29 Feb 2024 Kenneth Stanley Baylis · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Inadequate review following a serious suicide attempt or death View source
This report raised 5 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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Kenneth Stanley Baylis · 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
Kenneth Stanley Baylis took his own life on 23 January 2023 while on unescorted leave as an informal inpatient on Kingsley Ward. The report identified concerns including inadequate suicide risk assessment and mitigation, insufficient family involvement, failure to follow planned-leave procedures, and inadequate review and investigation after serious suicide attempts or a 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 Inadequate review following a serious suicide attempt or death
Wider context from the report “4. Inadequate review and incident investigation following a serious suicide attempt or a death
” Source location Kenneth Stanley Baylis · 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 IR1 incidents through assigned IR2 managers, monthly completion reports, and supervision-based learning.
Verbatim wording from the response “MHSOP have regular Time Out sessions with teams and in the session on the 22nd of March 2024 had a dedicated agenda item which covered learning and reflections from this quality improvement plan which included the learning about IR1s. Senior managers do regularly receive IR1s from all teams within MHSOP including ward and community teams. Following completion of an IR1 a manager is identified to complete an IR2 which reviews the incident and any learning that is identified from it. Senior managers receive monthly reports which indicate if the IR2s have been completed and ensure none have been missed and addition learning from incidents is included within management and clinical supervision which occurs monthly for each member of staff.” Source location Response from Nottinghamshire Healthcare NHS Foundation Trust
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How this respondent action was interpreted
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PFD Monitor interpretation Conduct serious-incident discussions and thematic reviews through MHSOP safety, risk, quality-assurance and improvement forums.
Verbatim wording from the response “Detailed discussion of serious incidents within the care unit is held in the MHSOP Health, Safety and Risk meeting and thematic review of serious incidents is completed via the MHSOP Quality Assurance and Improvement forum. These forums facilitate discussion and review across services and are Chaired by the Care Unit senior management team. The MHSOP care unit has a Learning the lessons bulletin which is shared across all services and teams to disseminate learning from serious incidents – this bulletin is featured on the agenda for the MHSOP Quality Operational Group and is disseminated across all service and team meetings to encourage active reporting and learning from incidents.” Source location Response from Nottinghamshire Healthcare NHS Foundation Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate learning from serious incidents through the MHSOP Learning the Lessons bulletin and service and team meetings.
Verbatim wording from the response “Detailed discussion of serious incidents within the care unit is held in the MHSOP Health, Safety and Risk meeting and thematic review of serious incidents is completed via the MHSOP Quality Assurance and Improvement forum. These forums facilitate discussion and review across services and are Chaired by the Care Unit senior management team. The MHSOP care unit has a Learning the lessons bulletin which is shared across all services and teams to disseminate learning from serious incidents – this bulletin is featured on the agenda for the MHSOP Quality Operational Group and is disseminated across all service and team meetings to encourage active reporting and learning from incidents.” Source location Response from Nottinghamshire Healthcare NHS Foundation Trust
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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 Require investigators to address staff interviews through standard allocation emails and clinical-governance oversight.
Verbatim wording from the response “To ensure that Serious Incident Investigators understand the requirement for staff interviews as part of the investigation each investigator is emailed when the investigation is allocated to ensure they are informed of this requirement, this is included in a standard email template to ensure consistent communication. The MHSOP Clinical Governance team maintain contact and act as a point of reference for the investigation panel and will oversee this as a consistent practice. Upon completion and approval of the Serious Incident investigation the final report is shared with the relevant service and team/ward manager so that they can discuss in detail with their team. The support in sharing lessons learnt is tailored dependent on the incident and could include reflective discussions to team time out sessions to ensure the correct level of learning is undertaken. The MHSOP Clinical” Source location Response from Nottinghamshire Healthcare NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share approved investigation reports with relevant teams and witnesses and support incident-specific learning reflections.
Verbatim wording from the response “To ensure that Serious Incident Investigators understand the requirement for staff interviews as part of the investigation each investigator is emailed when the investigation is allocated to ensure they are informed of this requirement, this is included in a standard email template to ensure consistent communication. The MHSOP Clinical Governance team maintain contact and act as a point of reference for the investigation panel and will oversee this as a consistent practice. Upon completion and approval of the Serious Incident investigation the final report is shared with the relevant service and team/ward manager so that they can discuss in detail with their team. The support in sharing lessons learnt is tailored dependent on the incident and could include reflective discussions to team time out sessions to ensure the correct level of learning is undertaken. The MHSOP Clinical” Source location Response from Nottinghamshire Healthcare NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a standardised ward and community meeting governance template incorporating incident data and learning discussions across MHSOP wards.
Verbatim wording from the response “The Mental Health Care Group, of which MHSOP is part of, is introducing a new governance structure which includes a standardised template for ward and community meetings and within this data on incidents will be included and discussions take place within the team to reflect on the incidents to ascertain whether there is any learning and improvement required. This is currently being piloted within the Care Group and is due to go live across all MHSOP wards during June 2024.” Source location Response from Nottinghamshire Healthcare NHS Foundation Trust
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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 Complete the PSIRF policy and local patient-safety incident response plan following stakeholder consultation.
