transferred under restraint from Shawside Care Home to hospital. The report identified concerns about inadequate planning for the transfer, ineffective communication between GMP and NWAS that delayed assistance, and an ineffective investigation into his death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of coordinated planning for least-distressing patient transport
Wider context from the report “1. There was a lack of planning or consideration between all those involved in his care as to the best time and the least distressing way in which Mr Hamid could be transported to the hospital . This in full knowledge that any move would likely cause distress to a patient with dementia and physical health issues.
” Source location Masood Hamid · Prevention of Future Deaths report
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How this respondent action was interpreted
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PFD Monitor interpretation Deliver the developed mental-health protocol briefing to all frontline officers force-wide.
Verbatim wording from the response “• Training for District Officers: A briefing item has been developed by GMP’s Prevention Branch for all frontline officers. This includes guidance on the Northwest Regional Mental Health Capacity Act Joint Protocol 2023, specifically regarding police support to NWAS in restraining or transporting patients lacking capacity and requiring emergency treatment. This will be delivered force wide imminently.” Source location Response from Greater Manchester Police
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How this respondent action was interpreted
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PFD Monitor interpretation Ensure patient-specific conveyance information is shared through patient-flow and bed-management processes.
Verbatim wording from the response “be shared more easily, as part of the regular bed management meetings, which are held every day, at three different intervals. As you know, the responsibility for conveyance when a bed is identified lies with the Local Authority, so the Trust cannot always influence decision making within this area. We will, however, ensure information sharing does take place to assist decision making which is patient centred and considerate of known needs or requirements.” Source location Response Pennine Care NHS Foundation Trust
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PFD Monitor interpretation Request Oldham Local Authority to review its AMHP referral form to include useful conveyance information.
Verbatim wording from the response “Our Head of Quality has also met with colleagues from Oldham Local Authority to discuss this further. She requested that the Local Authority team review their AMHP referral form so that additional useful information, particularly around conveyance, is included on the document for their consideration. Again, we are not able to enforce this, but it is hoped that this recommendation is recognised as a positive step to ensure the patient and their needs are at the centre of this process.” Source location Response Pennine Care NHS Foundation Trust
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How this respondent position was interpreted
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PFD Monitor interpretation The conveyance was appropriately planned, with patient welfare and distress considered when requesting hospital transport.
Verbatim wording from the response “• Mr Hamid’s conveyance was appropriately planned, and patient welfare was appropriately considered by the AMHP, including giving due consideration that there had been a significant delay of 5 days in admission due to bed availability. It was, therefore not considered appropriate to leave the patient in the setting unnecessarily any longer, due to the level of reported distress, and potential risk to staff and other residents.” Source location Response from Oldham Council
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PFD Monitor interpretation The Council has no influence or control over the ambulance service’s operational capacity or transport timing.
Verbatim wording from the response “• With regard to the timing of the patient transport, Oldham Council has no influence or control over the operational capacity of Northwest Ambulance Service. Patient transportation must occur at the earliest possible opportunity that suitable patient transport resource is available.” Source location Response from Oldham Council
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How this respondent position was interpreted
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PFD Monitor interpretation Existing daily bed management meetings provide established mechanisms for sharing patient information to support patient-centred conveyance decisions.
Verbatim wording from the response “The member of staff reflected on this and identified that he did not share this information directly with the Approved Mental Health Professional (AMHP) Service. They felt that in future, they would endeavour to ensure this type of personal information was shared. From a system perspective, there are robust mechanisms in place surrounding patient flow in which information like this can” Source location Response Pennine Care NHS Foundation Trust
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How this respondent position was interpreted
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PFD Monitor interpretation The Local Authority is responsible for arranging patient conveyance when a hospital bed is identified, limiting the Trust’s influence over decisions.
Verbatim wording from the response “be shared more easily, as part of the regular bed management meetings, which are held every day, at three different intervals. As you know, the responsibility for conveyance when a bed is identified lies with the Local Authority, so the Trust cannot always influence decision making within this area. We will, however, ensure information sharing does take place to assist decision making which is patient centred and considerate of known needs or requirements.” Source location Response Pennine Care NHS Foundation Trust
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How this respondent position was interpreted
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PFD Monitor interpretation The Trust cannot enforce changes to the Local Authority’s AMHP referral form, including adding information about conveyance.
