12 May 2017 Nasar AHMED · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2
Failure to verify school medication directly during medication reviews View source Lack of follow-up review tracking after replacement medication is requested View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 10
Action
Remind staff that medication must be physically present for reviews and treat comparable breaches as gross misconduct with professional referral.
Stated by Compass Wellbeing CICStated completedThe respondent said that this action was complete when they made their response on 3 May 2023. View source
Action
Introduce and scan a medication-review checklist into each child’s health record, with completion checked through biannual IHCP audits.
Stated by Compass Wellbeing CICStated completedThe respondent said that this action was complete when they made their response on 3 May 2023. View source
Action
Review all pupil Individual Health Care Plans and verify that emergency-box medicines are prescribed and in date.
Stated by Bow SchoolStated completedThe respondent said that this action was complete when they made their response on 3 May 2023. View source
Action
Use Safeguarding Committee governance, scheduling, spot checks and compliance reporting to monitor Individual Health Care Plans and medicines.
Stated by Bow SchoolStated completedThe respondent said that this action was complete when they made their response on 3 May 2023. View source
Action
Deliver tailored biannual school-nursing training covering record keeping, communication, action follow-up, electronic diaries and diary management.
Stated by Compass Wellbeing CICStated completedThe respondent said that this action was complete when they made their response on 3 May 2023. View source
Action
Implement measures requiring school nurses to follow up and update IHCP meeting actions routinely.
Stated by Compass Wellbeing CICStated completedThe respondent said that this action was complete when they made their response on 3 May 2023. View source
Action
Train clinical staff to use electronic diaries, reminders, shared calendars and mobile devices for appointment and action follow-up.
Stated by Compass Wellbeing CICStated completedThe respondent said that this action was complete when they made their response on 3 May 2023. View source
Action
Roll out the electronic diarising system fully across the service in the new academic year.
Stated by Compass Wellbeing CICStated plannedThe respondent said that this action was planned when they made their response on 3 May 2023. View source
Action
Reinforce contemporaneous record keeping, action-point ownership and follow-up dates through medico-legal training and competency-framework training.
Stated by Compass Wellbeing CICStated completedThe respondent said that this action was complete when they made their response on 3 May 2023. View source
Action
Implement monitored procedures for arranging and following up Individual Health Care Plan and medication reviews, including senior oversight and deadline reminders.
Stated by Bow SchoolStated completedThe respondent said that this action was complete when they made their response on 3 May 2023. View source See 7 more actions
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AI-generated summary
Nasar AHMED · 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
Nasar died following an anaphylactic reaction contributed to by asthma while he was in the internal exclusion room at school. The concerns included delayed or inappropriate advice about using his adrenaline auto-injector, discrepancies and gaps in asthma and allergy care planning, unsuitable emergency inhaler equipment, inadequate medication review systems, and shortcomings in staff awareness, training and emergency procedures.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to verify school medication directly during medication reviews
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist .
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” Source location Nasar AHMED · 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 Lack of follow-up review tracking after replacement medication is requested
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided .
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” Source location Nasar AHMED · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind staff that medication must be physically present for reviews and treat comparable breaches as gross misconduct with professional referral.
Verbatim wording from the response “We have reminded all of our staff that there are no circumstances when a school nurse would not be expected to have the medication in front of them when conducting a review. Our staff have been reminded that we would consider a similar breach to be an act of gross misconduct and would also result in a professional conduct referral.” Source location Response from Compass Wellbeing
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 Introduce and scan a medication-review checklist into each child’s health record, with completion checked through biannual IHCP audits.
Verbatim wording from the response “To assist with ensuring that medication is visually inspected by school nurses across the service at review meetings, a checklist has also been introduced for use during Individual Health Care Plan (“IHCP”) review meetings. This new measure is designed to ensure that all areas of the review process have been covered during the meeting. This new checklist will act as guidance and prompt to all school nurses and, once completed, will be scanned onto the Child’s Health Record. A copy of the ‘School annual review asthma/wheeze checklist’ is enclosed. The completion of this checklist will form part of the bi-annual IHCP audit, further details of which are provided later in this response.” Source location Response from Compass Wellbeing
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review all pupil Individual Health Care Plans and verify that emergency-box medicines are prescribed and in date.
