Recurring concern

Failure to review relevant clinical records before care decisions

First to latest report 23 Aug 2013 — 8 Jun 2026

Reports that mention this concern
54
Times this concern has been raised
59
Stated actions linked to this concern
70

What this concern includes

Includes failures to consult, check, cross-reference or review relevant existing clinical records as part of clinical assessment, prescribing, treatment, admission, transfer, escalation or other care decisions, including review of the correct record set and routine review requirements.

What is not included
  • Excludes failures to retrieve or make records available when the records were not accessible in the first place; those belong to access or record-availability concerns.
  • Excludes deficiencies in the completeness, accuracy or maintenance of the records themselves unless the asserted unsafe condition is also failure to review them.
  • Excludes generic failures to communicate or hand over clinical information where no record-review failure is identified.
  • Excludes non-clinical record reviews, such as administrative, inspection or mortuary monitoring records.

Reports and published responses 54 reports

See individual reports that have raised this concern, and the actions taken in response

  1. West Yorkshire Eastern

    AI-generated summary

    John Dickinson · 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

    John Dickinson was admitted to hospital after falls and treatment for a gall bladder infection, then moved to a care home. He later developed poor nutritional and fluid intake, dehydration, acute kidney impairment and a urinary tract infection, and died on 9 August 2020 while receiving palliative care. Concerns included inconsistent and insufficiently detailed record keeping, failures to document or act on advice about monitoring food and fluid intake, and delayed recognition of deterioration.

    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 check food records before assessing food refusal

    Wider context from the report

    “(1) The record keeping was inconsistent and lacked detail on general wellbeing. (2) The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained. (3) Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020. (4) Advice from the GP on 15th July 2020 were handed over orally at a ‘huddle’ and no record was kept as to this being mentioned. (5) Following the GP’s visit, no action planned regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring. (6) The inconsistent and sometimes non-existent record keeping meant that Mr Dickinson was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before he began refusing lunch and evening meal. ”

    Source location

    John Dickinson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Essex

    AI-generated summary

    Fiona May Humberstone · 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

    Fiona May Humberstone, who had longstanding mental health conditions, alcohol misuse and chronic pain, died at home from an inadvertent overdose of prescribed Oromorph taken with other medication. The concerns included mental health clinicians relying solely on patients’ accounts of their medication and inadequate access to accurate, up-to-date prescribing information between primary and secondary care.

    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

    Insufficient time for responsible clinicians to consider medical records before mental health reviews

    Wider context from the report

    “(3) Issues regarding the necessity for access to (and adequate time for the consideration of) medical records including prescriptions and concordance with medication in advance of mental health reviews undertaken by responsible clinicians has been raised in relation to mental health related death in Essex previously. I am concerned that the evidence from FH’s inquest indicates that such matters remain unresolved. ”

    Source location

    Fiona May Humberstone · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Wiltshire and Swindon

    AI-generated summary

    Vhari Ingall · 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

    Vhari Ingall died from an oxycodone drug overdose, with the inquest returning a conclusion of suicide. The principal concerns were the failure to review an outdated Treatment Escalation Plan/Do Not Resuscitate form after her diagnosis changed, and whether healthcare professionals and emergency services could access accurate and current information about such forms.

    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 review TEP/DNAR documents when clinically significant diagnostic information changes

    Wider context from the report

    “During the Inquest into the death of Vhari I heard evidence from the Senior Partner of her GP surgery, New Court Surgery at Royal Wootton Bassett, Wiltshire as I had a concern in relation to the Treatment Escalation Plan/Do Not Resuscitation (“TEP/DNAR”) form which ████████ had completed with Vhari back in February 2017. I have enclosed a copy of that TEP/DNAR marked “A”. As you will see the reason for issuing it was that Vhari had been diagnosed, late during the previous year, with a pancreatic tumour and she was considered for palliative care only. Towards the end of 2017, the Consultant at Great Western Hospital in charge of her care, reviewed Vhari’s case and the diagnosis changed to one of chronic pancreatitis as opposed to a terminal tumour. This was confirmed in writing to the surgery on the 17 September 2017. During the course of ████████ evidence he explained to me the quite sensible reason why there is no fixed date review of these types of documents but did indicate that such a review was entirely appropriate when it was clinically appropriate to review the TEP/DNAR document. I was firmly of the view that a change in such a fundamental diagnosis should have ordinarily given rise to a review, however, I found no evidence that was recorded in Vhari’s case to suggest that such a review was undertaken by the surgery even though there was a number of consultations with different doctors following Mr. Payne’s letter of September 2017. The notes were completely silent as regards any such review being carried out. In fact I noted an entry in the records on the 5 March 2020 by one of the doctors at the surgery, ████████ who referred to “reminder/alert: DNAR-priority: high.” I also heard evidence from Vhari’s sister, ████████ that in going through Vhari personal possession she found no subsequent TEP/DNAR form after the February 2017 form. I did consider sending a Regulation 28 Report to the surgery but heard evidence from ████████ that they now have provided by the local CCG an add on to their SystemOne system called an Arden’s module which assists in clinical decision making which they are also using in relation to recording TEP/DNARs. Whilst there is never a 100% guarantee that such a failure to review a document like this will not occur in the future and in respect of Vhari’s case it was in no way contributory to her death, I was satisfied that this step was an improvement and an attempt to mitigate against the risk of such a recurrence. Obviously, this package is available to surgeries within my own coronial area, but I am unclear as to the position in other areas and obviously you have a greater awareness of these sorts of matters as part of your inspection processes. ”