Verbatim wording from the response “Our Head of Quality has also met with colleagues from Oldham Local Authority to discuss this further. She requested that the Local Authority team review their AMHP referral form so that additional useful information, particularly around conveyance, is included on the document for their consideration. Again, we are not able to enforce this, but it is hoped that this recommendation is recognised as a positive step to ensure the patient and their needs are at the centre of this process.” Source location Response Pennine Care NHS Foundation Trust
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PFD Monitor interpretation Including additional patient information would not have changed the transfer decision because the patient presented a serious risk to others.
Verbatim wording from the response “Following review and discussion with Oldham Local Authority, it is not believed that the inclusion of this information would have changed the decision made to transfer Mr Hamid from the care home to hospital. This was because Mr Hamid was detained under Section 2 of the Mental Health Act as he presented as a risk to other people, including residents and colleagues within the care home. Mr Hamid had presented as a risk that day to others and it was only later in the day that he had appeared to have calmed with the use of PRN medications.” Source location Response Pennine Care NHS Foundation Trust
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28 Oct 2024 Susan Patricia SHIPLEY · Prevention of Future Deaths report North Yorkshire and York
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Concerns raised 3
Failure to undertake subsequent ‘fit to sit’ reassessments before onward ambulance transport View source Failure to document initial ‘fit to sit’ assessments View source Failure to make appropriate ‘fit to sit’ determinations for patients unable to weight bear 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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Each statement is shown once, even when linked to more than one concern.
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Susan Patricia SHIPLEY · Prevention of Future Deaths report
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Report summary
Susan Patricia Shipley, who had critical limb ischaemia and previous amputations, fell from a hospital wheelchair while being transferred between hospitals on 28 January 2024 and fractured her right neck of femur. She underwent further amputations, developed pneumonia, and died in hospital on 4 February 2024. The principal concerns were the lack of documented and appropriate “fit to sit” assessments, the decision to transport her in a wheelchair despite her inability to weight bear, and the potential risk of death to others if similar issues recur.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to undertake subsequent ‘fit to sit’ reassessments before onward ambulance transport
Wider context from the report “1. I heard evidence that Yorkshire Ambulance Service (YAS) use ‘fit to sit’ assessments of patients attending Emergency Departments (ED) by ambulance, to determine whether they are fit to sit and wait to be assessed by hospital staff, or need to remain on an ambulance stretcher. ‘Fit to sit’ is thus an important part of YAS’s attempts to reduce handover times for ambulances at acute hospitals. I heard evidence from an ED clinician and a senior YAS paramedic that ‘fit to sit’ assessments should involve a senior practitioner in the ED (such as an ACP or Registrar) going into the waiting ambulance to take a brief history from the patient and undertake a brief physical examination to assess the patient’s ability to sit and wait in a chair for what is likely to be a considerable period of time. This assessment should be recorded and should involve discussion with the Hospital Ambulance Liaison Officer (HALO) deployed by YAS.
2. Mrs Shipley was a right below knee amputee with an ischaemic/gangrenous left foot and a wheelchair user who was unable to weight bear. Despite this, she was deemed ‘fit to sit’, and transported to another hospital, in a hospital issue wheelchair. There was no documentary evidence of any assessment of her fitness to sit made by the paramedics concerned, nor the ACP and HALO who were said to have been involved in it. I found from the evidence of a senior YAS paramedic that any assessment appropriately undertaken could not have concluded that Mrs Shipley was ‘fit to sit’. I found that attempting to transport Mrs Shipley in the hospital wheelchair was inappropriate and resulted in her falling from it and sustaining a fractured neck of femur which contributed to her death.
3. My concerns relate to –
a) The absence of any documentary evidence that an initial ‘fit to sit’ assessment was undertaken involving the parties mentioned above;
b) The decision that Mrs Shipley was ‘fit to sit’ despite being an amputee and unable to weight bear;
c) The absence of any subsequent ‘fit to sit’ assessment being undertaken by the second ambulance crew transporting Mrs Shipley to York, because of an assumption of fitness to sit, and the role of the HALO in this assumption;
d) The absence of evidence that all relevant learning arising from the above has occurred and any actions arising from such learning have been completed, particularly in relation to the first paramedic crew and the HALO;
e) The potential risk of death to others in the event of a recurrence of any of the above.
