6 Feb 2026 Mansoor Zaman · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to communicate patient safety investigation findings to treating staff View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
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Mansoor Zaman · 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
Mansoor Zaman, a 27-year-old man with a history of suicidality, substance misuse and EUPD, absconded from a mental health ward on 8 December 2024 after displaying suicidal intent and erratic and aggressive behaviour. His body was recovered on 29 December 2024. The substantive concerns included failures to use available mental health authorisations, reassess risk and observation levels, adequately document care, and promptly report him missing to police; the inquest jury identified some of these failures as factors that probably or possibly contributed to his death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate patient safety investigation findings to treating staff
Wider context from the report “9. The inadequacy of the Trust patient safety framework investigation which neither sought the recollections of treating staff, nor communicated the findings of the report to the same staff.
” Source location Mansoor Zaman · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Investigations may not obtain every clinician account or provide feedback when staff absence conflicts with timely completion.
Verbatim wording from the response “33. I understand it is frustrating that recollections of all staff are not always sought in PSII’s nor the findings communicated to all staff. Unfortunately, it is sometimes a balance of trying to obtain all clinician accounts (due to things such as sick leave) versus timely completion of the investigation. The same applies to feedback sessions. Though, to mitigate these issues, when staff are unable to attend feedback sessions they are routinely provided with a copy of the final report via email and asked to comment on it.” Source location 2026-0072 - Response from East London NHS Foundation Trust
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21 May 2025 Etta-Lili Stockwell-Parry · Prevention of Future Deaths report North West Wales
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Concerns raised 2
Failure to contextualise learning in staff memoranda View source Inadequate sharing of incident learning with uninvolved staff 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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Etta-Lili Stockwell-Parry · 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
Etta-Lili Stockwell-Parry was born in poor condition on 3 July 2023 and died four days later after transfer for specialist neonatal care. The report identified missed opportunities to recognise static growth and fetal distress, inadequate monitoring and incomplete records during labour, and concerns that the neonatal investigation and sharing of learning were insufficiently thorough and contextualised.
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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 contextualise learning in staff memoranda
Wider context from the report “c. The memoranda sent to staff highlighting the learning did not include context or narrative around the circumstances of investigation. Therefore, those not directly involved would not have been fully aware of the context of what had occurred.
” Source location Etta-Lili Stockwell-Parry · 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 Inadequate sharing of incident learning with uninvolved staff
Wider context from the report “Having issued Reports to the Health Board regarding quality of investigation previously, this concern remains. Specifically, I have concerns that the neonatal element of the investigation was not thorough enough such that without this genuine learning and change will not and cannot occur. Even where learning has been shared, I am concerned that this is not contextualised sufficiently. I am also concerned that staff not involved in the incident will not learn fully enough from events where there is inadequate sharing of learning from an incident.
” Source location Etta-Lili Stockwell-Parry · 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 Develop and test a searchable learning repository, evaluate it with staff, and roll it out across the Health Board.
Verbatim wording from the response “Furthermore, work is being finalised to improve how learning is shared once a review or investigation is completed. A learning repository is being developed which is a key digital initiative designed to support our journey toward becoming a learning and self-improving organisation. This is believed to be the first of its kind in Wales.” Source location Response from Betsi Cadwaladr University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Lead the Foundations for the Future programme to integrate women’s and neonatal services and improve investigations and learning across them.
Verbatim wording from the response “I am also leading work to improve how the organisation functions as part of a programme called Foundations for the Future, and this will have a range of interventions of which the closer integration of women’s services and neonatal services will be an outcome. This will also improve the way investigations and learning is conducted across these two deeply interconnected services).” Source location Response from Betsi Cadwaladr University Health Board
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16 Sep 2024 Samuel Finlay Parkin · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Lack of formal consideration and dissemination of learning points View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England St George'S University Hospitals 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. 6
St George'S University Hospitals NHS Foundation Trust
Present consolidated learning from the case at St George’s paediatric, paediatric surgery and radiology Clinical Governance meetings.
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St George'S University Hospitals NHS Foundation Trust
Meet with Epsom St Helier clinical leads to discuss the learning and resulting practice changes.
