21 Mar 2024 Alan Richard Miles Davies · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Failure to devise and implement a clear plan for assessing capacity to refuse food or fluid View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
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Alan Richard Miles Davies · 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
Alan Richard Miles Davies was transferred to HMP Cardiff after 16 days of refusing food and was found collapsed in his cell 10 days later; he later died in hospital. The reported concerns included inadequate communication and handover of information, insufficient care planning and observation, the absence of a food and fluid refusal policy, inadequate staffing, and missed opportunities to escalate his care.
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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 devise and implement a clear plan for assessing capacity to refuse food or fluid
Wider context from the report “(7) No clear plan for the assessment of Mr Davies’ capacity to refuse food or fluid was devised or implemented at HMP Cardiff
” Source location Alan Richard Miles Davies · 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 Provide basic life support, mental capacity and bespoke prison-nursing training, with the bespoke programme underway from May 2024.
Verbatim wording from the response “Since September 2021, there has been a shift in the Healthcare Team's skill mix, with the appointment of more nurses possessing general medical skills. These nurses are better equipped to identify and respond to patients at risk of deterioration. Training initiatives, including basic life support and mental capacity assessment, have been implemented, supported by a Practice Development Nurse. Additionally, a bespoke training program for Prison Nurses in Wales has commenced. in May 2024.” Source location Response from Cardiff and Vale University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide mental capacity assessment training to medical staff and plan annual refresher updates.
Verbatim wording from the response “Capacity Assessment has been imparted to medical staff, with plans for annual updates.” Source location Response from Cardiff and Vale University Health Board
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31 Aug 2023 Donna Levy · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to undertake or consider a formal Mental Capacity Act assessment View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Donna Levy · Prevention of Future Deaths report
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Report summary
Donna Levy was admitted to hospital critically unwell after severe self-neglect, with extensive skin lesions, an infected pressure sore, oedematous and ulcerated lower limbs, and clinical signs of sepsis and acute kidney injury. She underwent surgical debridement but died in hospital on 14 December 2022 from complications associated with the pressure sore. Concerns included the failure to escalate her care despite deteriorating health, the absence of a formal Mental Capacity Act assessment or mental health referral, and the decision not to undertake a Serious Investigation.
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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 undertake or consider a formal Mental Capacity Act assessment
Wider context from the report “3. The inquest heard that as Ms Levy was believed to have capacity throughout this period, and consequently it was determined that there were on practical steps that could have been taken to improve the provision of care to her.
4. No formal Mental Capacity Act assessment was ever undertaken or considered .
” Source location Donna Levy · 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 Provide mental-capacity assessment training to all health and social care staff.
Verbatim wording from the response “• Provide mental capacity assessment training for all health and social care staff.” Source location Response from North East London Foundation Trust
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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 Complete mental-capacity assessments in complex cases.
Verbatim wording from the response “• Complete mental capacity assessments in complex cases.” Source location Response from North East London Foundation Trust
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1 Jun 2022 Samuel Joseph Gomm · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Failure of the WARRN assessment tool to prompt consideration and recording of advocacy referrals and capacity assessments View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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Samuel Joseph Gomm · Prevention of Future Deaths report
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Report summary
Samuel Joseph Gomm, who had chronic mental ill health exacerbated by periods of alcohol abuse, died after deliberately self-inflicting lacerations to his neck at home on 3 June 2019. The principal concerns related to the WARRN risk-assessment tool: its format, accessibility and presentation could make fluctuating self-harm risks difficult for new or infrequent users to identify, potentially resulting in under-estimation of risk and sub-optimal mitigating measures.
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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 the WARRN assessment tool to prompt consideration and recording of advocacy referrals and capacity assessments
Wider context from the report “(2) The evidence I received indicated that the WARRN assessment documentation/tool could be routinely accessed, updated & revised by the Integrated Team. It was a fluid document for the purpose of recording information as to the current assessment of risk(s) of self-harm & how that risk(s) was to be mitigated. Whilst I received evidence that in practice, such risk assessments were being undertaken with Sam, the WARRN documentation did not necessarily reflect that, nor was it optimally viewable in terms of clearly recording fluctuating presentations & any accompanying re-assessment of risk.