” Source location Susan Patricia SHIPLEY · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to document initial ‘fit to sit’ assessments
Wider context from the report “1. I heard evidence that Yorkshire Ambulance Service (YAS) use ‘fit to sit’ assessments of patients attending Emergency Departments (ED) by ambulance, to determine whether they are fit to sit and wait to be assessed by hospital staff, or need to remain on an ambulance stretcher. ‘Fit to sit’ is thus an important part of YAS’s attempts to reduce handover times for ambulances at acute hospitals. I heard evidence from an ED clinician and a senior YAS paramedic that ‘fit to sit’ assessments should involve a senior practitioner in the ED (such as an ACP or Registrar) going into the waiting ambulance to take a brief history from the patient and undertake a brief physical examination to assess the patient’s ability to sit and wait in a chair for what is likely to be a considerable period of time. This assessment should be recorded and should involve discussion with the Hospital Ambulance Liaison Officer (HALO) deployed by YAS.
2. Mrs Shipley was a right below knee amputee with an ischaemic/gangrenous left foot and a wheelchair user who was unable to weight bear. Despite this, she was deemed ‘fit to sit’, and transported to another hospital, in a hospital issue wheelchair. There was no documentary evidence of any assessment of her fitness to sit made by the paramedics concerned, nor the ACP and HALO who were said to have been involved in it. I found from the evidence of a senior YAS paramedic that any assessment appropriately undertaken could not have concluded that Mrs Shipley was ‘fit to sit’. I found that attempting to transport Mrs Shipley in the hospital wheelchair was inappropriate and resulted in her falling from it and sustaining a fractured neck of femur which contributed to her death.
3. My concerns relate to –
a) The absence of any documentary evidence that an initial ‘fit to sit’ assessment was undertaken involving the parties mentioned above;
b) The decision that Mrs Shipley was ‘fit to sit’ despite being an amputee and unable to weight bear;
c) The absence of any subsequent ‘fit to sit’ assessment being undertaken by the second ambulance crew transporting Mrs Shipley to York, because of an assumption of fitness to sit, and the role of the HALO in this assumption;
d) The absence of evidence that all relevant learning arising from the above has occurred and any actions arising from such learning have been completed, particularly in relation to the first paramedic crew and the HALO;
e) The potential risk of death to others in the event of a recurrence of any of the above.
” Source location Susan Patricia SHIPLEY · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to make appropriate ‘fit to sit’ determinations for patients unable to weight bear
Wider context from the report “1. I heard evidence that Yorkshire Ambulance Service (YAS) use ‘fit to sit’ assessments of patients attending Emergency Departments (ED) by ambulance, to determine whether they are fit to sit and wait to be assessed by hospital staff, or need to remain on an ambulance stretcher. ‘Fit to sit’ is thus an important part of YAS’s attempts to reduce handover times for ambulances at acute hospitals. I heard evidence from an ED clinician and a senior YAS paramedic that ‘fit to sit’ assessments should involve a senior practitioner in the ED (such as an ACP or Registrar) going into the waiting ambulance to take a brief history from the patient and undertake a brief physical examination to assess the patient’s ability to sit and wait in a chair for what is likely to be a considerable period of time. This assessment should be recorded and should involve discussion with the Hospital Ambulance Liaison Officer (HALO) deployed by YAS.
2. Mrs Shipley was a right below knee amputee with an ischaemic/gangrenous left foot and a wheelchair user who was unable to weight bear. Despite this, she was deemed ‘fit to sit’, and transported to another hospital, in a hospital issue wheelchair. There was no documentary evidence of any assessment of her fitness to sit made by the paramedics concerned, nor the ACP and HALO who were said to have been involved in it. I found from the evidence of a senior YAS paramedic that any assessment appropriately undertaken could not have concluded that Mrs Shipley was ‘fit to sit’. I found that attempting to transport Mrs Shipley in the hospital wheelchair was inappropriate and resulted in her falling from it and sustaining a fractured neck of femur which contributed to her death.