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St George'S University Hospitals NHS Foundation Trust
Deliver a dedicated malrotation session at the British Society of Paediatric Radiology meeting.
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St George'S University Hospitals NHS Foundation Trust
Audit children over one year old who underwent malrotation surgery across four regional centres and present the findings regionally.
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St George'S University Hospitals NHS Foundation Trust
Share the malrotation audit findings at national paediatric surgery and paediatrics meetings in 2025.
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NHS England
Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across the NHS nationally and regionally.
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Samuel Finlay Parkin · 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 Finlay Parkin died on 16 September 2022 from hypoxic brain injury following a cardiac arrest caused by midgut volvulus. The volvulus resulted from undiagnosed intestinal malrotation, which had been present since birth and was not identified despite repeated symptoms and hospital attendances. The principal concerns included failure to undertake appropriate diagnostic testing, false reassurance from ultrasound reporting, inadequate safety-netting advice, and communication and learning issues between clinical teams.
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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 formal consideration and dissemination of learning points
Wider context from the report “1. St George’s have noted a number of learning outcomes in the course of their M&M process and the Child Death Analysis Form. Whilst I heard evidence of training and informal discussions amongst colleagues both at St George’s and regionally, I consider that action is required to ensure that those learning points are formally considered and disseminated throughout St George’s and more widely in the NHS.
” Source location Samuel Finlay Parkin · 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 Present consolidated learning from the case at St George’s paediatric, paediatric surgery and radiology Clinical Governance meetings.
Verbatim wording from the response “The paediatric and radiology departments at St George’s have worked together to summarise all the learning from Samuel’s case and are presenting this formally at departmental Clinical Governance meetings in paediatrics, paediatric surgery and radiology. These presentations will be completed by the end of January 2025.” Source location Response from St George's Epsom and St Helier University Hospitals
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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 Meet with Epsom St Helier clinical leads to discuss the learning and resulting practice changes.
Verbatim wording from the response “We have met with the clinical leads in paediatrics and radiology at Epsom St Helier Trust to discuss this learning and our changes in practice. They presented this to their sonographers and paediatric radiologists at their Radiology Quality meeting on 9th October 2024.” Source location Response from St George's Epsom and St Helier University Hospitals
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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 Deliver a dedicated malrotation session at the British Society of Paediatric Radiology meeting.
Verbatim wording from the response “The limitations of the SMA/SMV axis alone as a marker for malrotation, in particular in older children, are part of the shared learning being disseminated locally. This is now a regular topic for departmental training for paediatric radiology registrar level doctors. The change in the paediatric abdominal reporting standard at St George’s is formalised in local radiology protocols, with quality assurance through active audit of reports. This will be part of a presentation during a dedicated malrotation session, organised and led by the St George’s team, at the British Society of Paediatric Radiology meeting in November 2024.” Source location Response from St George's Epsom and St Helier University Hospitals
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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 children over one year old who underwent malrotation surgery across four regional centres and present the findings regionally.
Verbatim wording from the response “The paediatric surgery department have carried out an audit of all children with malrotation operated on over 1 year of age across 4 surgical centres in South London and Surrey/Sussex to inform broader learning about this rare but important condition. It has been presented at the regional paediatric surgical meeting at King’s College Hospital and will be shared more widely via the national meeting of the British Association of Paediatric Surgeons and the annual meeting for the Royal College of Paediatrics and Child Health in 2025.” Source location Response from St George's Epsom and St Helier University Hospitals
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the malrotation audit findings at national paediatric surgery and paediatrics meetings in 2025.
Verbatim wording from the response “The paediatric surgery department have carried out an audit of all children with malrotation operated on over 1 year of age across 4 surgical centres in South London and Surrey/Sussex to inform broader learning about this rare but important condition. It has been presented at the regional paediatric surgical meeting at King’s College Hospital and will be shared more widely via the national meeting of the British Association of Paediatric Surgeons and the annual meeting for the Royal College of Paediatrics and Child Health in 2025.” Source location Response from St George's Epsom and St Helier University Hospitals
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across the NHS nationally and regionally.