Verbatim wording from the response “The Coroner also raised concerns that the system in place for ensuring that actions arising from individual health plans (‘IHP’) and medication reviews were undertaken was not sufficiently robust. Since Nasar’s death, the school’s Safeguarding Committee has undertaken a thorough review of all IHPs for pupils in the school. This included ensuring that all medicines kept within emergency boxes at the school are as prescribed and in date.” Source location Response from Bow School
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use Safeguarding Committee governance, scheduling, spot checks and compliance reporting to monitor Individual Health Care Plans and medicines.
Verbatim wording from the response “The Safeguarding Committee⁵ has developed a flowchart to outline the responsibilities under the ‘Support students with medical needs’ policy. The committee has an agenda item ‘IHP and medication reviews’ so that effectiveness of managing medical needs is considered at each meeting. It is responsible for setting the schedule of meetings for all IHP or medication reviews on a half termly basis. The school administrator is required to liaise with Compass Wellbeing and the YLM to ensure all parties are present at meetings. The Designated Safeguarding Lead (‘DSL’) also receives details of IHP meetings and the decisions made and conducts spot checks on the IHPs and medicines so that compliance with expectations can be maintained. The DSL provides a compliance report each half term to the safeguarding committee.” Source location Response from Bow School
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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 Deliver tailored biannual school-nursing training covering record keeping, communication, action follow-up, electronic diaries and diary management.
Verbatim wording from the response “In addition to the above training, the bi-annual training received by the school nursing service was delivered in June 2017. During bi-annual training, the service is suspended and training takes place across all staff groups. The training has been tailored to support the key learning points from the tragic death of Nasar Ahmed and the requirements and expectations of a school nurse. It covered a range of key areas including how to improve record keeping and the importance of this, the increased function of school nurse administrators in communication and following up of actions with key staff in school and the parents, the use of electronic diary systems and diary management. A copy of the training schedule undertaken in June 2017 is attached.” Source location Response from Compass Wellbeing
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement measures requiring school nurses to follow up and update IHCP meeting actions routinely.
Verbatim wording from the response “CWB have implemented additional measures to ensure that the checking and updating of actions from IHCP meetings are routinely followed up by all school nurses and to prevent this event from happening again.” Source location Response from Compass Wellbeing
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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 Train clinical staff to use electronic diaries, reminders, shared calendars and mobile devices for appointment and action follow-up.
Verbatim wording from the response “All clinical staff have received guidance on how to manage an electronic diary in order to assist staff in diarising appointment, reminders and sharing calendar appointments. All clinical staff have access to mobile working devices, for example laptops, and the service is moving to a fully electronic diarising system in order to support sharing of appointment calendars and the effective use of an electronic diary and reminder system. Specific training on electronic diarising and the use of this took place on 21 June” Source location Response from Compass Wellbeing
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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 Roll out the electronic diarising system fully across the service in the new academic year.
Verbatim wording from the response “All clinical staff have received guidance on how to manage an electronic diary in order to assist staff in diarising appointment, reminders and sharing calendar appointments. All clinical staff have access to mobile working devices, for example laptops, and the service is moving to a fully electronic diarising system in order to support sharing of appointment calendars and the effective use of an electronic diary and reminder system. Specific training on electronic diarising and the use of this took place on 21 June” Source location Response from Compass Wellbeing
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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 Reinforce contemporaneous record keeping, action-point ownership and follow-up dates through medico-legal training and competency-framework training.
Verbatim wording from the response “CWB have re-enforced to all staff the requirement and expectation across the service to ensure that accurate and contemporaneous records are kept, including recording and documenting action points and dates for follow up, as well as documenting who is responsible for each action point. This has been re-enforced through medico-legal training which was arranged for all staff in order to address the implications of poor documentation keeping and the effect this has on the delivery of healthcare. This training took place on 19 June 2017.” Source location Response from Compass Wellbeing
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 Implement monitored procedures for arranging and following up Individual Health Care Plan and medication reviews, including senior oversight and deadline reminders.
