25 Aug 2022 Charles Evans · Prevention of Future Deaths report Black Country
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Concerns raised 1
Failure to establish and implement a service-provider action plan for improving quality and safety View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission Hibiscus Housing Association Limited Wolverhampton City 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. 4
Care Quality Commission
Require the provider to submit an action plan addressing safety concerns and meet with the provider to discuss it.
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Care Quality Commission
Follow internal enforcement processes to take appropriate regulatory action and monitor progress against the provider’s action plan.
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Wolverhampton City Council
Implement and monitor an improvement plan addressing care quality and service safety concerns.
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Hibiscus Housing Association Limited
Draw up an action plan addressing the three improvement areas identified by the CQC.
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Charles Evans · 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
Charles Evans, a resident at Hibiscus House, choked on food in the communal dining room on 29 May 2022, suffered cardiac arrest and severe hypoxic brain injury, and died in hospital the following day. The concerns included inadequate CPR and first-aid provision, absence of a defibrillator and emergency communication arrangements, insufficient staffing and emergency procedures in the dining room, and weaknesses in risk assessment and reporting processes.
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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 establish and implement a service-provider action plan for improving quality and safety
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises;
4. There was no defibrillator on site;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time;
9. There was no proper procedure in place for staff to report concerns about residents;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan.
” Source location Charles Evans · 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 Require the provider to submit an action plan addressing safety concerns and meet with the provider to discuss it.
Verbatim wording from the response “5. CQC inspected Hibiscus DCA on 7 September 2022 and found concerns around the safety of people’s care. As a result, CQC requested the provider to submit an action plan to address the concerns and held a meeting with the Provider to discuss these following the inspection on 9 September 2022.” Source location Response from Care Quality Commission
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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 Follow internal enforcement processes to take appropriate regulatory action and monitor progress against the provider’s action plan.
Verbatim wording from the response “6. CQC are currently following their internal enforcement processes to take the appropriate regulatory action to drive the necessary improvements needed and to monitor their progress within their action plan. An inspection report will be published and in the public domain within the next month. CQC will continue to monitor this service, assess the risk and identify the appropriate action to take in our regulatory duties.” Source location Response from Care Quality Commission
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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 and monitor an improvement plan addressing care quality and service safety concerns.
Verbatim wording from the response “An unannounced monitoring visit to the service was undertaken by the Quality Assurance Team. The Council was not assured that the service was operating safely, therefore a recommendation to suspend the service from any new business was proposed and agreed. An improvement plan has been implemented and agreed with the provider. A meeting will be held in due course to review this plan.” Source location Response from Wolverhampton City Council
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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 Draw up an action plan addressing the three improvement areas identified by the CQC.
Verbatim wording from the response “The current Chief Officer ████████ has been in post since 3 March 2020 and upon joining Hibiscus drew up an Action Plan for the three areas of improvement which were identified by the CQC. Training had been put in place to address specific issues, however could not be undertaken for a significant length of time due to COVID restrictions. At this point work had already been undertaken to redesign care plans and upgrade systems which held vital information, but there was difficulty in implementing this. There was no monitoring of, or involvement by the CQC in this regard.” Source location Response from Hibiscus House
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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 CQC did not inspect Hibiscus DCA during the pandemic because of changing priorities.
Verbatim wording from the response “4. Inspections scheduled for 4 June 2020 and 21 January 2021 were both cancelled due to the pandemic and changing priorities. A CQC Inspector completed a ‘Portfolio Review Activity’ (PRA) on 15 April 2021 which was a monitoring tool in use by CQC at the time of the pandemic. A PRA enabled Inspectors to record they have reviewed the information CQC held about a service and to make a decision as to whether any further action is required to respond to risk or improvement. The outcome of the PRA was that further monitoring activity was required and consider inspecting. Unfortunately, due to changing priorities during the pandemic, Hibiscus DCA was not inspected.” Source location Response from Care Quality Commission
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22 Jun 2022 Derek Holmes · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure of formal investigation learning to address the breadth of identified patient safety issues View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Tameside and Glossop Integrated Care 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. 7
Tameside and Glossop Integrated Care NHS Foundation Trust
Review and update the incident reporting and incident and complaints investigation policy in alignment with the NHS England Patient Safety Framework.