    Source location

    Vhari Ingall · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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

    Continue consulting on regulatory next steps and reviewing and updating regulatory approaches, including scope for end-of-life and DNAR/TEP regulation.

    Verbatim wording from the response

    “We are currently now in a period of consultation about our next steps of regulation. During this time, we will continually keep our scope of regulation under review and”

    Source location

    2020-0084-Response-from-CQC-to-further-PFD-report-Redacted
    Page 2 · response
    Published 20 April 2020

    Open published response

    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

    Continue responding to DNAR/TEP risks through routine regulatory monitoring and inspection during the consultation period.

    Verbatim wording from the response

    “We continue to respond to risk via routine monitoring and inspection during this consultation period, including concerns and issues raised in this report.”

    Source location

    2020-0084-Response-from-CQC-to-further-PFD-report-Redacted
    Page 3 · response
    Published 20 April 2020

    Open published response

    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

    Share key learning and practice points from the inquest with inspectors.

    Verbatim wording from the response

    “Where CQC identifies that regulations are not being met, we use our enforcement powers to require improvements to be made. We continue to do this and will share key learning and practice points from the inquest into the death of Vhari Ingall and Mary Grace Johnson with inspectors.”

    Source location

    2020-0084-Response-from-CQC-to-further-PFD-report-Redacted
    Page 3 · response
    Published 20 April 2020

    Open published response

    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

    Previous inspections found no relevant concerns about either practice’s policies, training, systems, or end-of-life care arrangements.

    Verbatim wording from the response

    “CQC undertook an inspection in June 2016 at the GP practice where Vhari Ingall was registered as a patient. This inspection was undertaken prior to the death of Ms Ingall. There were no areas of concern in relation to the relevant practice policies, staff understanding, training and systems to support patients with their care, treatment or planning for their end of life.”

    Source location

    2020-0084-Response-from-CQC-to-further-PFD-report-Redacted
    Page 3 · response
    Published 20 April 2020

    Open published response

  4. South Wales Central

    AI-generated summary

    IAN JAMES WEEKS · 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

    Ian Weeks was remanded into custody at HMP Cardiff and was later found to have hung himself from the shower rail in his cell, sometime between 20 and 21 October 2017. The concerns included that healthcare staff did not check records showing a recent suicide attempt or notice that he had been prescribed antidepressants, and that there was no effective process for reviewing System 1 records or a suicide and self-harm warning flag.

    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 review System 1 and medical records on prison admission

    Wider context from the report

    “(1) Although it was recorded on System 1 that Mr Weeks had recently attempted suicide in another prison shortly before his admission to HMP Cardiff no member of Healthcare staff checked the medical records and further that although the GP records which were sent to the prison confirmed that Mr Weeks was prescribed anti-depressants in the community no member of Healthcare staff noticed this and as a consequence Mr Weeks was not given anti-depressants in HMP Cardiff. The Healthcare witnesses, including the Head of Healthcare, indicated that a red flag for suicide or self-harm would be of great value for staff who because of insufficient staff and a heavy workload did not have time to review the System 1 record in any or any sufficient detail. Further it was considered that all System 1 records should be reviewed when an individual is admitted into the prison and that there should be in place a process for doing so. ”

    Source location

    IAN JAMES WEEKS · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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

    Implementing a red-flag system requires partnership with the technology provider, health authorities and other prisons because it would affect all prisons.

    Verbatim wording from the response

    “In order to pursue a red flag system, a partnership with TPP (SystmOne technology provider), NHS England, NHS Wales Informatics Service (NWIS) and other prisons will be required as this would be a change that would affect all prisons. The clinical team from HMP Cardiff intend to raise this issue at their next All Wales Prison Healthcare Meeting which Public Health Wales and Welsh Government also attend.”