Verbatim wording from the response “The Executive Headteacher, along with Headteacher representatives from across the area, has been invited by the Local authority to meet to discuss the school nursing service as part of a scheduled contract renewal process. This meeting is due to take place later this year, but it is understood that the concerns identified during the Inquest will inform that process. In the interim the school has been working with Compass Wellbeing to clarify the procedure for setting up IHP meetings and medication reviews. The school has had additional processes to ensure this procedure is robustly monitored at senior level. The procedure requires that, in all cases an update of the pupil’s medical need is required at each review.” Source location Response from Bow School
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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 Checking that in-date medication is provided is a shared responsibility between the school and school nurse.
Verbatim wording from the response “The Supporting Medical Needs Policy indicates that the responsibility of checking that in-date medication is provided is a shared one between the school itself and the school nurse. It is fully expected that the school nurse and the school would have a conversation to discuss follow-up actions arising from a meeting and appropriately diarise to check that the correct medication has been received and, if not received, to chase this up in a timely manner. As a qualified health professional, the school nurse is able and expected to understand whether a prescription is appropriate and whether the correct medication has been received. Any outstanding actions must be followed up and completed as a matter of course and in accordance with their professional duties.” Source location Response from Compass Wellbeing
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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 Parents or the school nurse are principally responsible for contacting the pupil’s GP or other treating medical professionals before reviews.
Verbatim wording from the response “Principally it remains the responsibility of the child’s parents or school nurse to make contact with the child’s GP or other medical professionals involved in their care prior to the meeting. Where, at the review meeting, this hasn’t been done or there is any uncertainty regarding the pupil’s current need the school nurse is required to follow up with direct contact to the pupil’s GP and confirm the position to the school administrator by email. The deputy head responsible for safeguarding is also copied into those emails. The procedure also differentiates between medication reviews and IHP meetings/reviews to ensure that necessary follow up can be scheduled separately. For example, where actions are required as a result of the medication review, a follow up review is scheduled for the following week.” Source location Response from Bow School
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10 Feb 2017 Rachel Morgan · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to initiate timely medication reviews View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Rachel Morgan · 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
Rachel Morgan, who had post-natal depression with psychotic symptoms and was considered at high risk of suicide, was found with a ligature around her neck on 16 April 2016 and died from severe anoxic brain injury on 24 April 2016. The principal concerns were delays in reviewing her medication, failures to update risk assessments after information about her suicide risk was received, insufficient observation levels, and a lack of clarity about observation procedures.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to initiate timely medication reviews
Wider context from the report “(1) I am concerned that despite the fact that Rachel Morgan and her family made it clear to the staff at the Medlock Ward from the start of her admission that she wanted her medication to be reviewed as felt that her anti-depressant medication was not working, no steps were taken to begin the review process during the 4 days she was an inpatient before her death . I am concerned that in the knowledge that Rachel was reporting issues with her medication, a medication summary could have been undertaken before the first ward round took place on the 15th April. Please consider whether on admission patients should have a medication summary completed as part of the clerking process, which would allow any medication reviews to be conducted by an appropriate Doctor at the first available opportunity.
” Source location Rachel Morgan · Prevention of Future Deaths report
Open source report
14 Jul 2016 Mr Harold Goulding · Prevention of Future Deaths report London (East)
View report summary
Concerns raised 1
Failure of General Practitioners to review and approve care home residents’ Medication Administration Records View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mr Harold Goulding · 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
Mr Harold Goulding suffered two falls at a care home on 5 and 6 November 2015, followed by a subdural haematoma, seizure and cardiac arrest; he died on 10 November 2015. The concerns included communication failures between the anticoagulation clinic, GP and care home, and the GP not checking the care home’s medication administration record, meaning he was unaware that Mr Goulding was receiving warfarin.
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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 of General Practitioners to review and approve care home residents’ Medication Administration Records
Wider context from the report “1. The evidence revealed a breakdown of communication between the anti-coagulation clinic, the General Practitioner and the Care Home. The Care Home had registered Mr Goulding with a new General Practitioner but did not notify the anti-coagulation clinic of the details of the new General Practitioner. The community pharmacist therefore continued to provide reports to the old GP.
