16 Aug 2019 George Benjamin Rimmer · Prevention of Future Deaths report West Sussex
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Concerns raised 1
Unmeasured dosing from the medication bottle View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
George Benjamin Rimmer · 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
George Benjamin Rimmer was found deceased at home on 25 October 2018 after being prescribed Oramorph for pain following decompression surgery. The concerns included taking the medicine directly from the bottle rather than measuring doses, possible lack of counselling about exceeding the prescribed dose, and insufficient warnings about excess or cumulative dosing.
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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 Unmeasured dosing from the medication bottle
Wider context from the report “(1) Mr Rimmer was known to swig out of the bottle rather than take a measured dose as many patient do;
(2) Mr Rimmer self medicated as required;
(3) Mr Rimmer’s GP did not recall advising him of the possible consequences of exceeding the prescribed dose.
(4) There was no evidence to show that anyone had counselled Mr Rimmer with regards to the use of this drug.
(5) The leaflet that comes with the bottle does not provide a sufficient warning of the dangers of taking an excess dose.
(6) There is no mention of the dangers of drinking from the bottle and not measuring the dose.
(7) There is no warning on the bottle to act as a reminder of the dangers of taking an excess dose or of the cumulative effect of taking more than the prescribed amount.
” Source location George Benjamin Rimmer · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request MHRA approval to add an explicit warning against drinking Oramorph directly from the bottle and describe overdose risks in the patient information leaflet.
Verbatim wording from the response “However, we will propose to the MHRA that we include within the ‘HOW TO TAKE ORAMORPH ORAL SOLUTION’ section the following statement (or words to that effect to be agreed with the MHRA):” Source location 2019-0269-Response-by-Boehringer-Ingelheim
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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 Existing dosing instructions and approved labelling were considered sufficiently clear despite lacking an explicit warning against drinking directly from the bottle.
Verbatim wording from the response “Whilst there is no explicit warning in the PIL not to drink directly from the bottle, the wording of the ‘HOW TO TAKE ORAMORPH ORAL SOLUTION’ is also consistent with other oral morphine solutions (ref 9,10) available in the UK. These also provide specific instructions about measuring the correct dose but, like Oramorph®, they do not have an explicit warning not to drink directly from the bottle.” Source location 2019-0269-Response-by-Boehringer-Ingelheim
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11 Jul 2019 Robert Charles Rostron · Prevention of Future Deaths report Manchester West
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Concerns raised 1
Medication administration by agency nurses unfamiliar with the unit View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
Hc-One Limited
Block-book agency staff where possible to improve familiarity with home standards and residents’ needs.
View source
Hc-One Limited
Complete and distribute a strengthened agency-staff orientation booklet across the company.
View source
Hc-One Limited
Orient agency nurses to risk assessments, care plans, diabetes resources, hypoglycaemia materials, medicines, and relevant policies through senior home staff.
View source
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AI-generated summary
Robert Charles Rostron · 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
Robert Charles Rostron, who had Type 1 diabetes and Alzheimer’s disease, became unconscious after an agency nurse administered insulin despite recording a low blood sugar reading of 2.2. He did not recover to his previous baseline and later died in hospital; the inquest found that the insulin administration exacerbated his natural illness. Concerns included the use of agency nurses without formal induction, insufficient knowledge of records and care plans, and an agency nurse being the only qualified nurse in charge of the unit.
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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 Medication administration by agency nurses unfamiliar with the unit
Wider context from the report “I am concerned by the use of Agency Nurses in the homes under the management of HC One. In particular, I am concerned by the lack of formal induction and orientation to the unit on this occasion. I am concerned that reliance is placed upon the nursing qualification itself and the agency providing the nurse. I am concerned that an Agency Nurse was used as the senior member of staff in charge of the shift. I am concerned that the Agency Nurse was giving out medication when he had never worked at the Unit before and. I am concerned that there were no other qualified nurses on the Spring Unit at the time.
” Source location Robert Charles Rostron · 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 Block-book agency staff where possible to improve familiarity with home standards and residents’ needs.