(3) It appeared to me that the format/layout of the WARRN tool, its accessibility, & in particular, its ability to provide a user with clear & easily viewable information as to how Sam’s risk of self-harm had fluctuated/altered/changed in the months preceding his death, could lead to important information/assessments being lost to a new/infrequent user. This, for example, might be a new care co-ordinator (as in Sam’s case), Crisis Team/Community Nurse, or clinician not previously involved with Sam.
(4) Given the variety of services involved in Sam’s care, this central document, addressing & recording fluctuating risk appeared to me to be a crucial document in the recording of current risk (eg emphasis). The ability of those charged with Sam’s care to view those fluctuations might be hampered by the current presentation of/access to such information. That could lead to an under-estimation of the current risk & sub-optimal mitigating measures being put in place.
(5) The WARRN assessment tool might also benefit from a greater degree of interaction between it & the user. For example, it was clear, on the evidence that Social Worker’s, Mental Health Nurses & Clinicians were all busy addressing the needs (& assessing risk) of a wide number & variety of patients. Prompting (my emphasis) the user to consider & record referrals for, for example, to advocacy services & for capacity assessments might optimise the benefits of the tool & reduce the risk of such opportunities being missed/un-recorded . Such then leading to the potential absence of key information for new/infrequent users when assessing risks of self-harm
” Source location Samuel Joseph Gomm · 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 Continue six-monthly Welsh Applied Risk Research Network record audits by Powys Teaching Health Board.
Verbatim wording from the response “22. In October 2021 and April 2022 Powys Teaching Health Board undertook an internal audit of Welsh Applied Risk Research Network documentation. Compliance with reviews and the quality of content was rated as good. Powys Teaching Health Board will continue to audit Service User records on a 6 monthly basis.” Source location Response from Powys County Council and Powys Teaching Health Board
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How this respondent action was interpreted
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PFD Monitor interpretation Reinstate advocacy clinics in community mental-health teams and inpatient units.
Verbatim wording from the response “36. The offer of advocacy is a legal requirement of both the Mental Health Measure (2010) and the Social Services Well Being Act, 2014. This is reflected in Care and Treatment Programme documentation, where staff are directed to offer advocacy and to confirm whether it is required. This is reported on through Powys County Council Business Insight programme and in Powys County Council audits. Advocacy clinics have been reinstated in CMHT’s and inpatient units following Covid19. These are advertised in patient access areas and can be booked directly with the advocate if preferred.” Source location Response from Powys County Council and Powys Teaching Health Board
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Welsh Applied Risk Research Network form cannot be altered because it must remain in its original evidence-based form.
Verbatim wording from the response “27. Work is currently in progress to ensure that the correct Welsh Applied Risk Research Network is available on the WCCIS system by the end of July 2022. This will enable all Community Staff to have access to the copyrighted version, stored in an easily accessible part of the database. This can be accessed by both Powys Teaching Health Board and Powys County Council. To enable the Welsh Applied Risk Research Network to maintain its evidence base it needs to remain in its original state and cannot be altered to provide additional prompts or data collection. The accompanying CTP documentation focuses on areas not directly included in Welsh Applied Risk Research Network. For example, capacity is” Source location Response from Powys County Council and Powys Teaching Health Board
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19 Apr 2022 Volodymyr KOROL · Prevention of Future Deaths report Surrey
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Concerns raised 1
Failure to carry out mental capacity assessments 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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Volodymyr KOROL · 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
Volodymyr Korol died from a fatal ventricular arrhythmia in his bedroom at Shrewsbury Court Independent Hospital on 1 August 2020, following cardiac and other physical health conditions. The inquest identified concerns including failures to assess his capacity regarding weight management, investigate and manage cardiac and other physical health conditions, share medical information, and escalate abnormal vital signs. The Coroner was concerned that similar practices might be present at another site operated by Whitepost Healthcare Group.
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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 carry out mental capacity assessments
Wider context from the report “Following Mr Korol’s death Shrewsbury Court Independent Hospital did not declare a Serious Incident. As such, whilst there was a 72 hour serious incident review into the events of 31 July and 1 August 2020, there was no investigation into the wider circumstances leading up to his death.
Accordingly, none of the matters which form part of the jury’s narrative conclusion were identified by Shrewsbury Court Independent Hospital either at the time as part of their own internal investigation or thereafter as part of their preparation for the inquest.