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Tameside and Glossop Integrated Care NHS Foundation Trust
Disseminate organisational learning on investigation methodology and responding to people who raise concerns.
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Tameside and Glossop Integrated Care NHS Foundation Trust
Operate bimonthly oversight meetings to triangulate inquests with related investigatory processes and identify status changes or delays.
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Tameside and Glossop Integrated Care NHS Foundation Trust
Develop a cohesive clinical review process for incident investigations, inquest statements and learning-from-deaths reviews before inquests.
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Tameside and Glossop Integrated Care NHS Foundation Trust
Implement the Ulysses Safeguard improvement project to standardise use and increase reporting functionality.
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Tameside and Glossop Integrated Care NHS Foundation Trust
Implement strengthened inquest triage with seven-day clinical review, investigation review, communication and delay monitoring.
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Tameside and Glossop Integrated Care NHS Foundation Trust
Add a full-time clinical staff member to support the strengthened inquest triage and review process.
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Derek Holmes · 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
Derek Holmes, who had advanced metastatic prostate cancer and congestive cardiac failure, was admitted to hospital with several acute problems and fell while attempting to get out of bed. He sustained a left hip fracture requiring surgery and died after developing vomiting and signs of a chest infection. Concerns included errors in the Trust’s Root Cause Analysis, inadequate formal examination of issues including patient call-bells and delays in obtaining specialist advice, and the grading of the fall’s 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 of formal investigation learning to address the breadth of identified patient safety issues
Wider context from the report “1. Notwithstanding the fact that the document had passed through the Trust’s quality assurance process, it is a matter of concern that the Root Cause Analysis investigation into the circumstances of Mr Holmes’s fall contained a number of basic and obvious errors. Prompt, rigorous and effective investigations of clinical incidents are essential to deriving learning and improving patient safety, thereby reducing the risk of future deaths;
2. The formal learning derived from the Trust’s investigation (in the form of an Action Plan to the Root Cause Analysis) does not appear to take into account the breadth of issues raised by the case and which were apparent to the Trust from complaints correspondence and statements obtained from staff in advance of the inquest. As such, the Trust does not appear to have taken the opportunity to formally examine and critically analyse key issues such as:
• the adequacy of existing processes designed to ensure patient call-bells are working at all times; and
• why a delay has occurred in obtaining advice from a specialist hospital in the present case and whether the processes by which such advice is obtained are fit for purpose.
3. Connected with the above, the Trust does not appear to have revisited the grading of “moderate” harm originally assigned to Mr Holmes’s fall on the Acute Medical Unit notwithstanding his death being reported to the Coroner on the basis there was reason to suspect it contributed to his death. The court heard evidence to the effect that this grading informs the nature and extent of investigation which arises from a patient safety incident (thus impacting upon the learning which can be derived from such an incident).
” Source location Derek Holmes · 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 Review and update the incident reporting and incident and complaints investigation policy in alignment with the NHS England Patient Safety Framework.
Verbatim wording from the response “Prior to the inquest of Mr Holmes, I had instructed a review of the Trust’s Incident Reporting and Incident and Complaints Investigation Policy. This was in the context of Patient Safety 2, as information and resources become available to inform the Trust approach. The learning from this inquest has further informed the quality assurance process. The review and update to the Policy has been undertaken by the Head of Investigations, Learning and Audit and Head of Nursing for Professional Standards and Assurance, overseen by the Assistant Director of Integrated Governance.” Source location Response from NHS Tameside and Glossop Integrated Care
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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 Disseminate organisational learning on investigation methodology and responding to people who raise concerns.
Verbatim wording from the response “The policy builds of the principles of good compliant handling that have been recommended by the Parliamentary Health Service Ombudsman. This includes the Trust’s approach to managing the complaints, responding to complainants and keeping people informed about the concerns that they raise. As part of this approach, learning will be disseminated across the organisation regarding the required methodology and how we respond and support people when they raise concerns. Ongoing monitoring of the policy will take place through local audits of informal concerns and formal investigations. This will support the completion of other investigations such as root cause analysis and use the same principles so that these can be communicated across the organisation, alongside learning from investigations.” Source location Response from NHS Tameside and Glossop Integrated Care
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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 Operate bimonthly oversight meetings to triangulate inquests with related investigatory processes and identify status changes or delays.