    Source location

    2020-0064-Response-from-Cardiff-and-Vale-NHS-Trust-1
    Page 2 · response
    Published 27 March 2020

    Open published response

    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 dual screening reviews, supported by prison staff reviewing records and sharing important information, are considered sufficient for new admissions.

    Verbatim wording from the response

    “As indicated, a large volume of information is contained within SystmOne. Existing process is for healthcare staff in the prison to undertake two screening reviews of new individuals in order to assess and plan their care. This is done in conjunction with prison staff who also review the SystmOne records and share important information.”

    Source location

    2020-0064-Response-from-Cardiff-and-Vale-NHS-Trust-1
    Page 3 · response
    Published 27 March 2020

    Open published response

  5. Hampshire (Central)

    AI-generated summary

    Sophie Hannah May Boothe · 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

    Sophie Hannah May Boothe had a history of mental health issues and died in a hotel in Hook on 19 June 2019 after an overdose and subsequent contact with mental health services. Concerns were raised that information about her treatment in Australia was not properly reviewed or understood, contributing to the downgrading of her urgent referral, and that poor communication between services led to missed opportunities for assessment and intervention.

    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 identify, review and understand relevant clinical information from foreign jurisdictions during referral triage

    Wider context from the report

    “It became very clear in evidence that the overseas involvement was not properly flagged up when the CPE came to triage Sophie’s referral; this includes both the discharge summary and Sophie’s own self-referral via email whilst she was in Australia. The full discharge summary from Australia was sent by the GP along with his referral on the 8th May 2019 to ensure that all relevant information was shared at the earliest stage. These notes were either not fully reviewed and/or understood by the CPE and this appears to have contributed to the downgrading of Sophie’s referral. It became clear in evidence that the UK services did not understand that “Scheduled” is the Australian equivalent of being “Sectioned” and there was a lack of probity and curiosity to as what this meant and what treatment Sophie had in Australia; albeit that the evidence was not convincing (or even persuasive) that the Australian discharge summary had been thoroughly read at all on being received by the CPE. Overall, there appears, on the evidence, to be very poor communication between the departmental services and, as a result, opportunities appear to have been missed to fully appreciate Sophie’s full clinical presentation when making an assessment about the timeliness of appropriate interventions and assessments. I believe that whilst the service remains disjointed, with insufficient exploration of information sent from foreign jurisdictions, there remains a risk that future death will continue to occur. ”

    Source location

    Sophie Hannah May Boothe · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Pilot a requirement for triage workers to contact every referrer before downgrading referrals.

    Verbatim wording from the response

    “Following learning from this case, the CPE service is piloting a policy that requires triage workers to contact all referrers before downgrading referrals. This is explored further below. This pilot has the additional benefit that there is dialogue between CPE and referrers in relation to specific cases. The information within the referral forms can be discussed and evaluated as there is the opportunity for professional discussion and challenge over the rationale for downgrading. This provides specific feedback and education to referrers about how the information they provide on referral forms is used and interpreted, and how they can improve the content.”

    Source location

    2020-0142-Response-from-Berkshire-NHS-Foundation-Trust.pdf
    Page 3 · response
    Published 1 October 2020

    Open published response

    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 e-referrals with clearer referral information, service-remit prompts and feedback to GPs.

    Verbatim wording from the response

    “The Transformation Team is working to improve the referral system through e-referrals, which will include timescales for ‘drop-downs’, and immediate feedback to GPs. The E referrals went live”

    Source location

    2020-0142-Response-from-Berkshire-NHS-Foundation-Trust.pdf
    Page 3 · response
    Published 1 October 2020

    Open published response

    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

    Refer all referrals with a substantive international element to a manager for triage.

    Verbatim wording from the response

    “The Trust has recognised that the CPE triage team may not always have sufficient time to complete the due diligence required to interpret and translate referrals with substantial additional information from abroad. As a result, all referrals with a substantive international element are now referred up for triage by a manager. This has been taking place successfully since Sept 2019.”

    Source location

    2020-0142-Response-from-Berkshire-NHS-Foundation-Trust.pdf
    Page 4 · response
    Published 1 October 2020

    Open published response

    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

    Transform wellbeing services so Talking Therapies becomes the planned front door, gathers referral information and provides timely feedback.

    Verbatim wording from the response

    “In light of these resource pressures, the Trust has recognised that the current model of triaging referrals needs re-evaluating. It is in a process of transformation of all of its wellbeing services which will aim to address these issues. The final permutation of this transformation remains a work in progress, however the current plan is that Talking Therapies will be the ‘front door’ for all referrals. Talking Therapies will undertake the initial triage and ensure sufficient information is obtained from the referrer. As part of this new model all referrals will receive timely feedback on their referrals.”