Verbatim wording from the response “To date the trust has completed the PSIRF policy and PSIRP (patient safety incident response plan), which sets out the local priorities for the next year. As part of the development of the PSIRP the trust met and consulted with a number of stakeholders; commissioners, service users, clinical staff and services and continue to do so.” Source location Response from Nottinghamshire Healthcare NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement PSIRF across the Trust by August 2024.
Verbatim wording from the response “The Trust is in the process of moving towards the Patient Safety Incident Response Framework. (PSIRF) It represents a significant shift in the way the NHS responds to patient safety incidents and is a major step towards establishing a safety management system across the NHS and is also a key part of the NHS patient safety strategy. This new framework replaces the SI Framework and makes no distinction between ‘patient safety incidents’ and ‘Serious Incidents’ and so it removes the SI classification and the threshold for it.” Source location Response from Nottinghamshire Healthcare NHS Foundation Trust
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19 Feb 2024 Samuel Curless (Sam) · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Lack of institutional learning, reflection or training following reported-death call handling incidents 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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Each statement is shown once, even when linked to more than one concern.
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Samuel Curless (Sam) · 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
Samuel Curless died in hospital on 24 October 2022 after being found suspended from a ligature and receiving delayed life-support intervention. The concerns included failures to call an ambulance promptly, delays in checking vital signs and removing the ligature, and possible inadequacies in police training and refresher training for responding to hanging casualties.
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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 institutional learning, reflection or training following reported-death call handling incidents
Wider context from the report “1. That in respect of GMP Call Handler’s being required to call an ambulance to attend the scene, even where it is reported that someone is “dead” there has been no institutional learning following this incident . I asked ████████ if there had been any learning, reflection or training since this incident. He said that there hadn’t on this issue .
” Source location Samuel Curless (Sam) · 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 Audit similar incidents to assess call-handler compliance with ambulance-contact procedures.
Verbatim wording from the response “As a result of the issues identified in this case GMP commissioned an audit of 33 similar incidents. The purpose of the audit was to understand whether call handlers were following the correct processes and taking the required action when dealing with these types of incidents or whether the issue identified in this case was a symptom of a broader issue across the department. The result of the audit identified one case where the call handler hadn’t contacted the Northwest Ambulance Service (NWAS) or asked a colleague to assist in making a call to NWAS. The call handler in question has received individual feedback on the issue. The other 32 calls examined each resulted in call handlers either asking colleagues to call NWAS or the call handler calling NWAS themselves when the initial call had concluded.” Source location Response from Greater Manchester Police
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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 Reinforce call-handler requirements to call an ambulance through force-wide email and team briefing-site messages.
Verbatim wording from the response “While the result of the audit undertaken following the inquest doesn’t indicate a broader issue across the branch, the Force Contact, Crime and Operations Branch will further reinforce the requirements on call handlers to call an ambulance when faced with a scenario such as that which presented in the case of Mr Curless. This will be achieved by way of an email being sent to all call handlers and by including an item on each call handling team’s briefing site.” Source location Response from Greater Manchester Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The audit did not indicate a broader call-handling issue across the branch, although one individual failure was identified and feedback provided.
Verbatim wording from the response “As a result of the issues identified in this case GMP commissioned an audit of 33 similar incidents. The purpose of the audit was to understand whether call handlers were following the correct processes and taking the required action when dealing with these types of incidents or whether the issue identified in this case was a symptom of a broader issue across the department. The result of the audit identified one case where the call handler hadn’t contacted the Northwest Ambulance Service (NWAS) or asked a colleague to assist in making a call to NWAS. The call handler in question has received individual feedback on the issue. The other 32 calls examined each resulted in call handlers either asking colleagues to call NWAS or the call handler calling NWAS themselves when the initial call had concluded.” Source location Response from Greater Manchester Police
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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 There is nothing to suggest that online training created a broader force-wide issue, although learning from the inquest was disseminated.
Verbatim wording from the response “While the officers’ actions in this case have given rise to questions in relation to the adequacy of the training delivered via online methods there is nothing to suggest that this is a broader Force-wide issue. However, in line with normal practice, the learning arising from the inquest has been raised at the TOLB to ensure that learning is shared, and key messages are disseminated across the force.” Source location Response from Greater Manchester Police
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2 Feb 2024 Susan Wendy Bracegirdle · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to obtain input from key people involved in care during safeguarding reviews View source
This report raised 5 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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Susan Wendy Bracegirdle · 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
Susan Wendy Bracegirdle, who had limited mobility and lived in a care home, developed a stage 3 pressure ulcer that deteriorated and was associated with osteomyelitis and sepsis. She died in hospital on 9 February 2023 after treatment was unsuccessful. Concerns included inadequate information sharing and joint working between district nurses, care staff, the GP, the family and the Tissue Viability team, which increased the risk that deterioration would not be recognised or managed promptly.
