21 Oct 2021 David Ayontunde Walker · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to provide continuity of care coordination View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
North East London NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
North East London NHS Foundation Trust
Deploy semi-permanent agency staff to support community recovery teams during recruitment.
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North East London NHS Foundation Trust
Recruit additional staff above establishment to reduce care-coordinator caseloads and support relationship building.
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North East London NHS Foundation Trust
Provide induction training and clinical supervision for permanent and temporary staff managing risks and patient relationships.
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North East London NHS Foundation Trust
Provide clinical supervisors with a care-coordination prompt covering relationship building, risk management and caseload management.
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AI-generated summary
David Ayontunde Walker · 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
David Ayontunde Walker died on 27 November 2020 after his mental health deteriorated following discharge from hospital. The report identified concerns about repeated changes of care co-ordinator and the failure to obtain and share important risk information between the mental health trusts, resulting in an incomplete discharge risk assessment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide continuity of care coordination
Wider context from the report “1. Between end of May 2020 to November 2020, Mr Walker was allocated four different care co-ordinators . There was evidence that only one of these care co-ordinators established a therapeutic relationship with Mr Walker . Many of the care co-ordinators were locum staff .
” Source location David Ayontunde Walker · Prevention of Future Deaths 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 Deploy semi-permanent agency staff to support community recovery teams during recruitment.
Verbatim wording from the response “High turnover of care coordinators and only one formed a therapeutic relationship
To act on the concerns immediately, agency staff have been sourced to support the Waltham Forest Community Recovery Teams. These staff have been recruited on a semi-permanent basis, whilst staff recruitment is taking place.” Source location Response from North East London 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 Recruit additional staff above establishment to reduce care-coordinator caseloads and support relationship building.
Verbatim wording from the response “High turnover of care coordinators and only one formed a therapeutic relationship
To act on the concerns immediately, agency staff have been sourced to support the Waltham Forest Community Recovery Teams. These staff have been recruited on a semi-permanent basis, whilst staff recruitment is taking place.” Source location Response from North East London 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 Provide induction training and clinical supervision for permanent and temporary staff managing risks and patient relationships.
Verbatim wording from the response “All staff, including temporary staff will be supported with training during induction and will be provided clinical supervision, to ensure that they are appropriately managing patients’ identified risks and are building relationship with patients they work with.” Source location Response from North East London 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 Provide clinical supervisors with a care-coordination prompt covering relationship building, risk management and caseload management.
Verbatim wording from the response “All clinical supervisors will be provided with a template / prompt that highlights the key elements of care coordination such as relationship building, risk management and caseload management, so staff are supported in their work with patients.” Source location Response from North East London NHS Foundation Trust
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10 Dec 2019 Bethany Tengquist · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 1
Insufficient substantive staffing and reliance on bank and agency staff View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Bethany Tengquist · 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
Bethany Tengquist hanged herself on 29 December 2018 after two telephone charging cables had been removed from her room but her dressing gown cord remained available. The report raises concerns that room checks and the removal of dangerous items were incomplete and flawed, and that staff may not have been properly trained.
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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 Insufficient substantive staffing and reliance on bank and agency staff
Wider context from the report “5. Staffing levels.
It was accepted by the Unit Co-ordinator, the Clinical Lead Nurse Manager and on behalf of the Trust, that on 29th December 2018 staffing levels on Caburn Ward had reached crisis point: there had been no Ward Manager and no Matron in post and available for a significant period of time, in conjunction with a 50% reduction of substantive staff . There was a reliance on bank and agency staff , and - unsurprisingly in my view - low staff morale. A number of members of staff in evidence emphasised that they had raised the issue of staffing and their concerns with managers and senior managers, to no avail. The obvious concern is that in the context of an acute female ward, such as Caburn, but equally applicable to the male acute ward, where the cohort of patients have such complex and challenging mental health issues, it is critically important that there is a consistency of staffing, management and leadership. The conclusion of the jury reflects and reinforces my concern that the extensive reliance on bank and agency staff undermines the safe operation of the acute wards at Mill View Hospital and, should the position persist, gives rise to the risk of future deaths.