The court heard evidence that Shrewsbury Court Independent Hospital has now closed down but that Whitepost Healthcare Group continues to operate one other site, namely Iden Manor Nursing Home in Kent.
The jury found that there were a number of causative failures in relation to the carrying out of mental capacity assessments , the sharing of medical information with other agencies and the appropriate escalation of vital signs which fall outside of normal parameters. All of these issues are equally as important in nursing homes as they are in psychiatric hospitals.
Given that these issues were not identified and acted upon by Whitepost Healthcare Group at any point prior to the inquest, the Coroner is concerned that similar practices may be present at Iden Manor Nursing Home in Kent, which would present a risk of future deaths.
In the circumstances the Coroner considers that practices should be audited at Iden Manor Nursing Home to ensure that the deficient practices identified by the jury in relation to Mr Korol’s care at Shrewsbury Court Independent are not present at Iden Manor Nursing Home.
” Source location Volodymyr KOROL · Prevention of Future Deaths report
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23 Mar 2022 Emily Jane CALDICOTT · Prevention of Future Deaths report Worcestershire
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Concerns raised 1
Failure to apply the correct Mental Capacity Act 2005 test when assessing capacity for medication decisions View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Emily Jane CALDICOTT · 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
Emily Jane Caldicott was admitted to hospital after an overdose and was later found unresponsive after tying a ligature around her neck. She died on 23 March 2020 from pneumonia and cerebral anoxia due to the application of a ligature. The principal concerns were that staff failed to adequately assess her capacity regarding Lorazepam, did not administer it in her best interests, and failed to remove the item used to make the ligature; the jury found these failures probably or possibly contributed to her death and identified a risk of future deaths.
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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 apply the correct Mental Capacity Act 2005 test when assessing capacity for medication decisions
Wider context from the report “(6) Although staff on Holt Ward were undoubtedly having to deal with a very difficult situation in this case, I am concerned that if a such a decision has to be made in similar circumstances in the future, staff may not apply the correct test under the Mental Capacity Act 2005 , and there is therefore a risk of future deaths occurring.
” Source location Emily Jane CALDICOTT · Prevention of Future Deaths report
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3 Dec 2021 TERENCE TALBOT · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Lack of formal mental capacity assessments for treatment decisions View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Kent and Medway Mental Health NHS Trust Maidstone and Tunbridge Wells NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Kent and Medway Mental Health NHS Trust
Implement a streamlined Mental Capacity Assessment process for physical-health interventions and monitor compliance through Mental Health Act Committee and CLiQ checks.
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Kent and Medway Mental Health NHS Trust
Deliver and monitor mandatory Mental Capacity Act training for clinical staff.
View source
Maidstone and Tunbridge Wells NHS Trust
Commission and complete an audit of consent and mental capacity practices.
View source
Maidstone and Tunbridge Wells NHS Trust
Introduce a clinical advisor role and appoint a Mental Capacity Act clinical practitioner to support complex capacity cases.
View source
Maidstone and Tunbridge Wells NHS Trust
Provide mandatory tailored capacity-assessment training and conduct Trust-wide audit and monitoring.
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TERENCE TALBOT · Prevention of Future Deaths report
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Report summary
Terence Talbot died at Maidstone & Tunbridge Wells NHS Trust on 9 April 2020 from multiorgan failure due to empyema and pneumonia associated with DRESS Syndrome, following a severe reaction to prescribed medication for bipolar affective disorder. The concerns included repeated discharge and readmission, lack of formal mental-capacity assessments, insufficient dermatology review and emollient application, inadequate food and fluid leading to malnutrition, and issues concerning a requirement to attend in person to claim benefits while severely ill.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of formal mental capacity assessments for treatment decisions
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” Source location TERENCE TALBOT · 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 Implement a streamlined Mental Capacity Assessment process for physical-health interventions and monitor compliance through Mental Health Act Committee and CLiQ checks.