Verbatim wording from the response “There are still unfortunately occasions when we are required to call upon the need to cover nursing shifts at this and other homes with agency nurses. However, we have implemented a series of additional measures to reduce the likelihood of an agency nurse being required to lead a shift without having worked at the home or individual House before.” Source location 2019-0237-Response-by-The-Kind-Care-Company
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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 Complete and distribute a strengthened agency-staff orientation booklet across the company.
Verbatim wording from the response “There are still unfortunately occasions when we are required to call upon the need to cover nursing shifts at this and other homes with agency nurses. However, we have implemented a series of additional measures to reduce the likelihood of an agency nurse being required to lead a shift without having worked at the home or individual House before.” Source location 2019-0237-Response-by-The-Kind-Care-Company
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 Orient agency nurses to risk assessments, care plans, diabetes resources, hypoglycaemia materials, medicines, and relevant policies through senior home staff.
Verbatim wording from the response “As part of the agency nurse’s orientation to the home, the location of all risk assessments, care plans, the diabetes resource file, physical posters regarding hypo/hyperglycaemia management, hypo box, medicines and policies and procedures would be shown, as mentioned previously, to them by the most senior member of staff at the home, to support them in their shift, which would be the Home Manager, Deputy Home Manager or Nurse in charge of the home. This ensures that any agency nurse is fully orientated and knows where to locate important documents as well as summoning support within the home.” Source location 2019-0237-Response-by-The-Kind-Care-Company
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22 May 2019 Jonathan Richard McCARTHY · Prevention of Future Deaths report North West Kent
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Concerns raised 1
Failure to administer the correct dose of insulin View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Jonathan Richard McCARTHY · 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
Jonathan Richard McCarthy was admitted to hospital with confusion, aspiration pneumonia, sepsis, acute kidney injury and swallowing difficulties, and later deteriorated with another aspiration pneumonia and hyperglycaemia. The stated concerns were failures to correctly monitor blood sugar and ketones, administer the correct insulin dose, and provide adequate nursing care and escalation to the medical team.
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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 administer the correct dose of insulin
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The Trust failed to correctly monitor the blood sugar and ketone testing of Jonathan Richard
McCarthy
(2) The Trust failed to administer the correct does of insulin
(3) There was inadequate nursing care and a failure to escalate to the medical team when it was clear
this should be carried out.
” Source location Jonathan Richard McCARTHY · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the pharmacy drug-chart auditing process and disseminate serious-incident learning through the monthly Medicines Safety News editorial.
Verbatim wording from the response “The Pharmacy Department are undertaking a review of the auditing process in regard to Drug charts as this was not identified in the case of Mr McCarthy and is being discussed and addressed at their team meetings. The Serious Incident findings are being highlighted in their monthly learning editorial (Medicines Safety News).” Source location 2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
Open published response
15 May 2019 Marion Hilda Prance · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Failure of paramedics to recognise the dangers of administering Rivaroxaban View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Marion Hilda Prance · 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
Marion Hilda Prance, aged 82, suffered a head injury after an unwitnessed fall at her care home and was given her usual morning dose of Rivaroxaban on the advice of paramedics. She was later diagnosed with a subdural haematoma, developed a catastrophic brain bleed and died the next day. The principal concerns were paramedic awareness and training regarding Rivaroxaban and the need for caution after head injuries caused by falls.
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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 paramedics to recognise the dangers of administering Rivaroxaban
Wider context from the report “(1) A paramedic with 40 years of experience was unaware of the dangers of administering Rivaroxaban, a blood-thinning medication to an elderly lady who had suffered a fall and banged her head;
” Source location Marion Hilda Prance · 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 Publish Clinical Notice 18 to clinicians, covering Novel Oral Anticoagulants including Rivaroxaban and providing advice on their use.