” Source location Bethany Tengquist · Prevention of Future Deaths report
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14 Nov 2019 Serena Jane Nicholas · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Failure to provide continuity of antenatal care for a high-risk pregnancy View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Serena Jane Nicholas · 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
Serena Jane Nicholas was born by category 1 emergency Caesarean section on 29 August 2017 after fetal bradycardia and died shortly afterwards at Leeds General Infirmary from intrauterine hypoxia, with the pregnancy also involving a diabetic mother and a fetal heart abnormality. Concerns included disjointed management and a lack of identified consultants overseeing the high-risk pregnancy, as well as inadequate continuity of care and monitoring, meaning reduced fetal activity and the potential desirability of an earlier Caesarean section were not recognised.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide continuity of antenatal care for a high-risk pregnancy
Wider context from the report “(1) The antenatal surveillance was largely carried out in Hull where the mother lived. She was seen by a variety of clinicians and at a late stage by a community midwife , despite the recognition that this was a pregnancy accompanied by clear risk factors . The absence of identified consultants responsible for the oversight of mother and baby’s care in relation to diabetic and gynaecological aspects resulted in disjointed management.
” Source location Serena Jane Nicholas · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to provide continuity of crisis team care View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Leicestershire Partnership NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Leicestershire Partnership NHS Trust
Recruit 8.5 whole-time-equivalent registered and 12.6 whole-time-equivalent unregistered Crisis Service staff to increase capacity.
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Leicestershire Partnership NHS Trust
Review and revise the Keyworker Standard Operating Procedure to define responsibilities for assessment, care planning, monitoring and discharge planning.
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Leicestershire Partnership NHS Trust
Review the Crisis-to-CMHT discharge process to establish a documented referral and prioritisation process for immediate CMHT allocation.
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Leicestershire Partnership NHS Trust
Implement the revised discharge process, retaining Crisis responsibility until a CMHT appointment is offered and updating crisis and contingency plans with CMHT.
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Leicestershire Partnership NHS Trust
Use rostered assessment-only periods for registered clinicians, with clinicians focusing on treatment outside those periods, to increase treatment capacity and continuity.
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Leicestershire Partnership NHS Trust
Audit Crisis patients open between September 2018 and September 2019 to assess staff bands and visit continuity by the end of November 2019.
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Leicestershire Partnership NHS Trust
Develop a continuity-of-care improvement plan informed by the Crisis Service continuity audit.
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Leicestershire Partnership NHS Trust
Review local staff guidance on pre-visit preparation, including prior-entry, risk-assessment, outstanding-action and communication-needs checks.
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Kim Morris · 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
Kim Morris died from the consequences of suspension by ligature after being found in the garage at home and resuscitated. The report raises concerns about a lack of continuity within the crisis team, inadequate handover to community psychiatric nursing, and whether the service was suitable to support high-risk individuals. It states that these pressures and service concerns remained unresolved.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide continuity of crisis team care
Wider context from the report “Mrs Morris was referred to the crisis team on more than one occasion but particularly as part of her discharge plan from ward based care in the Bradgate Unit, a mental health hospital during August 2018 having taken a significant overdose. It was clear from the notes that there were numerous visits and telephone encounters, with numerous different individuals , and the role of the key worker did not appear to reduce or impact on the number of different team members having separate contacts with Mrs Morris . It was accepted that she should be referred to a Community psychiatric nurse to continue her engagement and this may bring some continuity of only having to speak to and engage with one person. It was not apparent that actual contact had been made prior to her discharge from the crisis team.
The court was told that due to the team set up, that continuity of visits was not possible and that the demands on the teams service significantly outweigh the resources available. The service remains on the Trust’s “at risk” register.
There is no indication in the extensive notes that any efforts were made to alleviate the distress that Mrs Morris felt by having to repeat her story on each occasion to each new team member, or to try and find a better way to engage with her or improve continuity. The handover to the CPN was not carried out in a way that was apparent to Mrs Morris and potentially left her fearful of another delay in receiving help and treatment. She took her life the day after discharge from the crisis team.
My concerns are that the team is not offering a service that is suitable to support such high risk individuals and that the expectations of service users are low due to the high and unrelenting pressures and demands on the individuals trying to provide care. This is not a new, but a continuing situation that I have considered before and it remains unresolved.