Verbatim wording from the response “2) A robust monitoring of Mental Capacity Assessment of patients under our care is conducted via Mental Health Act Committee (led by the Chief Medical Officer and reporting to Trust Board) thereby ensuring the highest level of scrutiny around this. Assurance on this is provided via a Clinical Quality check (CLiQ check) process across all our services particularly the in-patient services. Since September 2021 we have implemented a streamlined process for Mental capacity assessment which was developed using Quality Improvement methodology by our Quality Improvement team. This has resulted in significant improvement in completion and documentation of Mental Capacity Assessments and Best Interest decisions where capacity is lacking.” Source location 2021-0419-Response-from-Kent-and-Medway-NHS-and-Social-Care-Partnership-Trust_Published
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver and monitor mandatory Mental Capacity Act training for clinical staff.
Verbatim wording from the response “3) The Mental Capacity Act (MCA) training for the organisation is closely monitored, again via the Mental Health Act Committee. MCA training is mandatory for all our clinical staff and we are currently at ninety percent completion rate for this training.” Source location 2021-0419-Response-from-Kent-and-Medway-NHS-and-Social-Care-Partnership-Trust_Published
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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 Commission and complete an audit of consent and mental capacity practices.
Verbatim wording from the response “Response
The Court is respectfully advised that the Trust has commissioned an audit into its consent and capacity practices. The external Trust Auditor has found that the Trust is broadly performing well. The recommendations from this review have been discussed by the Directorate leads and taken forward as part of the DATIX action plan noted above.” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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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 Introduce a clinical advisor role and appoint a Mental Capacity Act clinical practitioner to support complex capacity cases.
Verbatim wording from the response “Further, the Trust has introduced a new clinical advisor role as the lead clinician on capacity. The Trust has also appointed a new Mental Capacity Act clinical practitioner who will be available to assist the wards in dealing with complex cases. These leads will strengthen our oversight in ensuring the appropriate considerations around capacity are comprehensively covered.” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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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 Provide mandatory tailored capacity-assessment training and conduct Trust-wide audit and monitoring.
Verbatim wording from the response “Along with the above training, the Trust continues to provide tailored, bespoke training sessions to all staff regarding the vital importance of capacity assessments. Again, regular audit and monitoring is being applied Trust wide. Such training is mandatory for each clinical member of staff.” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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4 Oct 2021 Jude Daryl Lloyd · Prevention of Future Deaths report Manchester City
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Concerns raised 1
Failure to complete and properly record formal mental capacity assessments View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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Jude Daryl Lloyd · Prevention of Future Deaths report
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Report summary
Jude Daryl Lloyd was found dead at home on 8 May 2019 and died from diabetic ketoacidosis. The report identified concerns about inadequate diabetes monitoring and management, capacity assessment, communication and care transfer between services, follow-up with primary care, clinical review, and record keeping.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to complete and properly record formal mental capacity assessments
Wider context from the report “b. No appropriate formal mental capacity assessments were made and properly recorded although this would also be relevant in managing his mental and physical conditions.
” Source location Jude Daryl Lloyd · 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 Trigger formal Mental Capacity Assessments and Best Interest Meetings for inpatient concerns about capacity to consent to or refuse physical-health treatment, and disseminate the process.
Verbatim wording from the response “This was identified in the Trust’s investigation report under the sub-heading Summary of Inpatient Concerns and was addressed in recommendation 5 of the report. There are now clear processes in place in the inpatient service where any concerns raised in respect of a person’s capacity to consent to or refusal of physical health treatment would trigger a formal Mental Capacity Assessment and a Best Interest Meeting as part of the ward MDT meeting. This process has been shared at departmental meetings by the Lead Consultant for Salford Inpatients and the Salford Inpatient Operations Manager. In addition to this the Lead Consultant has introduced complex case meeting every 2 weeks. This is a medical peer group where cases can be brought for further discussion in respect of care planning.” Source location 2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver face-to-face Mental Capacity Act training to CMHT staff using case studies.
Verbatim wording from the response “The Trust expects all professionally qualified staff to undertake eLearning training in respect of the Mental Capacity Act (MCA). The current compliance with this training is; Salford inpatient wards 80-100% and CMHT 76%. In addition to the eLearning the social care lead for Central Manchester has developed and delivered 4 face to face sessions to CMHT staff regarding when MCA should be considered, using case studies to support learning. This delivery of these MCA training sessions is ongoing.” Source location 2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
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16 Sep 2021 Irene Ann Esaw · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to adequately assess patients’ mental capacity for care decisions View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Tameside and Glossop Integrated Care NHS Foundation Trust Tameside Borough Council
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 12
Tameside and Glossop Integrated Care NHS Foundation Trust
Maintain and expand the Trust’s Mental Capacity Act improvement programme, led by a dedicated Senior Mental Health Nurse.