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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 obtain input from key people involved in care during safeguarding reviews
Wider context from the report “4. There had been a safeguarding review undertaken. However key people involved in her care had not provided input to the review which meant there was no clear holistic assessment of what lessons could be learnt to reduce the risk of deaths from pressure ulcers in the future . It was unclear why such an approach had been taken
” Source location Susan Wendy Bracegirdle · 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 Complete the Safeguarding Adult Review, including a multi-agency practitioner learning event and production of the review report.
Verbatim wording from the response “I can confirm that following initial review of Ms Bracegirdle’s case it was confirmed that the circumstances of the case met the criteria for a Safeguarding Adult Review (SAR) as set out in Section 44 of The Care Act 2014.” Source location Response from Greater Manchester Integrated Care
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CQC previously had no remit over local authorities’ safeguarding reviews, although it now assesses local authorities’ safety duties.
Verbatim wording from the response “4. There had been a safeguarding review undertaken. However key people involved in her care had not provided input to the review which meant there was no clear holistic assessment of what lessons could be learnt to reduce the risk of deaths from pressure ulcers in the future. It was unclear why such an approach had been taken.” Source location Response from Care Quality Commission
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17 Jan 2024 Kane Christopher Boyce · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 2
Failure to implement learning from investigations following deaths in custody View source Lack of a culture of candour and staff reflection after deaths in custody View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Kane Christopher Boyce · Prevention of Future Deaths report
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Report summary
Kane Christopher Boyce, a serving prisoner at HMP Lowdham Grange, was found with a ligature around his neck on 3 October 2021 and could not be resuscitated. The jury found that alcohol intoxication and the failure of staff to share information, open an under-the-influence log, adequately monitor him, and consider risk when isolating cell power and ignoring cell bells contributed to his death. The report raised concerns about these practices, staff understanding of relevant policies, learning from deaths in custody, and organisational candour.
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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 implement learning from investigations following deaths in custody
Wider context from the report “5. A failure to implement learning from the investigations that follow deaths in custody
Many of the staff giving evidence explained that they had not read the PPO report, nor were they aware of the issues identified by the PPO prior to giving evidence at the inquest. I have seen no evidence of the systems in place at HMP Lowdham Grange to seek to learn from deaths in custody at the earliest opportunity .
” Source location Kane Christopher Boyce · 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 Lack of a culture of candour and staff reflection after deaths in custody
Wider context from the report “7. A Lack of Candour – both organisationally and individually
I would be very interested to understand how the duty of candour applies to the prison service and those individuals within the employ of the service (whether employed directly or through a private provider, as in this case).
There is a statutory duty of candour applicable to healthcare organisations and professionals, as well as a more recent agreement by the College of Policing for members to adhere to a Code of Candour.
In practise, candour creates a culture of being open and honest with all stakeholders by accepting when things go wrong, taking remedial steps as soon as practicable, and thus reducing the risk of events repeating themselves. In the context of a death, candour from the outset is essential in order to support the bereaved family.
The position adopted by Serco in this inquest, as it has in other inquests, could be said to represent the very opposite of candour. Having heard evidence supplied on oath by their own staff members that there were multiple failures to open an under the influence log (evidence which was not contested) the organisation nevertheless required the Jury to return a finding on this issue, and each and every issue, instead of a factual finding being presented to the jury as agreed by all Interested Persons.
The inquest is not an adversarial process, there is no burden of proof. The Interested Persons are under a duty to assist the investigative process in an open and honest manner. By identifying those issues that genuinely require determination by the jury, and those on which there is agreement. Sadly, in my extensive experience of conducting Article 2 inquests locally, this is not an isolated example of the uncomfortable position adopted by the prison service in failing to put forward sensible and reasonable factual admissions of shortcomings.
I am concerned by the apparent absence of a culture of candour supporting those staff who work within the prison service . Many of the staff members giving evidence explained that the inquest was the first time it had been suggested to them that they had not adhered to policy. In the intervening period of over two years between Kane’s death and the inquest, no-one at the prison had asked key staff to reflect on the care they provided to Kane that night and consider areas of learning . Again, this is not a position unique to this inquest, and is of great concern in the context of a rising number of self-inflicted prisoner deaths at HMP Lowdham Grange since Kane’s tragic death in 2021.
I would be grateful if your response could address what steps have been, or are being taken, to ensure that candour is applied throughout the death in custody process.
” Source location Kane Christopher Boyce · 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 Require Early Learning Reviews after deaths in custody and ensure resulting recommendations and learning are investigated and implemented.
Verbatim wording from the response “Following a death in custody at a Sodexo prison (whilst under Sodexo operational management) an Early Learning Review is required – this should be completed within 7 days. The Early Learning Review notes areas of good practice and recommendations, the Director is expected to ensure that any recommendations are complied with – alongside any recommendations made by the PPO.” Source location Response from Sodexo
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PFD Monitor interpretation Sodexo’s death-in-custody learning processes apply only while the prison is under Sodexo’s operational management.