” Source location Kim Morris · Prevention of Future Deaths 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 Recruit 8.5 whole-time-equivalent registered and 12.6 whole-time-equivalent unregistered Crisis Service staff to increase capacity.
Verbatim wording from the response “Service Response
We acknowledge your concerns that we are not able to offer a service to support such high risk individuals, and would like to reassure you that, as a Trust we take these concerns seriously. We have received additional investment to further enhance the Crisis Service, to enable us to improve the service we deliver.” Source location 2019-0261-Response-by-Leicestershire-Partnership-NHS-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 Review and revise the Keyworker Standard Operating Procedure to define responsibilities for assessment, care planning, monitoring and discharge planning.
Verbatim wording from the response “1. There were numerous visits and telephone encounters with many different individuals and the role of the key worker did not reduce these.” Source location 2019-0261-Response-by-Leicestershire-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Crisis-to-CMHT discharge process to establish a documented referral and prioritisation process for immediate CMHT allocation.
Verbatim wording from the response “2. It was accepted that Mrs Morris be referred to a Community Psychiatric Nurse to continue her engagement and continuity of care prior to discharge, but no contact was made prior to her discharge, potentially leaving her fearful of a delay.” Source location 2019-0261-Response-by-Leicestershire-Partnership-NHS-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 Implement the revised discharge process, retaining Crisis responsibility until a CMHT appointment is offered and updating crisis and contingency plans with CMHT.
Verbatim wording from the response “Service response
The discharge process for patients under the care of the Crisis team to Community Mental Health Team (CMHT) is being reviewed to ensure that there is an agreed and documented referral process with a prioritisation rationale for the patient to be immediately allocated to a CMHT team member. The Crisis team will retain responsibility for the patient until an appointment with the CMHT team member has been offered. The Crisis team will work with the CMHT to ensure that the crisis and contingency plan is updated. Our Town for Crisis Services will have responsibility for ensuring that ongoing monitoring is in place to ensure compliance is adhered to. This new process will be fully in place by the end of December 2019.” Source location 2019-0261-Response-by-Leicestershire-Partnership-NHS-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 Use rostered assessment-only periods for registered clinicians, with clinicians focusing on treatment outside those periods, to increase treatment capacity and continuity.
Verbatim wording from the response “Service response
We accept our continuity of care is challenged and want to assure you we are committed to improve this area of care with the new investment outlined above. We have already implemented new ways of allocating registered clinicians for assessments to increase the time available to deliver treatment. Registered staff members are now rostered four weeks of carrying out assessments only. Outside of these blocks they will then focus on treatment. This process was implemented in” Source location 2019-0261-Response-by-Leicestershire-Partnership-NHS-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 Audit Crisis patients open between September 2018 and September 2019 to assess staff bands and visit continuity by the end of November 2019.
Verbatim wording from the response “June 2019 and the team are currently monitoring the impact this has on continuity of care.
In addition our new resources and new posts associated with this will result in an increase in daily packages of care we are able to offer. We will be completing an audit reviewing patients open to Crisis Services between September 2018 and September 2019 to establish the band of staff, and the number of visits they have completed for patients open during this timeframe. This will be completed by end of November 2019 and will allow us to have a clear understanding of the current continuity of care delivered by the Crisis team, and enable us to develop an improvement plan in this area.” Source location 2019-0261-Response-by-Leicestershire-Partnership-NHS-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 Develop a continuity-of-care improvement plan informed by the Crisis Service continuity audit.
Verbatim wording from the response “June 2019 and the team are currently monitoring the impact this has on continuity of care.
In addition our new resources and new posts associated with this will result in an increase in daily packages of care we are able to offer. We will be completing an audit reviewing patients open to Crisis Services between September 2018 and September 2019 to establish the band of staff, and the number of visits they have completed for patients open during this timeframe. This will be completed by end of November 2019 and will allow us to have a clear understanding of the current continuity of care delivered by the Crisis team, and enable us to develop an improvement plan in this area.” Source location 2019-0261-Response-by-Leicestershire-Partnership-NHS-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 Review local staff guidance on pre-visit preparation, including prior-entry, risk-assessment, outstanding-action and communication-needs checks.