Verbatim wording from the response “I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Samuel, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.” Source location Response from NHS England
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7 May 2024 David RILEY · Prevention of Future Deaths report Warwickshire
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Concerns raised 1
Failure to specify and disseminate learning from the DOAC pausing incident View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care National Institute for Health and Care Excellence NHS England The Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
NHS England
Review the Report and consider whether learning should be shared across Midlands integrated care boards.
View source
NHS England
Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share their learning nationally and regionally.
View source
National Institute for Health and Care Excellence
Share the report with Agilio Software for awareness.
View source
The Trust
Present the incident and related learning at the cardiology Grand Round.
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The Trust
Prioritise Grand Round slots for cases whose formal investigations recommend presentation.
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AI-generated summary
David RILEY · 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 Riley developed a pericardial effusion after atrial fibrillation ablation and later suffered a stroke before dying on 10 June 2023. Concerns included inconsistent decisions about pausing Apixaban, delays in restarting it, inadequate communication and continuity of care, and difficulties using computerised clinical records.
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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 specify and disseminate learning from the DOAC pausing incident
Wider context from the report “Although the Warwick hospital conducted a Root Cause Analysis Investigation Report (RCAIR) of 6 July 2023 which indicated that the pausing of the DOAC was a lesson learned, it did not indicate what was learned . The only further action was limited to the incident being presented at the Grand Round, but this had not taken place at the time of the inquest, some 9 months after publication of the RCAIR . There are remaining outstanding matters of concern.
” Source location David RILEY · 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 the Report and consider whether learning should be shared across Midlands integrated care boards.
Verbatim wording from the response “The Regional Chief Pharmacist in the Midlands has also been asked to review your Report and consider whether any learnings need to be shared across the ICBs within the Midlands region.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share their learning nationally and regionally.
Verbatim wording from the response “I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of David, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the report with Agilio Software for awareness.
Verbatim wording from the response “We will share your report with Agilio Software for their awareness.” Source location Response from NICE
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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 Present the incident and related learning at the cardiology Grand Round.
Verbatim wording from the response “I can only apologise that, over a year after his death, Mr Riley’s case has still not been presented at the Trust’s Grand Round. His case will be presented by one of our Cardiology consultants to Grand Round on 19 July – and will incorporate the learning from the concerns you have raised in your Regulation 28 report.” Source location Response from S. Warwickshire NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prioritise Grand Round slots for cases whose formal investigations recommend presentation.
Verbatim wording from the response “Grand Round is an “open to all staff” learning forum – held weekly both in person and online – and there are always a large number topics vying for attention. This, combined with staff availability, means that there can sometimes be a significant time lag between an incident occurring and the learning being shared. That said, the delay in this particular instance is unacceptable, and we have asked our Medical Education Co-ordinator (who manages the programme) to ensure that priority slots are given to those cases where a formal investigation recommends that a case be discussed at Grand Round.” Source location Response from S. Warwickshire NHS
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operational responsibility for delivering health services and responding to related concerns lies with NHS England.
Verbatim wording from the response “NHS England is operationally responsible for delivering health services across the country and will be responding directly to your concerns at length. NHS England is an executive non-departmental public body, sponsored by the Department of Health and Social Care.” Source location Response from DHSC
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17 Jan 2024 Kane Christopher Boyce · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Failure to implement learning from investigations following deaths in custody View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Sodexo
Require Early Learning Reviews after deaths in custody and ensure resulting recommendations and learning are investigated and implemented.
View source
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Kane Christopher Boyce · 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
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 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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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
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
Failure to adequately share investigation learning with practitioners View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
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Vivienne Greener · 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
Vivienne Greener was taken by ambulance to Glan Clwyd Hospital after vomiting blood and died there on 20 March 2018 following a massive upper gastrointestinal haemorrhage. The report identified concerns including delayed admission and triage, delayed provision of blood products, failures to escalate and trigger haemorrhage pathways, insufficient staffing and the lack of out-of-hours emergency endoscopy.
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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 adequately share investigation learning with practitioners
Wider context from the report “7. Any learning from the Health Board’s Investigation Report is not adequately shared with its practitioners ;
” Source location Vivienne Greener · 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 Develop a new incident process for sharing investigation learning with clinicians.