Verbatim wording from the response “The above processes only apply when the prison is under Sodexo’s operational management.” Source location Response from Sodexo
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Concerns raised 1
Lack of a collective inter-agency response to learning lessons View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Martin Samuel WILLIS · Prevention of Future Deaths report
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Report summary
Martin Samuel Willis was a serving prisoner at HMP Stoke Heath when he was found hanging in his cell on 15 September 2022. He was on the suicide and self-harm prevention scheme, but concerns included failures in observation recording and supervision, uncertainty about the appropriate observation level and possible transfer for mental health treatment, and the need for a collective review of the care provided.
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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 a collective inter-agency response to learning lessons
Wider context from the report “4. Whilst the prison service and the mental health providers have reviewed the circumstances of Mr Willis’s death, I am concerned that there should be a collective and not individual response to ensure that all lessons can be learned . I therefore recommend that there be an inter-agency review between the prison service and mental health services as to the mental health care provided to the late Mr Willis including the evidence at the inquest and the jury’s findings. In so doing, I do not purport to suggest what the outcome of the review should be.
” Source location Martin Samuel WILLIS · 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 Organise and hold a Good Practice Meeting for case-review partners to share and discuss complex reviews and good practice.
Verbatim wording from the response “• A Good Practise Meeting will be organised and held by the Safer Custody Team inclusive of all Case Co-Ordinators, Mental Health Teams and external providers to share and discuss complex case reviews and good practises.” Source location 2024-0171 - Response from HMPPS
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PFD Monitor interpretation Meet Partner Agencies to communicate their responsibilities in multi-agency reviews.
Verbatim wording from the response “ACTION TO BE TAKEN:
I will be meeting with all Partner Agencies and relaying their responsibilities. Awareness Training for all Partner Agencies staff has been organised.” Source location 2024-0171 - Response from HMPPS
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PFD Monitor interpretation Conduct the inter-agency review of mental health care provided at HMP YOI Stoke Heath.
Verbatim wording from the response “Colleagues from HMP YOI Stoke Heath, Midlands Partnership University NHS Foundation Trust, Shropshire Community Health NHS Trust and North Staffordshire Combined Healthcare NHS Trust met on 29th January 2024, to undertake an inter-agency review as directed in the Regulation 28 Report.” Source location Response from Midlands Partnership University
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14 Dec 2023 Olivia Amy RUSSELL · Prevention of Future Deaths report Cheshire
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Concerns raised 1
Delays in conducting significant event reviews after deaths 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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Olivia Amy RUSSELL · Prevention of Future Deaths report
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Report summary
Olivia Russell had a history of anxiety, started citalopram in November 2020, stopped taking it without consulting a GP around June 2021, and restarted it in August 2021 after a relapse. She took her own life on 19 September 2021. Concerns included a lack of recorded evidence that risks associated with stopping medication or initially feeling worse had been discussed, uncertainty about consistent adherence to relevant guidance, and delay in carrying out a significant event review after her 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 Delays in conducting significant event reviews after deaths
Wider context from the report “I am also concerned that a significant event meeting (acknowledging I may have the name of this review meaning incorrect) has not yet taken place, despite Olivia’s death being over 2 years ago. The evidence of ████████ was that this will take place after the inquest and I am concerned that, if this is the practice following all deaths, there is a risk that learning from deaths will be delayed or missed .
” Source location Olivia Amy RUSSELL · 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 Conduct a Significant Event Analysis of Olivia’s death to identify learning and required system or practice changes.
Verbatim wording from the response “On 2 January 2024, the Practice conducted a clinical meeting / significant event meeting with our GP principal, ████████, our salaried GP, ████████, ████████ our regular Locum doctor, was unable to attend in person as she was working as locum doctor elsewhere at the time. We, as a practice, updated her on the discussion and the outcome.” Source location Response from Stretton Branch Surgery
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use a revised clinical meeting process to discuss all patient deaths monthly and complete Significant Event Analyses for unexpected deaths.
Verbatim wording from the response “The Practice would like to reassure you that all patient deaths will be discussed at our monthly MDT meeting. We have revised our monthly Clinical Team Meeting template and every unexpected death will be discussed with a view to complete a Significant Event Analysis on them to share any learning.” Source location Response from Stretton Branch Surgery
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7 Nov 2023 Irene Joy White · Prevention of Future Deaths report Somerset
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Concerns raised 1
Failure to learn from and reflect on DVT-related care to change practice View source
This report raised 6 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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Irene Joy White · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Irene Joy White, who had dementia and became immobile after a fall and hip-fracture surgery, was discharged to a nursing home without further thromboprophylaxis and was not mobilised beyond regular repositioning. She died of a pulmonary embolism, and concerns were raised about the nursing home's failure to identify and manage her DVT risk, including the absence of a DVT policy.