3. My concerns relate to –
a) The absence of any documentary evidence that an initial ‘fit to sit’ assessment was undertaken involving the parties mentioned above;
b) The decision that Mrs Shipley was ‘fit to sit’ despite being an amputee and unable to weight bear;
c) The absence of any subsequent ‘fit to sit’ assessment being undertaken by the second ambulance crew transporting Mrs Shipley to York, because of an assumption of fitness to sit, and the role of the HALO in this assumption;
d) The absence of evidence that all relevant learning arising from the above has occurred and any actions arising from such learning have been completed, particularly in relation to the first paramedic crew and the HALO;
e) The potential risk of death to others in the event of a recurrence of any of the above.
” Source location Susan Patricia SHIPLEY · 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 Draft and progress a dedicated fit-to-sit policy through internal review and final clinical governance approval.
Verbatim wording from the response “YAS recognises that the current guidance can be confusing, with the terms ‘fit to sit’ and ‘self-handover’ being used interchangeably between organisation when in fact these are not the same. As such, YAS is currently drafting a ‘fit to sit’ policy, specifically designed to support clinicians in this decision making that links to the existing self-handover process. It will go through internal review at YAS’s Clinical Quality Development Forum before being finally approved for use at YAS’s Clinical Governance Group. It therefore may be subject to amendments dependent on feedback from these groups hence it not being included within this letter. Once formally agreed it will be disseminated across the organisation for use by all clinical staff.” Source location Response from Yorkshire Ambulance Service
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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 Disseminate the approved fit-to-sit policy across YAS for use by all clinical staff.
Verbatim wording from the response “YAS recognises that the current guidance can be confusing, with the terms ‘fit to sit’ and ‘self-handover’ being used interchangeably between organisation when in fact these are not the same. As such, YAS is currently drafting a ‘fit to sit’ policy, specifically designed to support clinicians in this decision making that links to the existing self-handover process. It will go through internal review at YAS’s Clinical Quality Development Forum before being finally approved for use at YAS’s Clinical Governance Group. It therefore may be subject to amendments dependent on feedback from these groups hence it not being included within this letter. Once formally agreed it will be disseminated across the organisation for use by all clinical staff.” Source location Response from Yorkshire Ambulance Service
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a Patient Safety Incident Investigation into the moving-and-handling care, including fit-to-sit decisions, handover, diversion, HALO involvement and specialist-hospital transport.
Verbatim wording from the response “Following the conclusion of your inquest, the complexities and potential for learning was discussed at YAS’s Patient Safety Learning Group which is chaired by the Executive Medical Director. From this the commissioning of a full investigation into the care of Mrs Shipley. A Patient Safety Incident Investigation, under the theme of “Moving and Handling” has been initiated, which focuses on identifying learning responses to improve our service to patients. The family of Mrs Shipley have been contacted by letter to ask if they wish to participate in this investigation.” Source location Response from Yorkshire Ambulance Service
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1 Aug 2024 Kieran Lavin · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Insufficiently specific guidance for informal patient transport risk assessments View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Kieran Lavin · Prevention of Future Deaths report
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Report summary
Kieran Lavin, who had experienced worsening depression and suicidal thoughts, died after leaving a mental health unit with his wife for transport to another facility. Shortly afterwards, on the M5 motorway, he exited the vehicle and was struck by vehicles. The principal concerns were that critical suicide-risk information was not recorded or recorded promptly, and that the transport risk assessment and guidance for family transport were inadequate.
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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 Insufficiently specific guidance for informal patient transport risk assessments
Wider context from the report “2. Post-death trust learning led to new guidance for when an informal patient requests family, carer, or friend transport them from PDU. For ease of reference it states:
“Where appropriate, it is reasonable for the option of an informal patient to be transported by family/carer/friends. In all such cases, decision needs to be based on the risk/benefit ratio and this also needs to be clearly discussed with the person transporting to make sure there is understanding and agreement. This needs to be clearly documented within the patient’s notes. If there is any concern or disagreement expressed by the person, family/carer/friends, then alternative arrangements need to be made by us.”