Verbatim wording from the response “In relation to your concern that incident investigation reports are not shared with clinicians, I can confirm that following concerns from other coroners, a new incident process is being developed and will be implemented in April 2024.” Source location Response from Betso Cadwaladr University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the new incident process in April 2024.
Verbatim wording from the response “In relation to your concern that incident investigation reports are not shared with clinicians, I can confirm that following concerns from other coroners, a new incident process is being developed and will be implemented in April 2024.” Source location Response from Betso Cadwaladr University Health Board
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8 Dec 2023 WILLIAM BRIAN KIN GRAY · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure to incorporate investigation learning into training and alerts View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
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WILLIAM BRIAN KIN GRAY · 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
William had poorly controlled asthma and experienced a life-threatening asthma attack on 29 May 2021, followed by respiratory and cardiac arrest and a brain injury not compatible with life. The report identified multiple concerns, including failures to assess, review, escalate and treat his asthma, ambulance treatment and airway-management issues, gaps in investigation and training, and limitations in asthma and emergency-care services.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to incorporate investigation learning into training and alerts
Wider context from the report “(3) Learning and sharing lessons learned is a function of investigation. The Trust investigation report did not:
(a) scrutinise the ambulance attendance to William on 27 October 2020 in comparison to the attendance on 29 May 2021 and missed an opportunity to understand:
i. the timeliness of the administration of adrenalin during a life-threatening asthma attack in accordance with the JRCALC guidelines and that there may be additional training needs. Two paramedics attended both on 27 October 2020 and 29 May 2021 but did not consider the administration of intramuscular adrenalin on the second occasion.
ii. Whilst life-threatening asthma in children is an extremely rare call, the same two paramedics attended on 27 October and 29 May and initial treatment given differed during a life-threatening asthma attack
iii. that ambulance crew focused on the airway to exclusion of other treatment options and did not recognise the significant amount of inflation pressures that are required to manage the airway of an asthmatic child in respiratory arrest. Crew were misled in thinking that the airway adjunct equipment was not the correct size as a consequence, and were swapping the adjuncts
iv. that the same paramedic was left managing an airway throughout the arrest despite the arrival of more experienced colleagues that arrived as backup, including an LMO until HEMS took over.
The Trust did not address the issues at 3 (a) i-iv above in their annual training following William’s death and no alerts or learning notes have been circulated .
(b) East of England Ambulance NHS Trust investigation did not identify a number of risks and omissions its investigation of this child death:
i. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required
ii. Intramuscular adrenalin was not administered for life threatening asthma for a child in respiratory arrest in accordance with JRCALC
iii. Intravenous adrenalin was not given or attempted when the patient went into cardiac arrest in accordance with the resuscitation guidelines and Intraosseous access was not attempted for a child in cardiac arrest for at least 10 minutes and only when the patient was in the ambulance.
” Source location WILLIAM BRIAN KIN GRAY · 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 Include a case study in the Safety Matters Newsletter covering adrenaline, paediatric airway management and handover communication during critical asthma incidents.
Verbatim wording from the response “In order to raise further awareness, a case study will be included in the Safety Matters Newsletter and the Trust’s pharmacist will include information around the benefits of IM adrenaline being administered to a patient with life-threatening asthma together with the appropriate point to administer this. The aim is to demonstrate to staff the physiological benefits of administering in this situation.” Source location Response from East of England Ambulance Service
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17 Jan 2023 Teegan Marie Barnard · Prevention of Future Deaths report West Sussex
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Concerns raised 1
Failure to disseminate institutional learning from unexpected deaths View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Association Of Anaesthetists (Great Britain & Ireland) NHS England Royal College of Anaesthetists University Hospitals Sussex 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. 6
University Hospitals Sussex NHS Foundation Trust
Discuss HSIB investigation outputs and learning through Intensive Care, Maternity Mortality and Morbidity, and other Trust forums.
View source
Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists
Share learning that non-traumatic bilateral pneumothoraces can cause failure to ventilate and cardiac arrest through safety updates, education and events.
View source
NHS England
Share learning from Teegan’s death through the Safe Anaesthesia Liaison Group network and relevant organisations.