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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 learn from and reflect on DVT-related care to change practice
Wider context from the report “I am concerned following the evidence presented to the Inquest that:
(i) Frome Nursing Home employs clinically trained staff who would have been well aware (or should have been well aware) of the risk of developing DVT in an immobile patient and yet:
(a) Did not make any enquiries with the discharging hospital as to her care needs and lack of thromboprophylaxis. Despite appropriate medical/clinical knowledge the Home did not question this and/or take any active steps whatsoever to ascertain Mrs White’s needs or treatment plan;
(b) Did not take any steps to acquire any TED stockings, or similar, to minimise the risk of a DVT;
(c) Did not take any steps to mobilise Mrs White, over and above repositioning her in bed every four hours, to minimise the risk of a DVT
(ii) Frome Nursing Home did not have a DVT Policy in place at the time of Mrs White’s death, and no such active policy was in place at the time of the Inquest and so I am concerned that there has been no active learning and/or meaningful reflection since Mrs White’s death; meaning that practices have not changed and vulnerable residents remain at risk.
I am concerned that the Home did not take appropriate and reasonable steps to identify her risk and then take such steps to minimise it. The overwhelming thrust of the evidence presented indicated a poor attitude to a joined-up and cohesive response from the management and clinical teams and this resulted in a lack of clinical leadership, judgment and action being taken.
Mrs White lacked capacity due to her cognitive impairment and so was unable to appreciate the risks that immobility posed to her. She was entirely reliant (because of age, cognitive impairment and general infirmity) on the Home to anticipate her risks and needs in this regard.
” Source location Irene Joy White · Prevention of Future Deaths report
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27 Oct 2023 Francis Osborne Barnes · Prevention of Future Deaths report Berkshire
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Concerns raised 3
Failure to identify proposed changes after a death View source Failure to engage with other organisations to learn jointly from events View source Failure to investigate deaths and co-operate in joint investigations View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Francis Osborne Barnes · 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
Francis Osborne Barnes suffered an external iliac artery injury and major haemorrhage during elective hernia repair on 12 March 2022. He underwent amputation at Royal Berkshire Hospital on 14 March and died there on 16 March 2022. The concerns included whether he should have been transferred to a vascular centre sooner, and the Oxford Trust’s failure to investigate, cooperate with other organisations, maintain records, and demonstrate learning from the death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to identify proposed changes after a death
Wider context from the report “The focus of my concerns relates to the approach of your Trust to learning from deaths. Although Mr Barnes was not treated at the John Radcliffe Hospital, I concluded that he should have been transferred there, and that the delay in carrying out vascular surgery there contributed to his death. The Oxford Trust has been involved in this investigation almost from the start, and other Interested Persons involved in the investigation have attempted to work with your Trust to investigate the circumstances of Mr Barnes’ death.
I have been assisted by investigation reports and statements from the Spire Dunedin Hospital, and Royal Berkshire Hospital. This, I am afraid, sits in stark contrast to the response and approach by the Oxford Trust.
The Oxford Trust has carried out no investigation. They did not co-operate with the offer to conduct a joint investigation with Royal Berkshire Hospital.
There is no recorded morbidity and mortality meeting minute, although we were told at inquest that the case was discussed.
There is no recorded MDT meeting minute, although we were told at inquest that the case was discussed.
There is no evidence of proposed changes beyond evidence in court during the inquest that “we are looking into this”. Whilst I accept entirely that a knee-jerk response, even following a tragic death, is not appropriate, it is now some 18 months since Mr Barnes’ death .
Evidence from RBH and Spire Dunedin was consistent, namely that attempts to liaise with your trust and learn from this event jointly have been universally ignored.
It was also difficult for my office to obtain evidence for the inquest. We were provided with a joint statement, from three consultant vascular surgeons (only two of whom were clinically involved). It transpired that this statement was written by a clinical governance manager, and each of the witnesses who gave evidence was careful to tell the court that they did not agree with the wording of that statement. We subsequently received a statement from the consultant vascular surgeon in this case on the 29th of September, and from the clinical lead of vascular surgery some 5 days before the inquest started. We were also informed 11 days before the inquest started that the key vascular surgery witness would be on holiday abroad. This witness was summoned in May 2023. He ultimately gave evidence by video link, but this was difficult technically, and arrangements would have been made for him to attend in person, had we been made aware of this holiday arrangement, even aside from the fact that he had been formally summoned.
Multiple attempts have been made by the other Interested Persons in this case (notably Royal Berkshire Hospital and Spire Dunedin Hospital) to discuss the issues arising, but each of these offers has been ignored. The key clinical issues in this respect have been clarification of vascular surgery pathways, and use of an OARS system (or similar).
No records were made by the vascular surgery consultant involved, despite being consulted several times about the same patient in a short space of time, and the fact that there was a clinical difference of opinion about where the patient should best be managed.
We heard no evidence of a reason for the failure to engage with processes specifically aimed at learning from deaths – whether resourcing or any other reason.
The matters of concern can be summarised as follows:
1. Clarification of vascular surgery pathways - i.e. working with others in the Thames Valley network to consider how patients should be efficiently referred to the vascular team, wherever that patient is physically based (including in the private sector).
2. Consideration of an electronic referral system (such as OARS). I note that OARS was set up by the Oxford Trust itself, and is already in operation in a neurosurgery context, and indeed even for some vascular surgery patients.
