17 Feb 2015 Huseyin Hasan Erdogan · Prevention of Future Deaths report North London
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Concerns raised 3
Failure to complete steps in the Haringey Crisis Resolution Team action plan View source Delays in completing outstanding action-plan steps View source Failure to complete steps in the first action plan View source
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
Huseyin Hasan Erdogan · 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
Huseyin Hasan Erdogan hanged himself on 4 June 2014 and died on 13 June 2014 from cerebral hypoxia resulting directly from the hanging. The inquest identified a failure by mental health practitioners to conduct and act upon a fully informed assessment of his mental state, contributing to no steps being taken to prevent the hanging. Concerns were also raised that action-plan steps intended to address recommendations had not been completed by the inquest and that further deaths might not be prevented without their completion.
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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 complete steps in the Haringey Crisis Resolution Team action plan
Wider context from the report “(2) Although the Haringey Crisis Resolution Team (SUI) Action plan likewise set out nine steps to be taken (some of which corresponded very closely with those set out in the first Action Plan), and likewise set a “Date to be completed” of “November 2014”, there was, again, no evidence before me at the inquest that items numbers 1, and 3 to 9 had been completed .
” Source location Huseyin Hasan Erdogan · 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 Delays in completing outstanding action-plan steps
Wider context from the report “(3) The risk of further deaths not being prevented will not be diminished if all outstanding steps have not already been completed, and if they are not completed without avoidable delay .
” Source location Huseyin Hasan Erdogan · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to complete steps in the first action plan
Wider context from the report “(1) Although the first Action Plan set out six steps to be taken as “Action in Response to recommendations” and, although the “Date to be completed” for items 1 to 5 was stated to be “November 2014” there was, by the date of the inquest (over two months later) no evidence before me that any of those five steps had been completed .
” Source location Huseyin Hasan Erdogan · Prevention of Future Deaths report
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15 Jan 2015 Judith Anne SAVILLE · Prevention of Future Deaths report Exeter and Greater Devon
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Concerns raised 1
Failure to implement the action plan arising from the Root Cause Analysis 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
Devon 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. 10
Devon Partnership NHS Trust
Provide comprehensive assessments and formulate recovery, care and risk plans for people using CRHT services.
View source
Devon Partnership NHS Trust
Reassess CRHT patients before discharge when increased risks have been identified.
View source
Devon Partnership NHS Trust
Record all telephone calls received by CRHT teams in clinical records.
View source
Devon Partnership NHS Trust
Document discharge awareness and routinely consult and inform people and carers about CRHT discharge decisions.
View source
Devon Partnership NHS Trust
Register both CRHT teams for the Triangle of Care initiative.
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Devon Partnership NHS Trust
Contact people on the day they are discharged from CRHT, using face-to-face or telephone contact according to risk.
View source
Devon Partnership NHS Trust
Increase OPMH consultant input and provide CRHT teams with direct access to OPMH consultants or named backup.
View source
Devon Partnership NHS Trust
Have CRHT staff attend weekly Rougemont discharge-planning meetings to improve Adult/OPMH communication.
View source
Devon Partnership NHS Trust
Develop recovery plans face to face with people using CRHT services whenever safe and practicable.
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Devon Partnership NHS Trust
Consider the wishes and opinions of people receiving services in clinical decision making.
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Judith Anne SAVILLE · 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
Judith Anne Saville, who had a long history of agitated depression and previous psychiatric admissions and ECT treatment, was found deceased at home on 28 January 2014. The inquest concluded that she died from a Zopiclone and Paracetamol overdose and that she had taken her own life. Concerns included the quantity of medication prescribed, the need for warnings about a history of overdose in the practice’s computer system, and implementation and auditing of an action plan.
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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 the action plan arising from the Root Cause Analysis
Wider context from the report “(2) For the attention of Melanie Walker
The Inquest heard evidence from ████████████████████ who had conducted a Root Cause Analysis into the circumstances of Mrs Saville’s death. A copy of that Report is attached.
████████ gave evidence that there were a number of lessons to be learned and that an action plan had been drafted .
At Inquest I expressed my concern that the action plan was implemented and its effectiveness subsequently audited.
” Source location Judith Anne SAVILLE · 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 Provide comprehensive assessments and formulate recovery, care and risk plans for people using CRHT services.
Verbatim wording from the response “Action 1
Recommendation: That Crisis Teams should provide a comprehensive assessment (including a full mental state assessment) for all people using the service, required for the recovery plan. From this a recovery / care plan and risk assessment (including information of known risks) should be formulated to meet and manage identified needs and risks.” Source location 2015-0011-Response-by-Devon-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 Reassess CRHT patients before discharge when increased risks have been identified.
Verbatim wording from the response “Action 2
Recommendation: That the CRHT team reassess individuals prior to discharge where increased risks have been highlighted.” Source location 2015-0011-Response-by-Devon-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 Record all telephone calls received by CRHT teams in clinical records.