Verbatim wording from the response “The Trust has also introduced a bimonthly oversight meeting for triangulation of scheduled and new inquests with existing or newly instructed investigatory processes, with Head of Investigations, Audit and Learning, Head of Assurance, Compliance and Governance, Head of Nursing for Professional Standards and Assurance and Legal Services Manager, chaired by the Assistant Director of Integrated Governance. This process has sought to ensure the improved triangulation of current investigations and support early identification of any changes in status to the patient (such as their death) or delays in conclusion. Patient tracking list methodology will be used to inform this process and ensure that there is oversight of all learning activity associated with investigations and inquests.” Source location Response from NHS Tameside and Glossop Integrated Care
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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 Develop a cohesive clinical review process for incident investigations, inquest statements and learning-from-deaths reviews before inquests.
Verbatim wording from the response “The development of a clinical review process is ongoing at the time of preparing this response to ensure that all incident investigations, inquest statements and reviews undertaken as part of our learning from deaths process are assessed and considered cohesively before an inquest. This aims to ensure consistency across all streams of investigation and learning and will help provide an additional clinical check to ensure that any potential discrepancies are responded to, enhancing our approach to learning.” Source location Response from NHS Tameside and Glossop Integrated Care
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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 the Ulysses Safeguard improvement project to standardise use and increase reporting functionality.
Verbatim wording from the response “The Trust are currently undertaking a comprehensive improvement project focused upon the Ulysses Safeguard system, which is the electronic risk management system used by the Trust. It is a system which allows for web-based reporting of incidents and safeguarding concerns, alongside system based operational management of complaints, incidents, claims, inquests, safeguarding and risk. It is also a platform which has the facility to recognise and acknowledge good professional practice known as ‘Excellence reporting’. The improvement project aims to increase utility of this system, with standardisation of use and increased reporting functionality.” Source location Response from NHS Tameside and Glossop Integrated Care
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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 strengthened inquest triage with seven-day clinical review, investigation review, communication and delay monitoring.
Verbatim wording from the response “To provide an additional safety net in this process, the Trust has also taken steps to amend and improve the triage system for newly listed inquests. In the context of the recent letter HM Senior Coroner received from Mr Richard Jolly of Weightmans LLP, in relation to the provision of our inhouse legal team, processes have been reinvigorated to ensure triage, review and instruction sent out to clinicians within seven days of the initial inquest request.” Source location Response from NHS Tameside and Glossop Integrated Care
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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 Add a full-time clinical staff member to support the strengthened inquest triage and review process.
Verbatim wording from the response “As part of the new process, a clinical review of the case and a review of any previous investigations is also performed at the outset where we are able, in order to identify any linked actions. This process would allow for the revisiting of levels of harm for individual incidents to ensure that this is appropriate, with advice from the specialist teams. There is also the addition of a full time clinical member of staff to support this process moving forward, and a more rigorous review system to capture potential delays. The Trust has started to implement this process ensuring communication is maintained with HM Coroner throughout.” Source location Response from NHS Tameside and Glossop Integrated Care
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7 Dec 2021 ANTHONY JAMES FITZPATRICK · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Lack of a plan to address the known risk-assessment problem View source
This report raised 2 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
ANTHONY JAMES FITZPATRICK · 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
Anthony James Fitzpatrick had a long history of mental health problems and attended local A&E departments on three occasions in the year before his death, with two attendances followed by custody. The report identified inconsistent and inaccurate assessment of risk by healthcare professionals, with unclear risk grades recorded in the electronic custody record and no plan to address the problem despite it being known.
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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 a plan to address the known risk-assessment problem
Wider context from the report “(1) During the course of the evidence, it became apparent that the HCPs were not using objective and/or consistent criteria to assess the risk of ████████, meaning that (a) the grade of risk assigned to AF was inconsistent and/or inaccurate and (b) no one else knew what was meant by the grade of risk recorded in the electronic custody record.
(2) Further, none of the HPCs who gave evidence used the criteria described in the online training materials.
(3) Despite being aware of this problem, there was no plan in place to address it .