I am not persuaded this is sufficient to remove the risk of an inadequate risk assessment in the future. By way of contrast, trust guidance C52 ‘Mental Health Act Transport of Patients’ - which applies when a patient has been assessed under the Act and ambulance service transport is to be used - at paragraph 12 includes 15 specific questions that the risk assessor should ask as part of the transport risk formulation, including: How far does the patient have to travel? What is the patients age and gender? What is their current state of mind? Is there a risk to the driver/accompanying individuals? The updated guidance cited above is absent any equivalent specific questions or assistance on when it is or is not appropriate. For example, in Kieran’s case clinicians were aware his sex, age, and background of relationship breakdown statistically recognised him as being at a higher risk of suicide, PDU is only intended for a brief stay whereas Kieran was there for nearly 48 hours and his state of mind was not assessed in the hours before the risk formulation (even thought it was known to fluctuate), the journey if considered would have been noted to take him away from local roads onto a high speed motorway, and his wife/the driver was known to be a trigger for his low mood. Further, there was no consideration of what his wife had to be told to ensure she was safe, providing genuine informed consent given the interplay of patient confidentiality. In Kieran’s case the transport risk formulation did not consider whether his risk of suicide included road traffic collision as an unrelated mechanism. My concern is the above cited guidance in simply stating the decision should be based on ‘appropriateness’ and ‘the risk/benefit ratio’ does not sufficiently prompt clinicians to consider the full range of key issues and is inconsistent with the more expansive guidance in C52 for when an ambulance is to be used.
For completeness, (1) there was discussion during the inquest about why there cannot be a blanket ban on informal patients with recent suicidal ideation via road traffic collision being transported by family etc given they represent a very small cohort of patients. If no such ban is considered appropriate, in my view, the need for more expansive and specific guidance for clinicians equivalent to C52 is increased, and (2) there was discussion at the inquest of a transport risk formulation based on a points system with a written draft suggestion from the Family’s counsel; I attach a copy which may be of assistance for the trust when deciding what if any action to take.
” Source location Kieran Lavin · 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 Update the Transport Policy to require open, thorough discussions with family members, friends or carers before agreeing patient transport by them.
Verbatim wording from the response “As already conveyed to you, we have updated our Transport Policy to emphasise that an open and thorough discussion needs to be had with any family member/friend/carer prior to agreeing the transport of the patient by them. The option for patients to be transferred in this manner will remain, as that upholds the dignity and autonomy of the patient, and is in the spirit” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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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 Scoring the proposed transport-risk checklist cannot be undertaken because it would be arbitrary, unsupported by evidence, and could omit relevant risks.
Verbatim wording from the response “I would like to begin by thanking the family for their suggested checklist for this risk assessment. We are grateful for this offer. The factors identified in the checklist submitted by the family barrister includes risk factors that would and should be considered in a risk assessment and management conversation. However, it would not be possible to score these as this would be an arbitrary process, with no grounding in research or evidence based clinical practice. Given the areas of risk that need to be considered, having such a prescriptive list could potentially result in staff members omitting to review key areas of risk that may not be indicated on the list, thereby inadvertently replacing comprehensive clinical risk assessment and management processes, which would have serious negative impact on the quality and safety of patient assessment and management.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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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 Family-member transport will remain available where appropriate because retaining patient dignity, autonomy, choice and least restrictive practice is considered necessary.
Verbatim wording from the response “As already conveyed to you, we have updated our Transport Policy to emphasise that an open and thorough discussion needs to be had with any family member/friend/carer prior to agreeing the transport of the patient by them. The option for patients to be transferred in this manner will remain, as that upholds the dignity and autonomy of the patient, and is in the spirit” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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27 Apr 2022 Raphael Jeffery Gill · Prevention of Future Deaths report South London
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Concerns raised 1
Failure to ensure a suitably qualified clinician is available to provide emergency treatment during transport View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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Raphael Jeffery Gill · 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
Raphael Jeffery Gill was stopped by police, arrested for drug-related offences, and suffered multiple seizures, including seizures in police care and an ambulance. The inquest identified delays in ambulance response and hospital assessment, failure to recognise the combination of seizures and cocaine as a medical emergency, and omission or delay in carrying out a venous blood gas test. The medical cause of death was recorded as multiple seizures associated with an underlying seizure disorder, cocaine and prescribed medication.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure a suitably qualified clinician is available to provide emergency treatment during transport
Wider context from the report “(1) The evidence of the medical expert was that Mr Gill was so unwell by the time he arrived at hospital that it was more likely than not that his life was not rescuable with sooner treatment. Whilst Mr Gill was taken to hospital, it was not under blue lights and sirens, and the most senior clinician drove so was not on hand to provide emergency treatment that the technician was unqualified to provide . It was apparent that the ambulance crew were not aware that the combination of seizures and cocaine represented a medical emergency, a fact expressly found in the jury’s conclusion.