2. The General Practitioner provided the lead in relation to the administration of medication at the care home. The General Practitioner did not however consider the Medication Administration Record held by the home.
The staff providing evidence from the care home agreed that it would reduce risk in the future, if a system is in place to ensure that the General Practitioner attending for new resident reviews, considers and approves the medication set out within the Medication Administration Record. This would not only provide assurance to the Care Home staff in relation to medication that they are administering, but would also ensure that GPs are fully aware of the medication that residents are currently receiving.
It was further agreed that in order to reduce future risk, the Care Home staff should take the lead in ensuring that any other health agencies providing care to new residents are informed when the home registers new residents with a new General Practitioner, so that information can be correctly shared.
” Source location Mr Harold Goulding · 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 Have the duty nurse accompany GPs on rounds and review medication administration charts and care plans to share relevant information.
Verbatim wording from the response “When the GP visits the Home to attend to the resident’s needs, the Nurse on duty will accompany the GP on his rounds and go through the medication administration charts and care plans to ensure all information is shared where necessary. A handover document for use with new resident’s details has been created to ensure relevant information is shared with the new GP where required.” Source location 2016-0248-Response-by-Orchard-Care-Homes
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17 Dec 2015 Edna May CLEATON · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to ensure appropriate medical reviews of patients on citalopram before repeat prescriptions are issued View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Edna May CLEATON · 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
Edna May CLEATON died at home after serious pressure sores became septic. The report raised concern that she had not seen a doctor for over three years while receiving repeat citalopram prescriptions, and that systems were needed to ensure appropriate medical reviews before repeat prescriptions were issued.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure appropriate medical reviews of patients on citalopram before repeat prescriptions are issued
Wider context from the report “(1) The evidence heard at the inquest was that patients on citalopram should be reviewed by a doctor every 3 – 6 months . This lady had not been reviewed for over 3 years . The practice need systems in place to ensure patients received appropriate medical reviews before repeat prescriptions are issued . Had regular reviews been undertaken it is possible that medical staff would have identified deterioration in the deceased and a care plan could have been instigated which may have avoided the pressure sores that developed.
” Source location Edna May CLEATON · 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 Implement a repeat-prescribing protocol requiring antidepressant reviews at least every six months before further prescriptions are issued.
Verbatim wording from the response “When a repeat prescription for antidepressants is set up it is usually only for a maximum of six months. After this period a review must take place.” Source location Edna-Cleaton-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 Configure an electronic clinical-system prompt that prevents depression-coded repeat prescriptions without a documented review in the preceding six months.
Verbatim wording from the response “We also have an automatic electronic protocol that has been built into the clinical system that is activated if repeat prescription is generated with a read code of depression. If a review has not taken place, then an automatic prompt will appear, reminding the prescriber of the need for a review before the prescription can be issued.” Source location Edna-Cleaton-Response
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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 repeat-prescribing protocols and electronic prompts are considered sufficient to ensure timely antidepressant reviews.
Verbatim wording from the response “This has been agreed by all the doctors at Jockey Road Medical Centre. When a repeat prescription is generated, that person must ensure that an appropriate review has happened in the previous six months.” Source location Edna-Cleaton-Response
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Concerns raised 2
Failure to review medication in accordance with accepted medical practice View source Lack of a system to ensure medication review View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Nancy Hughes · 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
Nancy Hughes, who had Alzheimer’s disease and was receiving Risperidone, fell at a care home and later suffered a further unwitnessed fall in hospital before dying on 3 January 2014. The concerns were that her medication was not reviewed as required and that there was insufficient cohesion between mental health and medical treatment, potentially affecting care for vulnerable patients.
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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 review medication in accordance with accepted medical practice
Wider context from the report “1. That there was no review of her medication in accordance with accepted medical practice and no system in place to ensure that this was undertaken.