3. Consideration of how the Oxford Trust responds to and learns from deaths.
” Source location Francis Osborne Barnes · 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 Failure to engage with other organisations to learn jointly from events
Wider context from the report “The focus of my concerns relates to the approach of your Trust to learning from deaths. Although Mr Barnes was not treated at the John Radcliffe Hospital, I concluded that he should have been transferred there, and that the delay in carrying out vascular surgery there contributed to his death. The Oxford Trust has been involved in this investigation almost from the start, and other Interested Persons involved in the investigation have attempted to work with your Trust to investigate the circumstances of Mr Barnes’ death.
I have been assisted by investigation reports and statements from the Spire Dunedin Hospital, and Royal Berkshire Hospital. This, I am afraid, sits in stark contrast to the response and approach by the Oxford Trust.
The Oxford Trust has carried out no investigation. They did not co-operate with the offer to conduct a joint investigation with Royal Berkshire Hospital.
There is no recorded morbidity and mortality meeting minute, although we were told at inquest that the case was discussed.
There is no recorded MDT meeting minute, although we were told at inquest that the case was discussed.
There is no evidence of proposed changes beyond evidence in court during the inquest that “we are looking into this”. Whilst I accept entirely that a knee-jerk response, even following a tragic death, is not appropriate, it is now some 18 months since Mr Barnes’ death.
Evidence from RBH and Spire Dunedin was consistent, namely that attempts to liaise with your trust and learn from this event jointly have been universally ignored .
It was also difficult for my office to obtain evidence for the inquest. We were provided with a joint statement, from three consultant vascular surgeons (only two of whom were clinically involved). It transpired that this statement was written by a clinical governance manager, and each of the witnesses who gave evidence was careful to tell the court that they did not agree with the wording of that statement. We subsequently received a statement from the consultant vascular surgeon in this case on the 29th of September, and from the clinical lead of vascular surgery some 5 days before the inquest started. We were also informed 11 days before the inquest started that the key vascular surgery witness would be on holiday abroad. This witness was summoned in May 2023. He ultimately gave evidence by video link, but this was difficult technically, and arrangements would have been made for him to attend in person, had we been made aware of this holiday arrangement, even aside from the fact that he had been formally summoned.
Multiple attempts have been made by the other Interested Persons in this case (notably Royal Berkshire Hospital and Spire Dunedin Hospital) to discuss the issues arising, but each of these offers has been ignored . The key clinical issues in this respect have been clarification of vascular surgery pathways, and use of an OARS system (or similar).
No records were made by the vascular surgery consultant involved, despite being consulted several times about the same patient in a short space of time, and the fact that there was a clinical difference of opinion about where the patient should best be managed.
We heard no evidence of a reason for the failure to engage with processes specifically aimed at learning from deaths – whether resourcing or any other reason.
The matters of concern can be summarised as follows:
1. Clarification of vascular surgery pathways - i.e. working with others in the Thames Valley network to consider how patients should be efficiently referred to the vascular team, wherever that patient is physically based (including in the private sector).
2. Consideration of an electronic referral system (such as OARS). I note that OARS was set up by the Oxford Trust itself, and is already in operation in a neurosurgery context, and indeed even for some vascular surgery patients.
3. Consideration of how the Oxford Trust responds to and learns from deaths.
” Source location Francis Osborne Barnes · 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 Failure to investigate deaths and co-operate in joint investigations
Wider context from the report “The focus of my concerns relates to the approach of your Trust to learning from deaths. Although Mr Barnes was not treated at the John Radcliffe Hospital, I concluded that he should have been transferred there, and that the delay in carrying out vascular surgery there contributed to his death. The Oxford Trust has been involved in this investigation almost from the start, and other Interested Persons involved in the investigation have attempted to work with your Trust to investigate the circumstances of Mr Barnes’ death.
I have been assisted by investigation reports and statements from the Spire Dunedin Hospital, and Royal Berkshire Hospital. This, I am afraid, sits in stark contrast to the response and approach by the Oxford Trust.
The Oxford Trust has carried out no investigation. They did not co-operate with the offer to conduct a joint investigation with Royal Berkshire Hospital.
There is no recorded morbidity and mortality meeting minute, although we were told at inquest that the case was discussed.
There is no recorded MDT meeting minute, although we were told at inquest that the case was discussed.
There is no evidence of proposed changes beyond evidence in court during the inquest that “we are looking into this”. Whilst I accept entirely that a knee-jerk response, even following a tragic death, is not appropriate, it is now some 18 months since Mr Barnes’ death.
Evidence from RBH and Spire Dunedin was consistent, namely that attempts to liaise with your trust and learn from this event jointly have been universally ignored.
It was also difficult for my office to obtain evidence for the inquest. We were provided with a joint statement, from three consultant vascular surgeons (only two of whom were clinically involved). It transpired that this statement was written by a clinical governance manager, and each of the witnesses who gave evidence was careful to tell the court that they did not agree with the wording of that statement. We subsequently received a statement from the consultant vascular surgeon in this case on the 29th of September, and from the clinical lead of vascular surgery some 5 days before the inquest started. We were also informed 11 days before the inquest started that the key vascular surgery witness would be on holiday abroad. This witness was summoned in May 2023. He ultimately gave evidence by video link, but this was difficult technically, and arrangements would have been made for him to attend in person, had we been made aware of this holiday arrangement, even aside from the fact that he had been formally summoned.