(2) Whilst it was reasonable for the LAS staff to suspect a link between the arrest and seizures, the arrest unduly influenced the assessment of urgency.
” Source location Raphael Jeffery Gill · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review existing primacy-of-care guidance and improve its accessibility with examples of when paramedics should attend patients directly.
Verbatim wording from the response “The LAS recognises that the paramedic drove the ambulance to the hospital while her clinically more junior, non-registered colleague remained in the back of the ambulance attending to Mr Gill. On balance, despite Mr Gill being fully conscious, there was a history of abnormal muscle rigidity and possible seizure activity. As such, we would be of the view that the paramedic should have attended to Mr Gill in the rear of the ambulance as they would have been immediately available in the case of deterioration. As you would be aware from the documentation provided to you at the close of the inquest, the LAS has a number of guidance notices and policies around the primacy of care. In addition, there is helpful documentation from the professional regulator on this subject.” Source location Response from London Ambulance Service
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30 Sep 2021 Robert Walaszkowski · Prevention of Future Deaths report East London
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Concerns raised 2
Failure to reconsider vehicle appropriateness for patients unable to walk, sit unaided or hold their heads upright View source Failure to secure patients safely in the transport vehicle View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Robert Walaszkowski · 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
Robert Walaszkowski, a detained mental health patient, sustained head and cervical spine injuries after likely colliding with a locked door and later died from catastrophic cervical spine, vertebral artery and hypoxic brain injuries on 15 November 2019. Concerns included excessive lorazepam dosing, failure to perform a cervical spine CT scan and full medical assessment before discharge, and his transfer in an unsuitable vehicle without support or restraints while in very poor physical condition. The inquest heard that placing detained mental health patients on the floor of secure vans appeared to be an accepted practice, and the jury concluded that his death was contributed to by neglect.
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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 reconsider vehicle appropriateness for patients unable to walk, sit unaided or hold their heads upright
Wider context from the report “It is of concern that:
(i) There was no review by Patient Transport UK Ltd into the service provided to Robert in the early hours of 20 October 2019.
(ii) The apparently trained transport staff did not re-consider the appropriateness of the vehicle when they observed Robert’s very low level of consciousness and his inability to walk; sit unaided and hold his head upright.
(iii) The staff placed Robert, in this concerning condition, on the floor of the vehicle without any seat belt or other mechanism to keep him safe and secure.
(iv) Placing mental health patients on the floor of the caged area, seems to be an accepted practice by Patient Transport UK Ltd.
” Source location Robert Walaszkowski · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to secure patients safely in the transport vehicle
Wider context from the report “It is of concern that:
(i) There was no review by Patient Transport UK Ltd into the service provided to Robert in the early hours of 20 October 2019.
(ii) The apparently trained transport staff did not re-consider the appropriateness of the vehicle when they observed Robert’s very low level of consciousness and his inability to walk; sit unaided and hold his head upright.
(iii) The staff placed Robert, in this concerning condition, on the floor of the vehicle without any seat belt or other mechanism to keep him safe and secure.
(iv) Placing mental health patients on the floor of the caged area, seems to be an accepted practice by Patient Transport UK Ltd.
” Source location Robert Walaszkowski · Prevention of Future Deaths report
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11 Aug 2020 Moses Victor Boardman · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure of transport staff to properly assess venue suitability View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Moses Victor Boardman · 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
Moses Victor Boardman, an elderly and frail man, was mistakenly discharged to his home instead of sheltered accommodation, where he was found without heating, light or food and subsequently readmitted to hospital after a further cerebrovascular accident. While assessed as being at risk of aspiration and requiring supervised feeding, he was later found eating a whole fruit unsupervised, suffered a choking incident, and died at 04.48. The substantive concerns included discharge and transport safeguards, failure to escalate missed care visits, monitoring of patients fed at risk, and the response to a potential reversible cause of collapse when a DNACPR order was in place.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of transport staff to properly assess venue suitability
Wider context from the report “3. The failure of RLH transport staff to properly assess the suitability of the venue that a patient is being taken to.