    Source location

    2020-0142-Response-from-Berkshire-NHS-Foundation-Trust.pdf
    Page 5 · response
    Published 1 October 2020

    Open published response

    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 shared mechanisms for recording referrals and risk information and escalating cases to CPE.

    Verbatim wording from the response

    “Notwithstanding these immediate changes and the significant learning embedded following Sophie’s death, the transformation of the Trust’s wellbeing services is a much larger piece of work with changes that are designed to ensure that missed opportunities to share such referral information are minimised as far as is possible. Ongoing work within Talking Therapies will focus on clear shared mechanisms for recording referrals, risk information and escalating to the CPE.”

    Source location

    2020-0142-Response-from-Berkshire-NHS-Foundation-Trust.pdf
    Page 6 · response
    Published 1 October 2020

    Open published response

  6. Manchester City

    AI-generated summary

    Tomasz Nowosad · 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

    Tomasz Nowosad was found hanging by a ligature in an ordinary, non-safe cell at HMP Manchester on 2 February 2017, shortly after being transferred from the healthcare centre. The report identifies concerns about risk assessment, including reliance on his denials of suicidal thoughts, incomplete and delayed clinical records, inconsistent use of interpretation services, and his transfer to an ordinary wing despite expressed fears and mental health risks. The inquest jury concluded that the death was suicide contributed to by neglect.

    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 review and record relevant developing medical history before clinical interactions

    Wider context from the report

    “5 12 It is suggested that GMMH staff should ensure that when they have any clinical interactions with patient prisoners they familiarise themselves with all the developing relevant medical history including recent events and record what they have reviewed or considered ”

    Source location

    Tomasz Nowosad · Prevention of Future Deaths report
    Page 7 · concerns

    Open source report

    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

    The healthcare provider is responsible for responding separately to concerns about clinical issues.

    Verbatim wording from the response

    “I am grateful to you for bringing to my attention a number of matters of concern, many of which are relevant across the prison estate. I have consulted with the Governor of HMP Manchester and, where relevant, will mention action that has been taken locally at the prison as well as work that is taking place at national level. I understand that the healthcare provider is responding separately to your concerns about clinical issues.”

    Source location

    2019-0445-Response-from-HMPPS
    Page 1 · response
    Published 8 January 2020

    Open published response

  7. Gateshead and South Tyneside

    AI-generated summary

    ARCHIE RAY GRIEVES · 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

    Archie Ray Grieves was born on 24 May 2017 following a complicated delivery involving shoulder dystocia. He initially showed no signs of life, later showed signs of life, and died a short time after being taken to the special care baby unit. The report identified an avoidable neonatal death, with an eight-minute delay in delivering his body after his head and missed opportunities during antenatal care and delivery to identify risks and plan a safe birth.

    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 review and interpret antenatal records and Growth Chart on labour admission

    Wider context from the report

    “10.On presentation on the 24th May 2017 in labour this mother was received within the Delivery unit as a low risk delivery and no review was undertaken of her earlier management and care either because of the assumption of the appropriateness of her ante natal care together with a conclusion which identified her as simply low risk and/or because there was no meaningful interrogation of her records. In particular the significance of the Growth Chart present within those records with its all too apparent fundal height measurement was misunderstood/misinterpreted or overlooked as to its relevance. ”

    Source location

    ARCHIE RAY GRIEVES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Norfolk

    AI-generated summary

    Brian Robert HAVARD · 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

    Brian Robert Havard attended the Emergency Department with chest pain and vomiting, was discharged with a diagnosis of musculoskeletal pain, then collapsed in the car and died while being taken back to hospital. The concerns included failure to review ambulance records, inadequate senior review arrangements, and poor record keeping.

    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 obtain and review ambulance electronic records

    Wider context from the report

    “1. The doctor had not read the ambulance electronic records and was not aware of a system in place to obtain these notes prior to his seeing the patient. These notes contained information about Mr Havard having hematemesis and two doses of morphine given to Mr Havard by the crew. He did examine Mr Havard and had differential diagnoses and went to speak to the locum consultant who was just coming on shift for advice. The consultant did not ask to see the notes from the crew or the hospital notes and was just shown the ECG. He evinced no professional curiosity about a patient needing three doses of morphine and being considered for discharge. The locum consultant did not seem to be aware of any system in place to access the ambulance electronic records. He did not give any convincing explanation for not seeing this patient or his apparent ignorance regarding obtaining ambulance notes. He did not give a convincing explanation for not reviewing the patient. ”

    Source location

    Brian Robert HAVARD · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  9. Manchester North

    AI-generated summary

    Sarah Kiff · 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

    Sarah Kiff experienced repeated consultations for vaginal discharge, urinary symptoms, heavy menstruation and lower abdominal pain before cervical cancer was diagnosed after an urgent referral in July 2013. The cancer had metastasised to the liver and, after treatment and subsequent decline, she suffered a cardiac arrest and died at Fairfield General Hospital on 14 October 2015. The report identified concerns about failure to follow cancer referral guidance, inadequate examination and history-taking, poor record-keeping and communication, lack of continuity of care, reluctance to perform internal examinations, and inadequate processes for reviewing test results.