” Source location ANTHONY JAMES FITZPATRICK · Prevention of Future Deaths report
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8 Jun 2021 Darrell Spear · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Lack of a clear strategy to address identified risks View source
This report raised 2 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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Darrell Spear · 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
Darrell Leonard Spear died in a fire at his home on 22 September 2020. The fire was probably accidental and accelerated by extensive hoarding and an open conservatory door. Concerns included poor communication and information sharing between agencies, and the absence of a clear strategy to address the fire risk associated with self-neglect and hoarding.
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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 a clear strategy to address identified risks
Wider context from the report “2. The evidence before the inquest suggested that communication between agencies was poor in relation to information sharing and that there was no clear strategy to address the risk presented to both Mr Spear and his wife .
” Source location Darrell Spear · Prevention of Future Deaths report
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4 Jun 2021 Pathushan Sutharsan · Prevention of Future Deaths report West Sussex
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Concerns raised 1
Failure to establish definitive plans to address junction safety issues View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Pathushan Sutharsan · 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
On 22 July 2020, Pathushan Sutharsan fell from his bicycle while approaching the junction of the Downs Link and the A281 in West Sussex and was struck by a Heavy Goods Vehicle. The report identified inadequate warning signage and no physical barrier at the junction, which continued to pose a significant risk to cyclists, pedestrians and equestrians despite improvements made after his death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to establish definitive plans to address junction safety issues
Wider context from the report “Whilst it was accepted that West Sussex County Council had, following Pathushan’s death, made significant improvements to the junction between the Downs link and the A281 evidence was heard from a number of different organisations (speaking on behalf of all the different users of the Downs link) that the junction in question still posed a substantial risk for cyclists, pedestrians and equestrians alike.
This junction is the only part of the Downs link that crosses a major A-road where there is no alternative safe crossing, a Pegasus crossing or bridge. Evidence was heard that there is no pavement running alongside the A281 and therefore this causes poor sight lines for horse riders and, in some circumstances, cyclists who have to put their horse’s head or part of their bike out onto the road before they can see oncoming traffic.
It is understood that WSCC has identified a need to address the issues at this junction and has undertaken (or is about to undertake a feasibility study) but it appears that at this stage there are no definitive plans in place to take this forward . Therefore the significant risk to the users of this junction remains.
The Downs link is actively promoted as a recreational activity by West Sussex County Council.
” Source location Pathushan Sutharsan · 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 Undertake a feasibility study and options appraisal for improving the crossing point, including bridge and traffic-light-controlled crossing options.
Verbatim wording from the response “A feasibility study looking into ways to improve the crossing point is currently being undertaken by the authority’s term consultant, WSP. An options appraisal report will be completed by October 2021. The study is primarily focused on, but not limited to, the options for a bridge or traffic light controlled road crossing.
If the report determines that there are appropriate, technically feasible solutions, the preferred option will be progressed through the WSC’s capital governance procedures, either as a project to be taken forward in the Local Transport Investment Programme or as a major scheme. In either case a full business case will be developed and the scheme assessed against the County Council’s objectives and priorities for potential inclusion in a future capital programme.” Source location 2021-0193-Response-from-West-Sussex-County-Council_Published
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Concerns raised 1
Inadequacy of the action plan for reducing delays in NG tube insertion and decompression View source
This report raised 8 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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Gillian McKinlay · 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
Gillian McKinlay, aged 68, was admitted to Royal Blackburn Hospital on 23 April 2018 with a provisional diagnosis of small bowel obstruction. A nasogastric tube requested by clinicians was not sited before her death four hours later, and the Coroner considered this contributed to the death. Concerns included unclear responsibility for patients in the Accident and Emergency Department, failure to undertake or escalate a clinically indicated review, and inadequacies in the Trust's investigation and subsequent 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 Inadequacy of the action plan for reducing delays in NG tube insertion and decompression
Wider context from the report “1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care.
2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams.
3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy.
4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken:
a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate ;
b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred;
c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken;
d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect;
e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked;
f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect.