Verbatim wording from the response “Whilst the Trust acknowledges that during the Inquest you heard verbal evidence from the paramedic who attended Mrs Prance, I would like to take the opportunity to confirm with you that during 2014 a Clinical Notice number 18 entitled, Novel Oral Anti-coagulant, was published to all clinicians. In that document anti-coagulant therapies including Rivaroxaban were referred to and advice was supplied to staff regarding their use. I attach for your reference a copy of that Clinical Notice.” Source location 2019-0154-Response-by-Welsh-Ambulance-Services-NHS-Trust
Open published response
Concerns raised 1
Failure to check administration of Oramorph and account for symptom masking View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
the Shrewsbury and Telford Hospital NHS Trust
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AI-generated summary
Mark Richard HINTON · 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
Mark Richard HINTON attended A&E with right calf pain and swelling after being advised to attend because of a possible clot. He was discharged before a markedly raised D-Dimer result became available; the inquest recorded pulmonary embolus due to deep vein thrombosis and bleeding duodenal ulcer, with a conclusion of “Preventable Natural Cause”. Concerns included failures in recording and communicating the D-Dimer request and result, delayed testing, inadequate documentation, and other system and process failures.
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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 check administration of Oramorph and account for symptom masking
Wider context from the report “(3) Other matters arising.
a) A second set of observations should have been made before Mark was discharged. This did not happen.
b) The D-Dimer test result was delayed due to a systems error with the CS2500 machine. It is stated that this may have happened intermittently and is then corrected. Had the system error not occurred it is likely that the (8th) result would have been available on screen for the discharging doctor to review.
c) Telephone results are not made if the patient is an in-patient in A&E. The Standing Operation Procedure (SOP) in Pathology states “D-Dimer greater than 500ug/l telephone to GP, out-patients and outlying hospitals (excludes SATH in-patients)”. Is a patient waiting assessment in A&E an out-patient or in-patient or some other category?
d) Differential diagnosis. Had all the information to the discharging doctor a differential diagnosis of DVT may have been made and recorded.
e) A body map had not been completed at any time.
f) Oramorph was recorded as having been given but not checked . Also it may the mask symptoms of pain .
g) Whilst D-Dimer tests were becoming routine rather than clinically required, Mark had come in with a possible ‘clot’ whether his earlier symptoms had improved or not.
h) The absence of documentation made it difficult if not impossible to resolve factual discrepancies between members of staff.
i) The impression given by witnesses was that they were under pressure (racing against the clock) to meet the 4 hour deadline in A&E.
” Source location Mark Richard HINTON · Prevention of Future Deaths report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There is no pharmaceutical requirement for Oramorph to be double-checked.
Verbatim wording from the response “f. Oramorph was recorded as having been given but not checked. Also it may mask symptoms of pain.” Source location 2019-0142-Response-by-The-Shrewsbury-and-Telford-Hospital-NHS-Trust
Open published response
24 Apr 2019 Ioannis AVGOUSTI · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 1
Failure to prevent prescribing and administration of a documented allergenic medication View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
University Hospitals Sussex NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
University Hospitals Sussex NHS Foundation Trust
Implement redesigned prescription charts displaying medication, reaction and allergy-safety decision information.
View source
University Hospitals Sussex NHS Foundation Trust
Finalise the EPMA specification and secure funding to purchase an electronic prescribing and medicines administration package incorporating allergy safeguards.
View source
University Hospitals Sussex NHS Foundation Trust
Undertake medicines reconciliation for every patient as soon as possible after admission.
View source
University Hospitals Sussex NHS Foundation Trust
Trial a single red allergy wristband system in the Acute Admissions Unit and Emergency Department, supported by compliance audits.
View source
University Hospitals Sussex NHS Foundation Trust
Deliver bespoke Acute Admissions Unit training on penicillin allergy risks and co-amoxiclav use.
View source See 2 more actions
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AI-generated summary
Ioannis AVGOUSTI · 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
Ioannis Avgousti died after an episode involving documented allergy to Co-Amoxiclav, during which the medication was prescribed and administered. The report identified concerns about failure to follow allergy guidance, inadequate communication, failure to act on elevated NEWS observations or escalate care, and staffing pressures during the relevant shift.