” Source location Nancy Hughes · 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 Lack of a system to ensure medication review
Wider context from the report “1. That there was no review of her medication in accordance with accepted medical practice and no system in place to ensure that this was undertaken .
” Source location Nancy Hughes · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Allocate a named care coordinator or nurse within 24 hours and require medication review and continuity of contact during transfers.
Verbatim wording from the response “This is a requirement under the Mental Health (Wales) Measure; there is a requirement for patients to have a named individual who coordinates their care, ie their Care Coordinator.” Source location 2015-0221-Response-by-University-Health-Board
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 Develop and embed prescribing guidance for behavioural and psychological symptoms of dementia, including scheduled monitoring and medication review or discontinuation.
Verbatim wording from the response “For patients known to community teams their care coordinator will be a member of staff from that team, this could be a Consultant, a nurse, a social work or other professional. For patients not previously known to community team prior to their admission, a named nurse (care coordinator) must be allocated to that patient within the first 24 hours of the admission – this is part of the patient’s 7 day admission pathway.
The care coordinator, or named nurse has a responsibility for maintaining contact with the patient and the care team looking after the patient, if they are transferred for medical treatment into an acute hospital setting. This would include review of medication.
BCUHB Mental Health Medicines Management Group has developed a Prescribing Guideline for the Management of Behavioural and Psychological Symptoms of Dementia.” Source location 2015-0221-Response-by-University-Health-Board
Open published response
29 Apr 2015 Jorge Emanuel Mousinho Assabay E Castro · Prevention of Future Deaths report Manchester West
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Concerns raised 1
Failure to review patients’ non-collection of prescribed medication View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jorge Emanuel Mousinho Assabay E Castro · 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
Jorge Emanuel Mousinho Assabay E Castro died at home on 16 October 2014 after being found collapsed and unresponsive. He had post-traumatic epilepsy but had not received sodium valproate after 3 July 2014, despite attending his GP practice three times without the medication issue being reviewed. The principal concerns were the lack of systems to identify uncollected prescriptions and to alert GPs to medication-adherence concerns, particularly for vulnerable patients.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to review patients’ non-collection of prescribed medication
Wider context from the report “1. During the Inquest evidence was heard that:
i. Jorge had not received sodium valproate medication for administration after 3rd July 2014 and he had been diagnosed with post traumatic epilepsy in February 2014 requiring regular treatment with sodium valproate as an anti-epileptic medication.
ii. Jorge had been seen by General Practitioners at the Springfield Medical Centre on three occasions after the 3rd July 2014 without any review of the fact that he had not collected prescriptions for sodium valproate and the fact that the General Practitioner had received a letter from ████████ alerting the General Practitioner to an issue in relation to his regular adherence with his anti-epileptic medication.
iii. Jorge was known to be a vulnerable person, who consumed excess amounts of alcohol on a regular basis and who was being treated with Citalopram for depression prior to his injuries on the 20th June 2013 and subsequently on the 18th September 2014 prior to his death.
iv. The General Practitioner’s surgery at Springfield Medical Centre does not appear to have any systems to identify and highlight a patient who has not collected prescriptions, particularly in relation to vulnerable patients who will be dependent on medication for the control of a diagnosed condition and, as in the case of Jorge, to reduce the risk of episodes of seizure.
In particular the computerised records do not have a system of highlighting any outstanding prescriptions at subsequent consultations so that a General Practitioner was not alerted to the fact that Jorge had not collected his prescriptions and would not have had a supply of his anti-epileptic medication after the 3rd July 2014 at any of the appointments following the 3rd July 2014.
v. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues.
2. I request you to consider the above concerns, particularly with regard to the following:
i. The procedures and systems to highlight and alert General Practitioners in relation to concerns or issues raised by a Hospital Consultant, namely in Jorge’s case by ████████ with regard to Jorge’s regular adherence with his anti-epileptic medication.
ii. A review of your systems and procedures to alert General Practitioners in relation to the issue of prescriptions and the failure of a patient to collect prescriptions for prescribed medications, particularly in relation to vulnerable patients who have not collected or received their prescriptions for a period of time.
iii. Training of all staff, both professional and administrative, in relation to record keeping and checks in relation to outstanding prescriptions, particularly when a vulnerable patient has not collected a prescription and has not received necessary and prescribed medications for a period of time.