View source
NHS England
Ask regional Regulation 28 Working Group members to share learning with Integrated Care Boards for onward dissemination to trusts across England.
View source
NHS England
Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group to share learning, identify trends and consider further review or action.
View source
Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists
Share learning that bilateral pneumothoraces can cause cardiac arrest without trauma or thoracic surgery through safety updates, education and events.
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Teegan Marie Barnard · 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
Teegan Marie Barnard suffered a prolonged PEA cardiac arrest during emergence from general anaesthesia after an emergency caesarean section, following significant postpartum haemorrhage and bilateral tension pneumothoraces. She sustained a non-survivable hypoxic brain injury and died at home six weeks later. Concerns included failure to consider and promptly recognise tension pneumothoraces during resuscitation, and inadequate investigation, clinical governance and learning 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 Failure to disseminate institutional learning from unexpected deaths
Wider context from the report “4. Trust Clinical Governance procedures
The senior management team within the Trust have not acknowledged that there was a lack of a proper and robust system in place to trigger an investigation into all the circumstances of the death of a 17-year-old patient, with no steps taken by them to do so either before or after the publication of the HSIB report or at any time prior to the Inquest hearing.
This gives rise to a concern of a lack of insight within the senior management team of the importance of undertaking a comprehensive investigation into unexpected deaths within their organisation and for there to be wider dissemination of any institutional learning with the aim of preventing future deaths .
The failure of the Trust to fully investigate how Teegan came by her death also gives rise to a concern regarding the Trust’s obligation to comply with the Statutory Duty of Candour and their requirement to share their findings with both the regulators and Teegan’s family as well as to indicate the steps, if any, they have taken to prevent future deaths.
” Source location Teegan Marie Barnard · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss HSIB investigation outputs and learning through Intensive Care, Maternity Mortality and Morbidity, and other Trust forums.
Verbatim wording from the response “The anaesthetic team cooperated fully with the HSIB investigation and responded comprehensively to the draft report. The outputs were discussed at length within the Trust in a number of forums and continues to be, including at the Intensive Care and Maternity Mortality and Morbidity meetings. This feedback was not fully reflected in the final report.” Source location Response from St Richards Hospital
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning that non-traumatic bilateral pneumothoraces can cause failure to ventilate and cardiac arrest through safety updates, education and events.
Verbatim wording from the response “Bilateral pneumothoraces occurring on emergence from a general anaesthetic, especially one for surgery that did not include thoracotomy or thoracoscopy, is so rare that most anaesthetists will never encounter such a situation. All anaesthetists are taught the 8 reversible causes of cardiac arrest through the Resuscitation Council’s Advanced Life Support course, or an equivalent, that they must complete as part of their training and maintain their competencies throughout their career. Bilateral pneumothoraces are mentioned only in the setting of trauma in the Resuscitation Council’s guidelines. For this reason, we will share the learning from Teegan’s death that bilateral pneumothoraces can be cause of failure to ventilate leading to cardiac arrest in the absence of trauma or thoracic surgery.” Source location Response from Royal College of Anaesthetists
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning from Teegan’s death through the Safe Anaesthesia Liaison Group network and relevant organisations.
Verbatim wording from the response “Bilateral pneumothoraces occurring as it did in this case is rare and we note that both the Royal College of Anaesthetists (RCoA) and Association of Anaesthetists has stated that most anaesthetists will never encounter such a situation. NHS England’s National Patient Safety Team forms part of the Safe Anaesthesia Liaison Group (SALG), together with the RCoA and the Association of Anaesthetists, who will therefore be sharing the learnings from Teegan’s death across its network of relevant organisations. The national Regulation 28 Working Group will also be asking its regional members to share the learnings with their Integrated Care Boards (ICBs) for onward sharing to Trusts across England.” Source location Response from NHS England
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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 Ask regional Regulation 28 Working Group members to share learning with Integrated Care Boards for onward dissemination to trusts across England.