Multiple attempts have been made by the other Interested Persons in this case (notably Royal Berkshire Hospital and Spire Dunedin Hospital) to discuss the issues arising, but each of these offers has been ignored. The key clinical issues in this respect have been clarification of vascular surgery pathways, and use of an OARS system (or similar).
No records were made by the vascular surgery consultant involved, despite being consulted several times about the same patient in a short space of time, and the fact that there was a clinical difference of opinion about where the patient should best be managed.
We heard no evidence of a reason for the failure to engage with processes specifically aimed at learning from deaths – whether resourcing or any other reason.
The matters of concern can be summarised as follows:
1. Clarification of vascular surgery pathways - i.e. working with others in the Thames Valley network to consider how patients should be efficiently referred to the vascular team, wherever that patient is physically based (including in the private sector).
2. Consideration of an electronic referral system (such as OARS). I note that OARS was set up by the Oxford Trust itself, and is already in operation in a neurosurgery context, and indeed even for some vascular surgery patients.
3. Consideration of how the Oxford Trust responds to and learns from deaths.
” Source location Francis Osborne Barnes · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss and minute clinically concerning, potentially learnable TVVN vascular deaths at quarterly network morbidity and mortality meetings, sharing minutes across the Network.
Verbatim wording from the response “3.1 Future Governance of cross-organisational incidents within TVVN” Source location Response from Oxford University Hospitals NHS Foundation Trust
Open published response
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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 Introduce three forms for documenting vascular surgery-related concerns about patient deaths in the Thames Valley.
Verbatim wording from the response “3.1.2 The M&M documentation will include three new forms which will require completion whenever there is a vascular surgery-related concern raised about a patient death in the Thames Valley region.” Source location Response from Oxford University Hospitals NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain the OUH Medical Examiner office to scrutinize all non-Coronial deaths and feed concerns to governance and clinical teams.
Verbatim wording from the response “3.2.3 OUH introduced the Medical Examiner (ME) office in June 2020. This is to provide greater safeguards for the public by ensuring proper scrutiny of all non-Coronial deaths. Currently 100% of Trust deaths are reviewed by the ME office who feedback any concerns directly to the Learning from Deaths team (part of the Clinical Governance team). Any concerns and compliments are also fed back to clinical teams for action.” Source location Response from Oxford University Hospitals NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the OUH Mortality Review Policy with an appendix governing cross-system learning responses across the BOB ICB and Frimley.
Verbatim wording from the response “3.2.8 In response to this inquest several new processes have also been introduced:” Source location Response from Oxford University Hospitals NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a weekly Patient Safety meeting with the BOB ICB to coordinate multi-organisational incident planning and progress.
Verbatim wording from the response “3.2.8.2 A weekly Patient Safety meeting with Buckinghamshire, Oxfordshire and Berkshire West (BOB) Integrated Care Board (ICB) has been established for Patient Safety Teams to plan and liaise on the progress of multi-organisational Patient Safety Incidents. Ad-hoc arrangements can also be made in the event of significant Patient Safety incidents that require urgent planning and response.” Source location Response from Oxford University Hospitals NHS Foundation Trust
Open published response
4 Sep 2023 Emma Louise MORRISSEY · Prevention of Future Deaths report Cheshire
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Concerns raised 1
Failure to investigate an operating-table death 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
Emma Louise MORRISSEY · 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
Emma Louise Morrissey travelled to Turkey for gastric sleeve surgery and died on 08 July 2022 after an instrument perforated her abdomen during the operation, causing a massive uncontrolled bleed. Concerns included inadequate pre-operative assessment by the health tourism company, unclear health screening questions, lack of investigation into the death, inadequate embalming for repatriation, discrepancies in the surgical records and the reported cause of death, and the absence of platelets despite continued bleeding.
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 investigate an operating-table death
Wider context from the report “3. There has been no evidence of an investigation into the operating table death by the Ministry of Health in Turkey, the private Termessos Hospital or Regenesis UK despite Regenesis having been informed that the death had been caused by the surgeon during the operation.
” Source location Emma Louise MORRISSEY · Prevention of Future Deaths report
Open source report
3 Aug 2023 Leah BARBER · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 1
Absence of a single point of oversight for deaths involving previous Council involvement 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.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
Action
Maintain a departmental risk register and management-team oversight of child deaths, serious incidents, significant events, actions and lessons learned.
Stated by Bradford City CouncilStated completedThe respondent said that this action was complete when they made their response on 4 August 2023. View source
Action
Implement Children’s Services Review Guidance, a notification form and coordinated processes to collect information, identify systemic issues, pursue enquiries and make recommendations after a child’s death.
Stated by Bradford City CouncilStated completedThe respondent said that this action was complete when they made their response on 4 August 2023. View source
Action
Implement serious-incident and significant-event guidance, forms and escalation processes requiring service actions, senior review and departmental management-team oversight.