” Source location Moses Victor Boardman · Prevention of Future Deaths report
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Concerns raised 1
Failure to manage an identified risk during patient transport View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Tracey Lynch · 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
Tracey Lynch, who had emotionally unstable personality disorder, died by suicide after hanging herself in her room at Oswald House on 9 October 2015. The report identified concerns about the lack of a final discharge meeting, familiarisation visits and appropriate escorted transport, and about the absence of adequate assessments and care planning after her presentation changed and she was transferred between services.
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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 manage an identified risk during patient transport
Wider context from the report “3. The evidence was that ████████ the mother of Tracey Lynch, had alerted the care co-ordinator and the responsible clinician with her concerns that her daughter’s state of mind was such that unless she was properly and appropriately escorted in the transport from The Harbour to Oswald House that she would attempt to jump from the motor vehicle. Those concerns were not addressed such that on the 28th September when only escorted by the occupational therapist who was driving the vehicle Miss Lynch was able to grab the steering wheel and cause a serious accident on the M55 motorway. Despite the fact that this risk had previously been identified there was no attempt to seek to manage that in an appropriate way .
” Source location Tracey Lynch · Prevention of Future Deaths report
Open source report
29 Apr 2014 Joanne Elizabeth Oliver · Prevention of Future Deaths report Manchester City
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Concerns raised 1
Lack of an appropriate written risk-assessment framework for transferring critically ill patients View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Joanne Elizabeth Oliver · 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
Joanne Elizabeth Oliver, aged 31, was transferred by air ambulance after treatment for H1N1 influenza and ECMO, but her condition deteriorated after arrival at Manchester Royal Infirmary. She developed severe metabolic acidosis with high carbon dioxide and potassium levels, suffered cardiac arrest, and died. The report identified an unacceptable delay in obtaining blood gas analysis and monitoring, and raised concerns about the lack of detailed guidance and risk assessment for transferring critically ill patients.
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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 an appropriate written risk-assessment framework for transferring critically ill patients
Wider context from the report “(1) Evidence was given that there is no detailed guidance from the Department of Health or the Intensive Care Society to assist in the decision to transfer a critically ill patient. Some guidance is given in a document “Guidelines for the transport of the critically ill adult (2011)” but that is focused on the actual transfer of the patient and not the decision whether to transfer or not, or when this should take place.
(2) It would be of assistance to doctors making the decision to transfer, and would help them to justify the transfer if it was later questioned, if Guidelines could be given to assist in the preparation of a written risk assessment . The evidence was that the “MEWS Score system”, now the “NEW Score system” was never designed with critically ill patients in mind .
(3) Any risk assessment would need to consider:
(a) The multitude of background clinical factors that indicate whether the patient was fit to travel
(b) The practical tests that should be undertaken to confirm fitness for transfer eg trial of transport ventilator, assessment of biochemical stability when renal replacement therapy is withheld
(c) The seniority of the doctors who make that decision, and the numbers of doctors to be involved
(d) Whether it is in the best interest of the patient to make the transfer
(e) The pressures for beds where there is, as in this case, an epidemic forcing doctors to make difficult decisions on the priority of patients.
(f) The danger that a patient is moved out to allow another one in when the first patient is not fully in a state to be moved.
(g) The risk that the doctor responsible for supervising and travelling with the patient may be pressured into agreeing to the transfer
(h) The distance and time of the journey
(i) The risks of deterioration during that journey time
(j) Whether there are risks that the journey time will be extended
(k) Whether it is by road or air, and any factors that arise from the mode of transport
(l) The equipment and medication available during the transfer
(m) The medical staff to accompany the patient and their skills in transferring patients
(n) The actions to be taken by the transferring or receiving doctors on receipt of the patient to confirm their stability after transfer, and the timeframe within which this should be undertaken
(o) The information that should be given to patients or their next of kin prior to transfer such that they too are aware of the rationale for transfer and the intrinsic risks
(p) The standards of documentation for the decision-making in these circumstances and in the above domains
(q) Audit of outcomes of patient transfers (acknowledging that outcomes will not necessarily be collated for those patients deemed unsuitable for transfer for whatever reason)
” Source location Joanne Elizabeth Oliver · Prevention of Future Deaths report
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Includes failures in patient-transport risk assessment and management, including transport-specific guidance, consideration of patient condition and fluctuating risk, assessment of the transporter's safety, suitability of the proposed transport arrangement, management of previously identified risks, and protective or alternative arrangements when transport is unsafe.