    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 by doctors to review clinical history before consultation

    Wider context from the report

    “3. There was lack of continuity of care and a failure by doctors to fully appraise themselves of the clinical history ahead of consultation. The care provided to Ms Kiff was, on occasions, perfunctory. ”

    Source location

    Sarah Kiff · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 protected time between consultations by changing schedules to allow clinicians to review patients’ past and current clinical problems.

    Verbatim wording from the response

    “Due to increasing complexity of many patients, the practice has altered consulting schedules so that blocks between every few patients allow the doctor time to ensure they are up to date with past and current clinical problems for each patient. The blocks result in the standard appointment time of 12 minutes instead of 10 minutes. I have already alluded in sections 1 & 2, to processes now in place to ensure that clinical records are more accurate and that the relevant examinations are performed.”

    Source location

    2017-0407-Response-by-Stonefield-Street-Surgery
    Page 3 · response
    Published 26 February 2018

    Open published response

  10. London Inner South

    AI-generated summary

    Name not published · 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

    The deceased died at St Thomas’s Hospital on 22 November 2017 from brain damage sustained after he hanged himself at home on 20 November 2017. Concerns included changes and prescribing of psychiatric and sedative medication, inadequate clinical records and review of past records, failure to make an urgent psychiatric referral, and uncertainty about the medication found after his death and what he had taken.

    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 examine patients’ past records in full

    Wider context from the report

    “3. On 5 October 2017 the deceased saw Dr A again. The Zolpidem was swapped to Nitrazepam, a more potent sedative, as the deceased had said that after 2 weeks he had not found the Zolpidem to be effective. Expert evidence adduced at the inquest from ████████ was to the effect that the deceased’s presentation at this point should have triggered a further inquiry into his psychiatric history. ████████ said that he would have contacted the deceased’s home GP. 4. On 19 October 2017 the deceased saw Dr A again. He said he was feeling better on the Duloxetine but was still stressed and anxious and got a few anxiety attacks. Dr A prescribed him Propranolol, Nitrazepam and Xanax. Dr A also prescribed the deceased 6 months’ worth of Duloxetine. ████████ evidence was that it was “most unusual” to prescribe such a large amount of medication (6 months’ worth of Duloxetine) during the initial period where a patient’s medication had been switched and where close monitoring was needed. He opined that the first 6 weeks of the ‘switch’ period were ones in which the patient might get worse before getting better, might get worse and might develop suicidal thoughts. ████████ said that such a volume of medication was not merited clinically and could create a risk of overdose. 5. On 8 and 9 November 2017 the deceased saw Dr B. She made no notes of his presentation or diagnosis on any occasion when she saw him which she accepted she should have done. She also did not note her rationale for changing his medication which again ████████ said should have happened. He also considered that Dr B should have examined the past records for the deceased which she accepted she had not done in full. 6. There are a series of further issues with the medication Dr B prescribed the deceased and her records of the same. The electronic patient notes reflect a prescription for Xanax but she said in evidence that the deceased had not in fact accepted this. She prescribed him Temazepam but this is a controlled drug in this country and cannot be prescribed in the usual way. She changed this to Nitrazepam but the dose was incorrect and this was refused by the pharmacy. The next day she prescribed him Lorazepam without him returning the Nitrazepam prescription to her. She made an error in the dose for Lorazepam and had to correct that. When he attended on 15 November 2017 asking for more medication she made no note of his attendance. 7. ████████ evidence was that the multiple changes to the medication regime made by Dr B were not medically indicated and that the deceased had needed an urgent psychiatric referral. He said this was the case by 8 November 2017. 8. Overall ████████ said his impression was that Dr B did not understand what she was prescribing. 9. I accepted ████████ opinion on the various issues set out above. 10. Large numbers of boxes of medication were found at the deceased’s flat after his death by the police and his family. There remains some uncertainty as to where he obtained all the medication from, and what exactly he had taken and when. ”

    Source location

    Name not published · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026