View source
Tameside and Glossop Integrated Care NHS Foundation Trust
Establish a multi-agency Mental Capacity Act group with the local authority to review and benchmark policies, procedures, strategy and training.
View source
Tameside and Glossop Integrated Care NHS Foundation Trust
Review the revised Mental Capacity Act Code of Practice and develop aligned audit processes, audit cycles and training linked to Liberty Protection Safeguards.
View source
Tameside and Glossop Integrated Care NHS Foundation Trust
Deliver a continuing Trust-wide Mental Capacity Act learning and awareness programme using masterclasses, e-learning, briefings, podcasts, animations and related resources.
View source
Tameside and Glossop Integrated Care NHS Foundation Trust
Launch the Trust’s Mental Capacity Act awareness campaign and assess staff knowledge and confidence through surveys and scheduled monitoring.
View source
Tameside and Glossop Integrated Care NHS Foundation Trust
Monitor the Mental Capacity Act improvement project through safeguarding, quality and governance committees and revised multi-agency audit arrangements.
View source
Tameside and Glossop Integrated Care NHS Foundation Trust
Develop and roll out electronic patient-record prompts and alerts to support capacity assessment, vulnerability recognition and safe discharge planning.
View source
Tameside and Glossop Integrated Care NHS Foundation Trust
Include Betty’s Story and its learning in recurrent multi-professional induction and training, and develop a live-play version for organisational dissemination.
View source
Tameside Borough Council
Embed the Mental Capacity Act in adult social care practice through forums, social-work training, quality assurance and workforce-development programmes.
View source
Tameside Borough Council
Update Mental Capacity Assessment and Best Interest documentation and link it with needs and risk assessments in social work practice.
View source
Tameside Borough Council
Implement a quality assurance framework incorporating the Mental Capacity Act Competency Framework and a skills and knowledge audit for social workers and managers.
View source
Tameside Borough Council
Embed multidisciplinary roles and responsibilities in staff induction, clinical supervision, multi-agency procedures and standards, and refresh related capacity procedures and training.
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Irene Ann Esaw · 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
Irene Ann Esaw, who had dementia and was dependent on her grandson for all nutritional, mobility, hygiene and personal care, was discharged from hospital without a formal care package or community referrals. She was later found deceased at home in an emaciated state, with severe untreated pressure sores, tissue damage and widespread sepsis. The principal concerns were failures to assess mental capacity, recognise clinical signs of neglect, and ensure effective multi-agency assessment and working.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to adequately assess patients’ mental capacity for care decisions
Wider context from the report “1. Identifying and Assessing Mental Capacity –
My findings in relation to Mrs. Esaw’s death were that there was a fundamental failure by the clinical and nursing staff to adequately consider and assess Mrs. Esaw’s capacity to make decisions about her own care needs whilst she was a patient at Tameside General Hospital between 12ᵗʰ and 28ᵗʰ September 2018. This failure in my view, undermined her discharge planning and was one of the key reasons why the discharge was unsafe. I understand that work is ongoing in this area, but I am concerned having heard the evidence of ████████, the Deputy Director of Nursing and Professional Standards that it is still a “work in progress” identified by this and other incidents reported to the Trust. I am concerned that there are still issues that the Trust aren’t completely compliant with and that this needs to be addressed.
” Source location Irene Ann Esaw · 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 Maintain and expand the Trust’s Mental Capacity Act improvement programme, led by a dedicated Senior Mental Health Nurse.
Verbatim wording from the response “To enhance further our work in relation to Mental Capacity Act awareness and overseen by the Executive Director of Nursing and Integrated Governance and the Deputy Director of Nursing Professional Standards, Safeguarding and Assurance has reprioritised resources for funding for a dedicated Senior Mental Health Nurse to take the lead on a revised improvement project focused on the application of the mental capacity act (MCA) in the Trust, this individual in post. Partnerships have” Source location Response from Tameside and Glossop NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a multi-agency Mental Capacity Act group with the local authority to review and benchmark policies, procedures, strategy and training.