Stated by Bradford City CouncilStated completedThe respondent said that this action was complete when they made their response on 4 August 2023. View source
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AI-generated summary
Leah BARBER · 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
Leah BARBER, aged 15, was found deceased at Bolton Woods Quarry on 3 June 2019 after falling from a height of around 30 metres. The inquest concluded that Leah had taken her own life. The principal concern was that Bradford Council had no system or single point of oversight providing an overview of its involvement with Leah and similar deaths, limiting its ability to identify and learn lessons and contributing to a risk of future deaths.
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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 Absence of a single point of oversight for deaths involving previous Council involvement
Wider context from the report “A detailed review of the evidence in this case, which included evidence from two Schools (████████), as well as from Bradford Children's Social Services, the TRACKS Education team (at Bradford Council), the SCIL Team and the Council's SEND Team, revealed that no one person or department at Bradford Council had an overview of Council's involvement in relation to Leah (prior to her death).
Of greater concern was that that remained so after each of the Council departments involved were notified that Leah had passed away.
Every organisation which had contact with the Coroner's service in relation to Leah's death, with the exception of Bradford Council, was able to provide the Court with an overview/analysis of their involvement with Leah prior to her death and (where appropriate) the lessons they had learnt as a result their involvement with Leah.
The Police and the local Mental Health Trust were examples of two public bodies who had and were able to provide an overview/analysis to the Court in terms of their involvement with Leah and confirm whether there were any lessons to be learned by them.
The evidence provided by witnesses from the various Bradford Council teams which were involved with Leah, showed a clear disconnect in the involvement of the various Council departments. That was not caused by those individuals who had provided written statements to the Court or the two who attended to provide oral evidence.
Whilst the Inquest hearing did not identify actions/omissions on the part of individuals/teams within the Council which more than minimally, negligibly or trivially contributed to Leah's death, the concern is that Bradford Council appeared not to have a system/process in place which allowed anyone (whether an individual / a team) within the Council to have an overview of deaths where there had been previous Council involvement with the deceased (in this case a child).
In the apparent absence of such oversight Bradford Council would not be able to learn lessons from such cases (or even know if there were lessons to be learned). The absence of such a single point of oversight as was apparent in Leah's case, contributes to the risk that future deaths could occur unless action is taken.
” Source location Leah BARBER · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain a departmental risk register and management-team oversight of child deaths, serious incidents, significant events, actions and lessons learned.
Verbatim wording from the response “The Children’s Services Departmental Management Team (DMT) now maintain a risk register to ensure their oversight of any serious incidents or significant events and that current progress is made on identified actions, and that lessons learned are acted on. At the DMT meeting the circumstances of the incident is discussed between the Director of Children’s Services (DCS) and the Assistant Directors (ADs) within Children Services. Where appropriate, actions are agreed, including the team that will coordinate a response. The child remains on the risk register until the actions have been resolved. This change means that the DCS as an individual and the appropriate team asked to coordinate the actions, have oversight and responsibility for those actions.” Source location Response from City of Bradford Council
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement Children’s Services Review Guidance, a notification form and coordinated processes to collect information, identify systemic issues, pursue enquiries and make recommendations after a child’s death.
Verbatim wording from the response “There have been improvements to the notification process following the death of a child since 2019. Children’s Services Review Guidance (2022) has been produced and this includes a new form and improved processes that systematically collects information within children services when a child has died. This form also seeks to identify systemic issues, key lines of enquiry and provides recommendations. This is coordinated by the Council’s Education Safeguarding Team.” Source location Response from City of Bradford Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement serious-incident and significant-event guidance, forms and escalation processes requiring service actions, senior review and departmental management-team oversight.
Verbatim wording from the response “The Serious Incident or Significant Events Guidance, Form and processes, were further developed and implemented in 2020. These processes are used when there is a death of any child, including where abuse or neglect are thought to have contributed to the child’s death. This also includes death by suspected suicide. One of the key changes to the form was the requirement for the relevant Head of Service (HoS) to set out the actions to be taken and for the relevant Assistant Director to give a view about any additional actions need to be taken. This is sent to the DCS to review and is then discussed on Departmental Management Team as outlined earlier. This makes sure that senior leaders in Children’s Services are sighted and reviewing information and decisions about a significant or serious event quickly. This change was put in place in November 2021.” Source location Response from City of Bradford Council
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing oversight, notification and information-sharing processes are considered sufficient to ensure organisational oversight and learning from child deaths.
Verbatim wording from the response “Having taken time to look into the concerns, I am able to reassure you that following Leah’s death we do now have strengthened processes to make sure that we have organisational oversight where we have more than one team involved and a child dies. We acknowledge that our staff who gave evidence at the inquest did not share the arrangements that have been put in place since Leah’s death.” Source location Response from City of Bradford Council
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Includes failures to review, investigate, reflect on or derive and communicate safety lessons from deaths, including the anchor's failure to review restraint-related deaths for licensing and responsibility lessons and failures to reflect on or learn from deaths in other services or settings.