Verbatim wording from the response “Action 3
Recommendation: That all phone calls received by CRHT teams are recorded in the clinical record.” Source location 2015-0011-Response-by-Devon-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 Document discharge awareness and routinely consult and inform people and carers about CRHT discharge decisions.
Verbatim wording from the response “Action 4
Recommendation: That RiO notes and recovery plans regarding the discharge of people from the CRHT team clearly state whether the person involved and their carers are aware of the discharge.” Source location 2015-0011-Response-by-Devon-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 Register both CRHT teams for the Triangle of Care initiative.
Verbatim wording from the response “Action to address recommendation: That the CRHT team CTL communicates the importance of the clinical record indicating that people using the service and their carers are aware of discharge. That carers are being informed about discharge by both CRHT being signed up to the Triangle of Care initiative and is also monitored by CRSM/random audits.” Source location 2015-0011-Response-by-Devon-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 Contact people on the day they are discharged from CRHT, using face-to-face or telephone contact according to risk.
Verbatim wording from the response “Action 5
Recommendation: That, unless clinically indicated otherwise, the CRHT team always contact people (face to face or telephone) on the day that they are discharged from the team.” Source location 2015-0011-Response-by-Devon-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 Increase OPMH consultant input and provide CRHT teams with direct access to OPMH consultants or named backup.
Verbatim wording from the response “Action 6
Recommendation: That the OPMH team and the CRHT team carry out a review of how to improve communication between teams with recommendations and actions reported into the CRHT team and OPMH team.” Source location 2015-0011-Response-by-Devon-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 Have CRHT staff attend weekly Rougemont discharge-planning meetings to improve Adult/OPMH communication.
Verbatim wording from the response “Action 6
Recommendation: That the OPMH team and the CRHT team carry out a review of how to improve communication between teams with recommendations and actions reported into the CRHT team and OPMH team.” Source location 2015-0011-Response-by-Devon-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 recovery plans face to face with people using CRHT services whenever safe and practicable.
Verbatim wording from the response “Action 7
Recommendation: That all cases open to the CRHT team have a recovery plan that is developed face to face with the individual.” Source location 2015-0011-Response-by-Devon-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 Consider the wishes and opinions of people receiving services in clinical decision making.
Verbatim wording from the response “Action 8
Recommendation: That the wishes and opinions of people receiving services are always considered in the clinical decision-making process.” Source location 2015-0011-Response-by-Devon-Partnership-NHS-Trust
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9 Oct 2014 Tracy Michelle ROOKE · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 1
Delays in acting on road safety recommendations 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
Tracy Michelle ROOKE · 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
Tracy Michelle Rooke died after losing control of her vehicle on the A3102 at Mile Elm, crossing the centre of the road and colliding with an oncoming van. The report identified thick fog and her unfamiliarity with the road as factors that more likely than not contributed to the incident and her death. A concern was raised about mud on the highway and the quality of nearby signage as potential hazards, although the report states that the mud played no part in Ms Rooke’s death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in acting on road safety recommendations
Wider context from the report “During the course of the Inquest I heard evidence from ████████ whose role is the Force’s Traffic Management and Road Safety Assessment Officer. He is a former Collision Investigator. As part of his evidence he produced a copy of his report dated 26 June 2014 in respect of which I believe you received a copy back in June.
In that report and specifically at pages 10 & 11 of the report, a copy of which I have attached to this Regulation 28 report, he sets out a number of recommendations. I share the concerns that are raised by ████████ in his report which focuses on identified issues concerning road signage, the location of road signage and the current state of road signage in this particular area.
I am concerned that if these are not addressed that they potentially could contribute to future road traffic incidents that may result in injury or even death.
I am additionally concerned having regard to the evidence that ████████ gave in respect of which he indicated that whilst you have been given a copy of his report including recommendations that no action would be taken until I make a report with a view to the prevention of future deaths . That concerns me as Highways Authority you believe there is merit in relation to the recommendations then it should not have to wait until a Coroner makes a report some months after the Traffic Management and Road Safety Assessment Report is submitted before action is taken .
” Source location Tracy Michelle ROOKE · Prevention of Future Deaths report
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9 May 2014 Gary Richards · Prevention of Future Deaths report Inner South London
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Concerns raised 1
Failure to complete identified clinical pathway and interagency service improvements View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Gary Richards · 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
Gary Richards had a forensic history and was at increased risk of taking his own life. He deliberately jumped in front of a moving train at Ladywell Station on 10 October 2012 and died at KCH on 16 October 2012. Concerns included inadequate assessment and communication of his self-harm risk, failures in follow-up and reliable communication, and uncompleted actions addressing identified service-delivery problems.
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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 complete identified clinical pathway and interagency service improvements
Wider context from the report “(2) After discharge in May, he was not followed up, as there was no address and his mobile phone number was not recorded. After attendance in June, again there was a failure to contact him for follow up, reported to be due to a phone failure. The failure to ensure reliable communication pathways for follow up is a potential risk for vulnerable patients.