Verbatim wording from the response “Service response
The additional investment will support our commitment to improving the continuity of care of all patients in Crisis we support. This includes the review of our local guidance for staff on pre-visit preparation, which expects all staff to read the previous visit entry, review any recent risk assessments, confirm outstanding actions from the previous visit have been completed, and check any communication needs prior to the scheduled visit. We will develop a spot check tool to establish that the changes as the result of the review of the local guidance have been imbedded into practice. We will ensure that we are able to offer assurances of our compliance on this through co-producing a spot check tool directly with our service users.” Source location 2019-0261-Response-by-Leicestershire-Partnership-NHS-Trust
Open published response
Concerns raised 1
Lack of continuity of care in antenatal appointments 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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AI-generated summary
Ezra James BOULTON · 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
Ezra James Boulton, aged two months, died on 20 May 2018 after being found unresponsive while co-sleeping with his mother on a sofa; alcohol had been consumed and he could not be resuscitated. The principal concerns were inadequate continuity of antenatal care, insufficient early safe-sleeping information for parents, and midwives’ lack of awareness about the legal implications of infant deaths involving co-sleeping and alcohol or drugs.
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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 continuity of care in antenatal appointments
Wider context from the report “(1) At Ezra's Inquest I was told in evidence that throughout her pregnancy (this being her first pregnancy) ████████ (Ezra's mother) did not see the same midwife twice . I believe that there should be some level of continuity of care in antenatal appointments to ensure that all of the necessary checks are preformed and appropriate antenatal advice is shared with the mother.
(2) I was also heard that ████████ own personal pregnancy was uneventful but I am concerned that the distinct lack of continuity of care appears to expose a risk that should there be any abnormalities and/or risk factors to either mother or baby as the pregnancy develops, that these have the potential to be missed; either entirely misses or not properly communicated to whichever midwife conducts the next antenatal appointment , causing significant risk to both mother and baby. I believe that there is a serious risk of future death posed by this lack of continuity of care.
” Source location Ezra James BOULTON · Prevention of Future Deaths 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 Establish two continuity-of-carer pathway teams providing named midwives and buddies throughout antenatal, birth and postnatal care.
Verbatim wording from the response “As a first step towards achieving this, PHT is setting up 2 continuity of carer pathway teams, of 6-8 community midwives, each with midwife having a caseload of approximately 40 women. This will enable those women to have a named midwife and a “buddy” who will coordinate care throughout the antenatal, birth and postnatal period. The first team will be in place by the end of August with the second team being established towards the end of 2019.” Source location 2019-0222-Response-by-Portsmouth-Hospitals-NHS-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 Handheld notes, scheduled checks and trained midwives are considered sufficient to identify and escalate pregnancy abnormalities despite lack of continuity.
Verbatim wording from the response “Nice Guidance “Antenatal care for uncomplicated pregnancies” CG62 sets out at Appendix D a schedule of appointments which should be provided for women with uncomplicated pregnancies. The requirement is for 10 appointments for nulliparous women and 7 for parous women. The schedule sets out in detail which checks and advice should be provided at each of the appointments. Each patient has their own hand held notes which are retained by them and brought to every antenatal appointment. As such each healthcare professional who meets a woman will have access to all the information they need to enable them to ensure that all necessary checks are performed and appropriate advice is shared with them.” Source location 2019-0222-Response-by-Portsmouth-Hospitals-NHS-Trust
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13 Mar 2019 Tamsin Rebecca Lianne GRUNDY · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Failure to provide continuity in the number of staff involved in care View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Tamsin Rebecca Lianne GRUNDY · 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
Tamsin Rebecca Lianne Grundy, who had a history of depression and was under the care of Mental Health Services, was found dead at home on 26 July 2018 with a weightlifting bar across her neck. Concerns included her difficulty relating to the more than 25 members of the Crisis Resolution Home Treatment Team involved in her care and the lack of a definitive, timed action or named person responsible for addressing this issue.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide continuity in the number of staff involved in care
Wider context from the report “1.Miss Grundy repeatedly spoke about her concern about the number of people involved in her care, particularly from the Crisis Resolution Home Treatment Team . It is understood Miss Grundy saw 25 plus members of the Team in some 14 months . The evidence was that she found it difficult to relate to so many people, having to repeat the difficulties she was experiencing which she felt was adversely impacting on her mental health. It was not clear from the evidence that this issue was addressed during Miss Grundy's contact with the service .