” Source location Jorge Emanuel Mousinho Assabay E Castro · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement patient-record alerts when medication-compliance concerns are raised, with staff notifying management so alerts are activated.
Verbatim wording from the response “medication. As a practice we have considered how our IT system can support the practice team in alerting us to similar issues with patients. It is possible for an alert to flag up when any member of staff enters the patient’s records and this will now be implemented for any patients who, similar to Mr Castro, are known to have compliance issues with their medication. All practice staff, clinical and administrative, have been advised to inform the practice management team immediately of any patient where compliance issues have been raised by family, carers or any other health care professionals. The management team will then ensure that an alert is activated on the patient’s records.” Source location 2015-0170-Response-by-Springfield-Medical-Centre
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 Amend the prescribing system to highlight overdue prescriptions after three months and prompt timely clinical follow-up.
Verbatim wording from the response “time period and the practice has made the necessary amendments so that in future any staff viewing a patient’s prescriptions will be alerted sooner (from 3 months) and appropriate action can be taken to mitigate any risk to the patient. This would include immediate notification to the General Practitioner who would then liaise with the patient, carers, family and pharmacy as appropriate. The practice can then work with all necessary individuals or agencies to help support the patient with compliance of their medication.” Source location 2015-0170-Response-by-Springfield-Medical-Centre
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 Create and regularly update a register of patients receiving weekly prescriptions, with monthly administrative checks and GP review of omissions.
Verbatim wording from the response “However, even this system has its limitations, as it would only highlight the issue of overdue prescriptions when a member of the practice team is actually in the patient’s records and looking at the repeat medication screen. As a practice we have over 3000 patients on regular repeat medication. Each prescription is usually for 1 to 2 months duration. However, approximately 300 of these patients, like Mr Castro, are issued medications on a weekly basis. This system is usually for patient safety or as a compliance aid. We have thus decided to create a register of all patients who are receiving prescriptions on a weekly basis. These prescriptions are issued in 4 weekly batches and the administrative staff will be checking the prescriptions have been issued for each patient every month. Those that have not been issued will be passed to a General Practitioner for review.” Source location 2015-0170-Response-by-Springfield-Medical-Centre
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 Notify and collaborate with local pharmacies regarding interruptions to weekly medication collection or supply, and disseminate the significant-event learning.
Verbatim wording from the response “Weekly prescriptions are all sent to the patient’s nominated pharmacy. We have written to our local pharmacies and asked them to kindly inform us if there is any interruption to any of these patients’ medication collection or supply.” Source location 2015-0170-Response-by-Springfield-Medical-Centre
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 Deliver a half-day training workshop for staff involved in repeat-prescription generation to support the revised systems and procedures.
Verbatim wording from the response “3. Training of all staff in relation to prescribing
As a practice we have taken this opportunity to look at our prescribing systems and the changes above do require staff training. However, we have also looked at the possibility of external facilitators who may bring further advice and expertise to the practice of effective management of repeat prescribing. We can confirm that a half-day workshop has been arranged for Thursday 25th June and we would be open to any further recommendations on this day.” Source location 2015-0170-Response-by-Springfield-Medical-Centre
Open published response
12 Feb 2015 Jane Marie Clark and Isobel Griffin · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 1
Failure to conduct planned medication, diagnosis and treatment reviews View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Jane Marie Clark and Isobel Griffin · 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
Jane Marie Clark died by suicide after leaving Berrywood Hospital on 22 August 2013 with an inadequate risk assessment, following recent suicide-related concerns and possession of a ligature. Isobel Griffin died after hanging herself on the ward on 17 August 2013, with death pronounced on 21 August 2013. The principal concerns included inadequate handover and risk assessments, failures to review relevant clinical information and treatment, and insufficient measures to minimise ligature risk.
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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 conduct planned medication, diagnosis and treatment reviews
Wider context from the report “Re Jane Marie Clark
1. The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave. Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented.