(3) The Serious Untoward Incident Report (Acute Mental Health Comprehensive Level Two Report, 10th October 2012) found seven areas of concern and service delivery problems, including weaknesses in risk assessment and recognition of suicide plan, lack of clarity of responsibility for risk assessment, inadequate 7 day follow up and communications with GP and problems in support as no mental illness. A plan was adopted which required review of clinical pathway focusing on risk assessment, staff induction and a review of homeless services and interagency working. Despite the intervening eighteen months, progress on these was not evident and it was clear that these actions had not been completed .
” Source location Gary Richards · 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 Secure £250,000 funding to pilot a mental-health-specific homeless project linked to an established homeless support scheme.
Verbatim wording from the response “Homelessness features highly amongst the patients that the Trust cares for. However, I am pleased to inform you that we have been successful in obtaining funding in the sum of £250,000 from the Guys and St Thomas’ Hospital Charity to pilot a mental health specific homeless project working with those who present to our services. This will be linked to an existing scheme which is in place across King’s and St Thomas’ Hospitals for those who enter our services who are homeless, and where our staff will have direct access to the expertise in an already established homeless scheme. I am sure that this will lead to an improvement in the service we can provide to patients who are in this unfortunate situation.” Source location 2014-0212-Response-by-South-London-Maudsley-NHS-Trust
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17 Dec 2013 William Alfred Andrews · Prevention of Future Deaths report South Yorkshire (West)
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Concerns raised 1
Failure to implement recommended strategies to reduce recurrence of plastic obstruction incidents 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
Department of Health and Social Care
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AI-generated summary
William Alfred Andrews · 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 Alfred Andrews, a 77-year-old man, underwent cardiac surgery and subsequently suffered repeated circulatory arrests after a bulb syringe cap entered and remained in his left ventricle. The cap was later removed during a second operation, but his condition deteriorated and he died. Concerns included the cap's lack of visibility, inadequate awareness of its presence, and the absence of a standard procedure to check and count syringe caps at the end of surgery.
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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 recommended strategies to reduce recurrence of plastic obstruction incidents
Wider context from the report “(1) If a simple precaution was taken in ensuring that the tip of a bulb syringe or similar was a different colour to the rest of the equipment then it is difficult to see how a surgeon could use a syringe with the tip still in place by error. As the attached photograph shows there is no significant difference between the syringe with the tip on or off.
(2) There is a further concern in respect of other information which is contained with the Trust’s SUI report as follows:
It is perhaps of some relevance that in 2001-2 a number of instances of items of anaesthetic airway equipment being blocked with extraneous pieces of plastic and causing harm to patients were the subject of a national police investigation (Operation Cordian). The police findings were examined by an Expert Group, which published a series of recommendations in 2004. Their conclusion was that there was no criminal intent but that the incidents had happened as a matter of chance. Strategies to reduce the chances of these events recurring were recommended. Recommendation 1 states “The MHRA should recommend to manufacturers and the relevant Standards Committees that ….. detachable caps (eg. On intravenous cannulae and giving sets) be manufactured in brightly coloured material, preferably red, to aid visibility”.
No action appears to have been taken in consequence of this.
(3) The SUI report goes on to indicate that none of the team undertaking the operation were aware that the bulb syringe came supplied with a cap. The previous brand used by the Trust was not supplied with a syringe cap. The current bulb syringes in use obviously do have a cap but this is normally removed by the scrub practitioner before the syringe is supplied to the operating surgeon. Thus there has been little opportunity for surgeons to appreciate that syringes now have caps. This underlines the importance of ensuring that such devices are manufactured with a brightly coloured cap, if one is to be used at all.
(4) There appears to be no standard procedure for checking for syringe caps (where used) at the end of the operation, such as there is with swabs. The evidence available to me suggests that items such as syringe caps are just discarded by the scrub practitioner without being retained for counting. Of course, the fact that some syringes are apparently manufactured with a cap and others without complicates the situation but is not actually a bar to counting the number of caps present at the outset of the operation.
” Source location William Alfred Andrews · 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 Responsibility for medicines and devices, including syringes, rests with the MHRA, which is gathering information on the case.
Verbatim wording from the response “I am aware that you have contacted the Medicines and Healthcare Regulatory Authority (MHRA), which is the body with responsibility for medicines and devices (including syringes), and that officials there are gathering information on this case, with a view to providing evidence to the inquest when it reconvenes.” Source location 2013-0368-Response-by-Department-of-Health
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing manufacturer safety measures, NHS surgical never-event work and revised guidance are considered sufficient to address the concerns and prevent future deaths.
Verbatim wording from the response “I am pleased to note that the MHRA has made significant progress in discussions with Rocielle - the manufacturers of the syringes and have written to let you know that the manufacturers;” Source location 2013-0368-Response-by-Department-of-Health
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.