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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 prevent prescribing and administration of a documented allergenic medication
Wider context from the report “(2) On the 6th October 2018 although the hospital had noted that he was allergic to Co-Amoxiclav and although the paper medication notes noted that fact he was written up for that medication and it was administered to him .
I saw evidence of a poorly documented, from the point of view of time, NEWS observation. Although at the top of the chart there were the numbers 2 0 (20) I found on the balance of probabilities that set of observations had more likely been taken at about 20:10 or 20:15 hours.
The observations were added up to 9. In fact the total was 13.
NEWS is a tool to ensure that the deteriorating patient is recognised and given help and escalated, if appropriate, to Intensive Care.
This set of observations was not acted on in accordance with the directions and no escalation was made. There should have been a MET call then i.e., at around 20:15 hours to a specialist registrar (there was one on duty)
If this call had been made and if the appropriate doctor had been called to see Mr. Avgousti it is possible that although the sepsis protocol would I believe have been implemented, it would have been realised that he had an allergy to Co-Amoxiclav and he would have been given an appropriate alternative.
Whilst I cannot say categorically that this would have been the case I believe it is highly likely.
NEWS is an important tool and should not be ignored as it was on Vallance Ward on the night of the 6th October 2018.
” Source location Ioannis AVGOUSTI · 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 redesigned prescription charts displaying medication, reaction and allergy-safety decision information.
Verbatim wording from the response “████████ Head of Nursing for Quality Improvement has undertaken work in conjunction with the Pharmacy team to ensure that the Trust is fully compliant with these NICE guidelines. ████████ has confirmed that the Trust is currently compliant with most of the guidelines and has produced an action plan for the remaining guidelines. This includes a tool, to describe reactions and to determine actual allergy status, which has been developed and this tool will be incorporated into the new design of the Trust’s Prescription chart. The next print run of our newly designed Prescription charts will include:” Source location 2019-0135-Response-by-Brighton-and-Sussex-University-Hospitals
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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 Finalise the EPMA specification and secure funding to purchase an electronic prescribing and medicines administration package incorporating allergy safeguards.
Verbatim wording from the response “All of the above will be incorporated into the EPMA (Electronic Prescribing and Medicines Administration) system. The business case for this package has been approved and the specification is currently being finalised. We are waiting for an imminent NHS England allocation of funding decision in order to purchase the EPMA package. Once commenced we our aim is for 80% of wards to have EPMA within 2 years. The Chief of Pharmacy and his team are leading on this work.” Source location 2019-0135-Response-by-Brighton-and-Sussex-University-Hospitals
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 Undertake medicines reconciliation for every patient as soon as possible after admission.
Verbatim wording from the response “Medicines reconciliation is now undertaken for every patient as soon as possible after they have been admitted to hospital.” Source location 2019-0135-Response-by-Brighton-and-Sussex-University-Hospitals
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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 Trial a single red allergy wristband system in the Acute Admissions Unit and Emergency Department, supported by compliance audits.
Verbatim wording from the response “We have undertaken extensive investigation into the use of red allergy wrist bands, led by the Head of Nursing - Quality Improvement. We have conducted three audits of the appropriate use of red wristbands since January 2019 and there has been 10% improvement on compliance. In addition, our Acute Admissions Unit and Emergency Department are trialing a single coloured wristband system whereby if a patient has an allergy, they will only wear a red wristband with their details on it, and not an additional white wristband. The aim of this trial is to see if it reduces the risk of the red wristband not being seen when checking patients’ details prior to medication administration and our patients like Mr Avgousti who I gather did not like wearing multiple wristbands and would sometimes pull them off, being more comfortable and reducing the risk of removal.” Source location 2019-0135-Response-by-Brighton-and-Sussex-University-Hospitals
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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 bespoke Acute Admissions Unit training on penicillin allergy risks and co-amoxiclav use.