Verbatim wording from the response “Bilateral pneumothoraces occurring as it did in this case is rare and we note that both the Royal College of Anaesthetists (RCoA) and Association of Anaesthetists has stated that most anaesthetists will never encounter such a situation. NHS England’s National Patient Safety Team forms part of the Safe Anaesthesia Liaison Group (SALG), together with the RCoA and the Association of Anaesthetists, who will therefore be sharing the learnings from Teegan’s death across its network of relevant organisations. The national Regulation 28 Working Group will also be asking its regional members to share the learnings with their Integrated Care Boards (ICBs) for onward sharing to Trusts across England.” Source location Response from NHS England
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 Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group to share learning, identify trends and consider further review or action.
Verbatim wording from the response “I would also like to provide further assurances on national NHSE work taking place around the Reports to Prevent Future Deaths. All reports receive are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.” Source location Response from NHS England
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 Share learning that bilateral pneumothoraces can cause cardiac arrest without trauma or thoracic surgery through safety updates, education and events.
Verbatim wording from the response “Bilateral pneumothoraces occurring on emergence from a general anaesthetic, especially one for surgery that did not include thoracotomy or thoracoscopy, is so rare that most anaesthetists will never encounter such a situation. All anaesthetists are taught the 8 reversible causes of cardiac arrest through the Resuscitation Council’s Advanced Life Support course, or an equivalent, that they must complete as part of their training and maintain their competencies throughout their career. Bilateral pneumothoraces are mentioned only in the setting of trauma in the Resuscitation Council’s guidelines. For this reason, we will share the learning from Teegan’s death that bilateral pneumothoraces can be cause of failure to ventilate leading to cardiac arrest in the absence of trauma or thoracic surgery.” Source location Response from Royal College of Anaesthetists
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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 identified care, evidence-handling, Duty of Candour and investigation concerns fall outside HEE’s current role and statutory responsibilities.
Verbatim wording from the response “I write in response to your report of 17 January 2023, made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. I have been asked to respond on behalf of Health Education England. Please may I start by offering my sincere condolences to the family of Teegan Marie Bernard, following her tragic death. However, having carefully considered the report, together with the facts of the case, we believe that whilst there are valuable lessons to be learned; Unfortunately, these do not come within the scope of HEE’s current role and statutory responsibilities.” Source location Response from Health Education England
Open published response
11 Jan 2023 Carol Ann Welch · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 1
Failure to embed patient-safety learning and convey it to new senior team members View source
This report raised 6 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
Carol Ann Welch · 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
Carol Ann Welch became unwell with symptoms initially diagnosed as migraine, returned to the emergency department with changed symptoms, and was discharged without further investigation. She suffered a cardiac arrest on 30 April 2022 and died on 1 May 2022 after an undiagnosed cerebral aneurysm and subsequent spontaneous subarachnoid haemorrhage. Concerns included failure to investigate possible neurological findings, failure to follow guidance on consultant review after an unexpected return within 72 hours, and uncertainty about how relevant learning and guidance would be embedded, assessed and communicated across the medical team.
Read the report on judiciary.uk
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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 embed patient-safety learning and convey it to new senior team members
Wider context from the report “(5) The evidence made it clear that the individuals concerned had subsequently undergone appropriate training and reflection to avoid any recurrence. However, it was less clear how either learning point identified would be embedded in the team as a whole and conveyed to new members joining the team , particularly those joining the team at a more senior level, who would not previously have operated within the guidelines .
” Source location Carol Ann Welch · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to provide Trust-wide learning and training from serious incidents View source
This report raised 4 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
Adam GALLAGHER · 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
Adam Gallagher, aged 30, died on 18 October 2021 after being found at around 9am, following communication of suicidal ideation while under the influence of alcohol. The report identifies a missed opportunity for urgent intervention, including limited assessment, no clinical input and no ambulance dispatch, and raises concerns about learning, retraining and mental-health incident protocols.
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 provide Trust-wide learning and training from serious incidents
Wider context from the report “(1) NEAS Trust confirmed in evidence that a more detailed assessment of AG should have
been undertaken and Clinical input sought leading to Ambulance dispatch and potentially an
alternative outcome for AG. Learning from the incident was limited to 'discussion' with 2 staff
involved.
Serious events of this nature should be subject of Trust wide learning and training to prevent
future deaths.
” Source location Adam GALLAGHER · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.