2. This issue is referred to in the Serious Incident Requiring Investigation Report, having been raised by Miss Grundy’s family, but there is no definitive, timed action arising from it and no named person responsible for any such action.
” Source location Tamsin Rebecca Lianne GRUNDY · Prevention of Future Deaths 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 Apply the national 39-point fidelity scale across the Trust to identify improvement areas and consistently match clinicians with patients using daily planning.
Verbatim wording from the response “Notwithstanding this challenge, it was the expressed experience of Ms Grundy that having such numbers of staff involved made it difficult to form therapeutic relationships. To support continued development of the service provided, the CRHT team is using a national 39 point fidelity scale to help it reflect on current practices identifying areas of focus and improvement. One of the points refers directly to this matter and the team are working to apply this on a consistent basis, using daily planning to match clinicians with individual visits where a positive therapeutic relationship has developed. The scale is being used more widely across the Trust.” Source location 2019-0088-Response-by-Norfolk-Suffolk-NHS-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 The CRHT cannot guarantee that service users will see a limited number of staff because intensive support requires flexible 24/7 staffing.
Verbatim wording from the response “Ms Grundy was in contact with the Trust’s Youth Service since 2016. She was allocated a staff member whose role was to coordinate her care. This member played an important role in forming a therapeutic relationship with the service user, working together to implement plans to help respond to the individual’s needs. There are occasions where an individual’s need changes requiring a period of more intensive support which is provided by the Trust’s acute services. The CRHT provide intensive periods of support in the community for short periods, supplementing the care provided by the community team. This means the team have to be flexible and adaptable in approach requiring staff to work over a 24 hour period, seven days per week. Appointments with users may range from multiple contacts in a day to every few days.” Source location 2019-0088-Response-by-Norfolk-Suffolk-NHS-Trust
Open published response
11 Jan 2019 Jacqueline Marie Elliott · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Lack of continuity of care preventing a clinician from maintaining an overview of the patient and her health View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Jacqueline Marie Elliott · 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
Jacqueline Marie Elliott, who had a long-standing history of back pain, was found deceased at home on 9 August 2018. Post-mortem and toxicology findings identified reduced liver function and significant toxicity from a combination of drugs. Concerns included inaccurate prescription records, insufficient clinical notes and medication-review detail, prescribing of 100 tramadol tablets despite a recorded history of non-compliance and self-medication, and a lack of continuity of care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of continuity of care preventing a clinician from maintaining an overview of the patient and her health
Wider context from the report “5. There was a lack of continuity of care. Mrs Elliott saw a variety of different locum GPs. This meant that no clinician had an overview of her and her health. As a result, painkillers were repeatedly prescribed and other potential ways of managing her persistent back pain were not explored. This led to a significant reliance by Mrs Elliott on painkillers to manage her on going back problems. The inquest was told that the lack of continuity of care was due to a national shortage of GPs and was a national not local issue.
” Source location Jacqueline Marie Elliott · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review clinical staffing numbers and clinical sessions to support patient continuity and existing staff.
Verbatim wording from the response “The CCG is working very closely with the practice including:” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
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9 May 2018 Lewis Daryl COLGAN · Prevention of Future Deaths report Buckinghamshire
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Concerns raised 1
Failure to maintain continuity of engagement and care during key staff changes and sickness absence View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Lewis Daryl COLGAN · 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
Lewis Colgan died immediately at Princes Risborough Station on 15 September 2017 after jumping onto the track in front of a northbound passenger train. Concerns included the robustness of supervision of care coordinators and care teams, continuity of mental health care during staff changes and sickness, the process for overdue Care Programme Approach meetings, and the robustness of the investigation and resulting actions.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain continuity of engagement and care during key staff changes and sickness absence
Wider context from the report “(2) Lewis’ mental health care revealed issues with regard to management of staff changes and sickness and particularly coordination of continuity of engagement and care in the context of Lewis’ care plan in the absence of key participants in his care on long term sick leave , notably the roles of care coordinator and psychologist and, notwithstanding evidence indicating steps being taken to address staffing issues, there remains a concern that , given the personal nature of the mental health care provided to individuals and the significance of regular engagement with specific individuals, that provision of care in compliance with specified care plans may be compromised .