Verbatim wording from the response “To supplement this trial, the Acute Admissions Unit team have put in a place a bespoke training programme for staff in order to highlight the risk of penicillin allergy and the use of co-amoxiclav. I am delighted to say that over the last month there have been no penicillin related incidents on the Acute Floor at the Royal Sussex County Hospital. These improvements will then be extended to other areas of the Trust.” Source location 2019-0135-Response-by-Brighton-and-Sussex-University-Hospitals
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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 Purchase of the EPMA package cannot proceed until NHS England decides its funding allocation.
Verbatim wording from the response “All of the above will be incorporated into the EPMA (Electronic Prescribing and Medicines Administration) system. The business case for this package has been approved and the specification is currently being finalised. We are waiting for an imminent NHS England allocation of funding decision in order to purchase the EPMA package. Once commenced we our aim is for 80% of wards to have EPMA within 2 years. The Chief of Pharmacy and his team are leading on this work.” Source location 2019-0135-Response-by-Brighton-and-Sussex-University-Hospitals
Open published response
29 Mar 2019 Ann Corfield · Prevention of Future Deaths report Manchester City
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Concerns raised 1
Failure to administer prescribed prophylactic anticoagulation View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Ann Corfield · 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
Ann Corfield was admitted to hospital with a urinary tract infection, low sodium levels and deteriorating mental health, later developing severe psychotic depression, poor oral intake and dehydration. She suffered a cardiac arrest and died after transfer between hospitals. Concerns included inadequate handover about anticoagulation, failure to administer prescribed prophylactic anticoagulation, poor completion of fluid balance charts, and the lack of suitably qualified staff to administer intravenous fluids at Park House.
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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 administer prescribed prophylactic anticoagulation
Wider context from the report “1. I heard evidence that although Mrs Corfield was at high risk of developing a VTE, following her admission to Park House on 28th June, prophylactic anticoagulation was not prescribed for her until 30th June when a prescription for clexane (enoxaparin) was issued. Further, although clexane was prescribed, it was never administered to Mrs Corfield .
” Source location Ann Corfield · Prevention of Future Deaths report
Open source report
Concerns raised 2
Failure to administer prescribed steroids View source Lack of a policy for steroid administration and use with multiple comorbidities View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Terence Bradfield · 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
Terence Bradfield entered Derriford Hospital on 1 December 2013 with gastric bleeding and died on 17 December 2013, primarily from the consequences of his gastrointestinal bleed. The report raised concerns that his long-term steroid medication was not given or adequately managed, including when he was vomiting, and about staff training and the absence of policies for steroid management and “Nil by Mouth” patients with co-morbidities.
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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 administer prescribed steroids
Wider context from the report “(1) They are :
1. Mr. Bradfield was not given his steroids on 2.12.13
2. Mr. Bradfield was not prescribed intravenous hydrocortisone on 4th and 5th December 2013 when Mr. Bradfield had reported vomiting
3. Mr. Bradfield was not put on a stress dose of steroids whilst in Derriford hospital
4. The awareness and training of staff on the issue of steroid management.
5. The lack of a policy on the administration of steroids generally and their use in situations where a number of co – morbidities are present despite this death having arisen in 2013.
6. The training and awareness of staff on the meaning of “Nil by Mouth “ in patients who are suffering from a number of co –morbidities and are on important prescribed medication which needs to be taken regularly notwithstanding any planned necessary procedures .
” Source location Terence Bradfield · 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 policy for steroid administration and use with multiple comorbidities
Wider context from the report “(1) They are :
1. Mr. Bradfield was not given his steroids on 2.12.13
2. Mr. Bradfield was not prescribed intravenous hydrocortisone on 4th and 5th December 2013 when Mr. Bradfield had reported vomiting
3. Mr. Bradfield was not put on a stress dose of steroids whilst in Derriford hospital
4. The awareness and training of staff on the issue of steroid management.
5. The lack of a policy on the administration of steroids generally and their use in situations where a number of co – morbidities are present despite this death having arisen in 2013.
6. The training and awareness of staff on the meaning of “Nil by Mouth “ in patients who are suffering from a number of co –morbidities and are on important prescribed medication which needs to be taken regularly notwithstanding any planned necessary procedures .