2. She did not place any boundaries on the leave for example providing a time by which Jane was to return.
3. Risk assessment documentation generally was poor and appeared perfunctory.
Re Isobel Griffin
1. Mrs Griffin was admitted on 1 August and was not allocated a key worker until 8th August. The key worker did not read the notes so was not aware of the events of the 7th.
2. The risk assessment was not updated with the events of the 7th.
3. Mrs Griffin’s responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3-4 times tried to hang herself using a ligature.
4. A planned review of medication, diagnosis and treatment never took place despite a number of references in the notes to it from 6 August 2013. Mrs Griffin had been substantially unmedicated for most of the admission despite concerns expressed by her family.
5. On 11 August Mrs Griffin started to express thoughts to harm others. These thoughts distressed her. She did not intend to act on them but they were something new and a measure of her distress. These thoughts and their significance were not included in any risk assessment.
6. A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances.
7. The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk.
” Source location Jane Marie Clark and Isobel Griffin · Prevention of Future Deaths report
Open source report
5 Dec 2014 Paul Leslie HYDE · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 1
Failure to provide face-to-face psychiatric medication reviews View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Paul Leslie HYDE · 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
Paul Leslie Hyde died after taking an overdose of medication that had been stopped, with the sedatory effect contributing to his death. The report raised concerns that his referral for a psychiatric medication review was not appropriately addressed, that he was not seen within the required period or followed up, and that the re-referral system was not fit for purpose.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide face-to-face psychiatric medication reviews
Wider context from the report “(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety.
(2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient.
(3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde.
It should have been obvious from the start that this was not a direction for this referral to take.
There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be.
In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up.
(4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose.
In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death.
” Source location Paul Leslie HYDE · Prevention of Future Deaths report
Open source report
22 Aug 2014 MARTIN ARNOLD HILL · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 1
Lack of Senior Pharmacist review of Medical Administration Record charts View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
MARTIN ARNOLD HILL · 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
MARTIN ARNOLD HILL arrived at A & E on 28 March 2014 after approximately three days of confusion, abdominal pain and vomiting, with raised inflammatory markers. The concerns included delayed antibiotics, failures to refer him to the Critical Care Outreach Team when his NEWS was elevated, inadequate withdrawal treatment, failures in managing constipation, poor handover and communication, and serious omissions in the Medical Administration Record.
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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 Senior Pharmacist review of Medical Administration Record charts
Wider context from the report “(5) There are serious omissions on the Medical Administration Record. I was told that it was believed that no Senior Pharmacist reviewed the MAR charts over a weekend . Given the importance of medicating patients correctly, it would seem advisable that there should be a review, if indeed it is the practice that records are not reviewed. It seems that in this particular case the charts are particularly poorly written and perhaps those involved with this patient would benefit from a discussion with the Chief Pharmacist.
” Source location MARTIN ARNOLD HILL · Prevention of Future Deaths report
Open source report
20 Jun 2014 Redmond Johnson · Prevention of Future Deaths report Suffolk
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Concerns raised 1
Failure to conduct medication reviews for complex medication issues View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Redmond Johnson · 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
Redmond Johnson, aged 67, suffered a cardio-respiratory arrest while being transferred to Ipswich Crown Court on 25 November 2011 and died after transfer to Ipswich Hospital. The report identified concerns about the assessment of his fitness for transfer, including a record stating that he had no known medical risks despite the healthcare professional not having seen him. It also identified concerns about the management and documentation of his complex healthcare needs in custody, including liaison with community providers, specialist appointments, investigations, medication and care monitoring.
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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 conduct medication reviews for complex medication issues
Wider context from the report “(3) Medication reviews should be conducted, with appropriate pharmacy input if required, if there are complex medication issues that need resolving or clarifying .
” Source location Redmond Johnson · Prevention of Future Deaths report
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Includes failures of the medication-review process, including identifying when a review is required, arranging or completing the review, obtaining relevant pharmacy or clinical input, reviewing medication-related discrepancies and maintaining required review frequency where the review is needed to support safe prescribing and treatment.