” Source location Lewis Daryl COLGAN · Prevention of Future Deaths report
Open source report
28 Dec 2017 Michael Richard Drewry · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Failure to ensure consistency and continuity of care 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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AI-generated summary
Michael Richard Drewry · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Richard Drewry had a history of anxiety and low mood, with deteriorating mental health and episodes involving knives shortly before he was found with a ligature around his neck on 3 April 2017. He sustained fatal injuries, suffered an unsurvivable hypoxic brain injury, and died in hospital on 8 April 2017. The substantive concerns were failures by the Crisis Team to provide consistent and continuous care, make accurate and prompt records, and escalate concerns appropriately and 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 ensure consistency and continuity of care
Wider context from the report “(1) The failure of the Crisis Team to ensure consistency and continuity of care for the deceased, in particular the changing personnel who visited the deceased ;
” Source location Michael Richard Drewry · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce the Modified Modified Continuity Index into routine reporting, trial it in one team, and then implement it across Crisis Teams.
Verbatim wording from the response “The Trust is shortly to introduce the Modified Modified Continuity Index (MMCI) into its routine reporting systems, at both individual and team levels. This is a measure calculated using the total number of patient visits and the number of different clinical staff visiting the patients and gives a resulting score between 0 and 1, the more staff providing care to the patient the lower the score will be.” Source location 2017-0386-Response-by-Nottinghamshire-Healthcare-NHS-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 Continuity of staff cannot always be provided because 24-hour crisis response requirements and high-intensity care create operational constraints.
Verbatim wording from the response “Continuity of care is a challenge within our Crisis Resolution and Home Treatment Teams due to the service operating 24 hours a day, 7 days a week. Staff work 12 hour shifts and need to be able to respond swiftly to urgent referrals, within 4 hours and 24 hours whilst also maintaining robust care and treatment for those patients already on their caseload.” Source location 2017-0386-Response-by-Nottinghamshire-Healthcare-NHS-Trust
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19 Dec 2017 Mrs Lindsey Parker · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Lack of continuity in medical care View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Northern Care Alliance NHS Foundation Trust
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AI-generated summary
Mrs Lindsey Parker · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Lindsey Parker had metastatic lung cancer and subsequently developed toxic epidermal necrolysis while receiving medical treatment. Her condition deteriorated on 8 July 2017, with concerns about delayed medical review, inadequate recognition and escalation of deterioration, gaps in observations and fluid-balance recording, lack of continuity in medical care, and the qualifications of out-of-hours coordinators. She died at Salford Royal Hospital on 9 July 2017.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of continuity in medical care
Wider context from the report “1. A lack of continuity in medical care. According to the family's evidence, Mrs Parker was seen by 16 different doctors during the course of her last admission. Of these, seven were junior doctors (FY grade).
” Source location Mrs Lindsey Parker · Prevention of Future Deaths report
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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 Mrs Parker was seen by three junior doctors, not seven.
Verbatim wording from the response “During this admission period Mrs Parker would have been seen by three Junior Doctors who were assigned to ward M3. These were: ████████ (GPST1), ████████ (FY2) and ████████ (GPST2).” Source location 2017-0378-Response-by-Northern-Care-Alliance-NHS-Group
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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 Multiple clinicians are normal practice because specialist input and full handover provide appropriate continuity of care.
Verbatim wording from the response “Unfortunately, Mrs Parker was seen by a number of different clinicians due to varying shift patterns, on call out of hours care and because Mrs Parker required the input of various different specialities. Nevertheless it should have been explained to Mrs Parker family why there was a need for all the various medical input. I do hope the above” Source location 2017-0378-Response-by-Northern-Care-Alliance-NHS-Group
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.