Verbatim wording from the response “In partnership with the Local authority we have taken the lead in establishing a multi-agency group focused on the application of the MCA with a view to a collective review and benchmarking of our policies and procedures in order to develop a multi-agency strategy, policy and training on the application of the Mental Capacity Act across the multiagency system, to promote a shared approach and understanding.” Source location Response from Tameside and Glossop NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the revised Mental Capacity Act Code of Practice and develop aligned audit processes, audit cycles and training linked to Liberty Protection Safeguards.
Verbatim wording from the response “- Legislation
Whilst the Trust has a current Mental Capacity Act Policy which is in line with the required statutory requirements and meets regulatory requirements, the Trust is cognisant that the new Mental Capacity Act Code of Practice is due to be published in 2022. In line with this the Trust will review the revised Code to ensure that its policies are aligned. As part of the Trust’s response to this the Trust, will develop an audit process and clear audit cycles, this will be aligned to the national implementation of Liberty Protection Safeguards. Our training will be aligned with this.” Source location Response from Tameside and Glossop NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a continuing Trust-wide Mental Capacity Act learning and awareness programme using masterclasses, e-learning, briefings, podcasts, animations and related resources.
Verbatim wording from the response “- Training and development
The Trust has a focused month on safeguarding throughout the month of November 2021. As part of this whole month of focus there is a Mental Capacity Act Masterclass entitled “back to basics” which will work in parallel with our community and social care partners as a multi-agency plan. In addition to this, a proposal for the inaugural integrated safeguarding conference has also been approved to be held in Spring 2022, hosted by the Trust, with invitations to multi-agency colleagues to promote a culture in which teams collaborate work and learn together.” Source location Response from Tameside and Glossop NHS England
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PFD Monitor interpretation Launch the Trust’s Mental Capacity Act awareness campaign and assess staff knowledge and confidence through surveys and scheduled monitoring.
Verbatim wording from the response “- Communications
As part of the Trust’s broader communications project in which specific topics receive focused exposure during a calendar month, November is ‘Spotlight on Safeguarding’ month, to coincide with Adult Safeguarding week. This will incorporate the launch of a Mental Capacity Act campaign and encouraged all staff to ‘think family’ by raising awareness and providing opportunities for learning to support and promote a culture and organisational approach, that safeguarding is ‘Our Everyday Business’. The Trust have also developing multimedia resources such as short animations, screensavers, MCA aide memoire cards and coverings to the lift doors to maintain a high profile throughout the organisation. To establish the positive impact upon staff awareness of MCA a short online survey has been developed for use across the Trust.” Source location Response from Tameside and Glossop NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor the Mental Capacity Act improvement project through safeguarding, quality and governance committees and revised multi-agency audit arrangements.
Verbatim wording from the response “The oversight and scrutiny of the MCA Quality Improvement Programme will be by the Trust’s Integrated Safeguarding Committee which is chaired by the Executive Lead for Safeguarding. Regular update reports and oversight of the Trust’s improvement project will also report to the newly formed Multi Agency Monitoring Group, established to monitor the significant learning and actions from this case.” Source location Response from Tameside and Glossop NHS England
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PFD Monitor interpretation Develop and roll out electronic patient-record prompts and alerts to support capacity assessment, vulnerability recognition and safe discharge planning.
Verbatim wording from the response “The Trust is in the process of transitioning towards electronic patient records in accordance with the NHS commitment to use all electronic patient records. Working closely with our Chief Clinical Information officer in relation to the transition to electronic notes work has progressed with clinical colleagues which has considered the potential to include prompts in relation to mental capacity assessments, in particular when preparing the discharge letter.” Source location Response from Tameside and Glossop NHS England
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include Betty’s Story and its learning in recurrent multi-professional induction and training, and develop a live-play version for organisational dissemination.
Verbatim wording from the response “We have liaised with teams who coordinate multi-professional inductions for staff across the Trust, all have committed to including Betty’s story and the learning from this to develop a recurrent programme of training.” Source location Response from Tameside and Glossop NHS England
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed the Mental Capacity Act in adult social care practice through forums, social-work training, quality assurance and workforce-development programmes.
Verbatim wording from the response “Identifying and Assessing Mental Capacity
Since 2019, one of Adult Social Care work force development priorities has been to improve our staff knowledge and application of the Mental Capacity Act.” Source location Response from Tameside and Glossop NHS England
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PFD Monitor interpretation Update Mental Capacity Assessment and Best Interest documentation and link it with needs and risk assessments in social work practice.