” Source location Terence Bradfield · Prevention of Future Deaths report
Open source report
15 Jan 2019 Marie Hilda Millward Winter · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 2
Administration of anticoagulation medication following a head injury View source Failure to restrict anticoagulation medication advice or administration involving ambulance technicians View source
Linked response
North West Ambulance Service NHS Trust
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AI-generated summary
Marie Hilda Millward Winter · 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
Marie Hilda Millward Winter fell at a nursing home on 19 August 2017, sustained a head injury and developed an intracranial bleed. The report states that Apixaban was administered after the fall and that this worsened the bleed and contributed to her death at hospital on 2 September 2017. The principal concern was the administration of anticoagulant medication after a head injury, reportedly on the advice of or in the presence of ambulance technicians.
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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 Administration of anticoagulation medication following a head injury
Wider context from the report “The evidence was that the medication (Apixaban) was given to Mrs Millward Winter at Each Step Nursing Home on the advice of and/or in the presence of the Ambulance Technicians from North West Ambulance Service after she had sustained a head injury and prior to transporting her to hospital. The concern is that the administration of this anticoagulation medication on the morning of the 19th August 2017, following a head injury, worsened an internal bleed and contributed to Mrs Millward Winter’s death. It is of concern that such medication has been given when the patient has suffered a head injury (and is at risk of an internal bleed). It is of concern that the medication has been given on the advice of and/or in the presence of the ambulance technicians.
” Source location Marie Hilda Millward Winter · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to restrict anticoagulation medication advice or administration involving ambulance technicians
Wider context from the report “The evidence was that the medication (Apixaban) was given to Mrs Millward Winter at Each Step Nursing Home on the advice of and/or in the presence of the Ambulance Technicians from North West Ambulance Service after she had sustained a head injury and prior to transporting her to hospital. The concern is that the administration of this anticoagulation medication on the morning of the 19th August 2017, following a head injury, worsened an internal bleed and contributed to Mrs Millward Winter’s death. It is of concern that such medication has been given when the patient has suffered a head injury (and is at risk of an internal bleed). It is of concern that the medication has been given on the advice of and/or in the presence of the ambulance technicians.
” Source location Marie Hilda Millward Winter · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Advising on Apixaban and other medications beyond six authorised medications falls outside an EMT’s scope of practice.
Verbatim wording from the response “████████ recollection is that there was no discussion in relation to the administration of anti-coagulant medication for two reasons; firstly, Mrs Millward-Winter was being conveyed to the hospital because she had suffered a head injury and was taking blood thinning medication and secondly, advising on the administration of an anti-coagulant was outside of his scope of practice as an Emergency Medical Technician (EMT).” Source location 2019-0020-Response-by-North-West-Ambulance-Service-NHS-Trust
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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 The nursing-home nurse, rather than an EMT, was responsible for deciding which medication should be administered and when.
Verbatim wording from the response “An Advanced Paramedic has provided an overview in light of the Regulation 28 Report and has noted that Mrs Millward-Winter was resident in a nursing home. In their view, the nurse on duty at the unit would supersede an EMT in respect of which medication should be administered and at what point.” Source location 2019-0020-Response-by-North-West-Ambulance-Service-NHS-Trust
Open published response
10 Jan 2019 Natasha Learline CHIN · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3
Unclear governance for non-administration of prescribed medication View source Lack of audit of on-time administration of critical medication View source Lack of follow-up and recording of prescribed medication non-attendance View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Natasha Learline CHIN · 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
Natasha Learline Chin died in her cell at HMP Bronzefield on 19 July 2016 after profuse vomiting associated with undertreated opiate and alcohol withdrawal. The report identified concerns about delayed medication, inadequate monitoring and escalation, failures in record-keeping and governance, and insufficient auditing and training.
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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 Unclear governance for non-administration of prescribed medication
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Source location Natasha Learline CHIN · 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 audit of on-time administration of critical medication
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Source location Natasha Learline CHIN · 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 and recording of prescribed medication non-attendance
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Source location Natasha Learline CHIN · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.