Verbatim wording from the response “On the 22 July 2020, a 12 month improvement plan was launched, which incorporates standards of practice, themed audits and themed Continuing Professional Development. The Individual Management Report (IMR) recommendations and action plan are annexed to this report as Appendix A.” Source location Response from Tameside and Glossop NHS England
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a quality assurance framework incorporating the Mental Capacity Act Competency Framework and a skills and knowledge audit for social workers and managers.
Verbatim wording from the response “The Principal Social Worker is currently reviewing the implementation of the quality assurance framework for social work practice, the application of the Mental Capacity Act will feature in this work. The aim is that a new framework will be in place from January 2022. Part of this work will include implementing the National Mental Capacity Act Competency Framework, developed by Bournemouth University. A skills and knowledge audit will take place of social workers and managers and the outcome will inform the ongoing training programme.” Source location Response from Tameside and Glossop NHS England
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed multidisciplinary roles and responsibilities in staff induction, clinical supervision, multi-agency procedures and standards, and refresh related capacity procedures and training.
Verbatim wording from the response “Integral to this, is ensuring that the multidisciplinary team have a good understanding of one another’s roles and responsibilities. Work will take place to ensure that this is embedded in practice. This will include ensuring that roles and responsibilities feature in the induction of all staff, in ongoing clinical supervision and in multiagency procedures and standards. A multiagency review and refresh of the Mental Capacity Act procedures and training regarding adults with care needs on discharge, will take place.” Source location Response from Tameside and Glossop NHS England
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9 Aug 2021 Terence Robert TUTTLE · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Failure to adequately assess under the Mental Capacity Act View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Norfolk and Suffolk NHS Foundation Trust
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AI-generated summary
Terence Robert TUTTLE · 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 Robert Tuttle, who lived in a care home, was admitted to hospital after testing positive for Covid-19 and was treated for acute kidney injury, pneumonia and a bleeding duodenal ulcer. His recorded poor oral intake was not acted on promptly, and he lost significant weight before being transferred to another nursing home, where he died three days later. The concerns included delayed dietetic and mental health assessments, inadequate action on weight loss, difficulties applying the Mental Capacity Act, insufficient care for a mentally unwell patient refusing food, exclusion of family from involvement in his care, and lack of recognition of serious harm.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to adequately assess under the Mental Capacity Act
Wider context from the report “3.Ability to assess Mr Tuttle adequately under the Mental Capacity Act .
” Source location Terence Robert TUTTLE · Prevention of Future Deaths report
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PFD Monitor interpretation The Queen Elizabeth Hospital should respond to the concerns outside the second part of the first concern.
Verbatim wording from the response “Out of the concerns listed below I would advise that NSFT are able to respond to the second part, in italics, of the first point only. The other points would be for the QEH to respond to:” Source location 2021-0265-Response-from-Hellesdon-Hospital_Published-1
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PFD Monitor interpretation For physical health decisions requiring capacity assessment, the physical health expert is the decision maker.
Verbatim wording from the response “Where a capacity assessment is required for a decision on a physical health issue or intervention, the team may assist in respect of mental illness symptomology and the potential impact on a persons capacity. However the decision maker will be the physical health expert.” Source location 2021-0265-Response-from-Hellesdon-Hospital_Published-1
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3 Feb 2021 CHRISTOPHER SMITH · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Failure to reassess fluctuating mental capacity View source
This report raised 12 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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CHRISTOPHER SMITH · 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
Christopher Smith was admitted to hospital with peripheral vascular disease, extensive leg ulcers, epilepsy and infections, and died on 4 March 2019 after deterioration following discharge home. Principal concerns included inadequate discharge planning and capacity reassessment, failure to arrange home and district nursing support, unsafe home conditions and an unacted-on safeguarding alert, and inadequate nutritional care.
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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 reassess fluctuating mental capacity
Wider context from the report “(3) Mr Smith remained on a discharge ward from 2nd February until his discharge on 10th February even though he suffered a deterioration in his medical condition. Mr Smith’s capacity fluctuated during his admission, he was noted by nurses to be confused and his capacity was not reassessed .
” Source location CHRISTOPHER SMITH · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.