” Source location Gillian McKinlay · Prevention of Future Deaths report
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20 Dec 2019 Matthew James Rogers · Prevention of Future Deaths report Blackpool and the Fylde
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Concerns raised 1
Lack of processes to address omissions of care arising from understaffing View source
This report raised 2 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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Matthew James Rogers · 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
Matthew James Rogers, aged 31, was admitted to hospital with worsening pain, weakness and lethargy and subsequently developed multiple organ injury before dying on 11 July 2019. His observations were not recorded for two and a half hours despite a NEWS score above 5, amid staffing levels below the planned establishment. The investigation report did not explain how the Trust intended to address omissions of care arising from understaffing.
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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 processes to address omissions of care arising from understaffing
Wider context from the report “The Serious Incident Investigation Report set out that the patient's observations were not monitored on an hourly basis in accordance with the Royal College of Physician's guidance for frequency of observations for a patient with a NEWS score of greater than 5. It was noted in the report that Mr Rogers did not have a set of observations recorded for two and a half hours from 03:30 to 06:00. Whilst it was not clear why this omission in care occurred, it was felt likely that this occurred because of understaffing of nurses compounded by the large number of patients within the department.
It was reported to me that the nurse staff levels were below template for the night shift. The staffing establishment was for 10 Registered Nurses. At the time in question six substantive Registered Nurses were on duty, plus one agency Emergency Department Registered Nurse. There were no Twilight Nurses or Long Day Registered Nurses.
The Serious Incident Investigation Report did not address how these problems were proposed to be resolved by the Trust and what processes were being put in place to address the issue of omission of care arising from understaffing .
” Source location Matthew James Rogers · Prevention of Future Deaths report
Open source report
16 Sep 2019 Ffion Louise Jones · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Failure of improvement planning to address specific shortcomings in service provision View source
This report raised 2 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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Ffion Louise Jones · 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
Ffion Jones died following an Addisonian crisis and cardiac arrest while waiting almost an hour for an ambulance at her GP’s surgery. Her urgent ambulance call was not escalated to the clinical support desk, and the report identified an ongoing lack of a dedicated means for external healthcare professionals to urgently discuss a patient’s clinical need with ambulance service staff. The report stated that there was a real risk of recurrence.
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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 improvement planning to address specific shortcomings in service provision
Wider context from the report “(1) The Improvement plan provided at the Inquest did not include any consideration of the specific shortcomings in service provision leading to Ffion’s death and the witness speaking to it was unable to address these issues
” Source location Ffion Louise Jones · Prevention of Future Deaths report
Open source report
13 Sep 2019 Lucia Jayne Stear · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 1
Failure of public authorities to address tree safety concerns before a fatal event View source
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Lucia Jayne Stear · 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
Lucia Jayne Stear was born after a large tree bough fell onto her pregnant mother's car on Arrowe Park Road, causing abdominal trauma. Lucia was delivered by emergency caesarean section, developed multi-organ failure, and died at 15 hours old. The inquest identified inadequate tree management, inspection, training, risk assessment, accountability and communication by Wirral Borough Council, and raised concerns about whether other public authorities faced similar risks.
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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 public authorities to address tree safety concerns before a fatal event
Wider context from the report “Before the inquest Wirral MBC put in place a “Tree Action Plan” which is address the concerns that had been before the court – This is included as an example of what can be achieved when this problem was highlighted by the death of a 15 hour old resident of the Borough.
How many other public authorities are in a similar plight, not having had a fatal tragic event to prompt action?
The Court asks the Rt. Hon. Secretary of State to address this issue nationally and that he advises the court as to what steps he has directed to be taken to ensure that there is national learning from Lucia’s short life and her tragic avoidable death.
The Court requests that the LGA brings this matter to the attention of its Local Authority members and that the LGA advises the court as to what steps the organisation has taken to ensure that there is national learning from Lucia’s short life and her tragic avoidable death
” Source location Lucia Jayne Stear · 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 Set up an online event for relevant local authority officers to raise and discuss the review findings.
Verbatim wording from the response “To raise and discuss the findings of your review directly with local authorities, the LGA will set up an event with relevant officers by the end of December 2019, using online/webinar technology to ensure that it is available to a wide range of locations. The outcomes of the event will be made available on the LGA website along with a link to the anonymised Section 28 report and good practice on tree management and reducing the risk of harm. We will ask relevant professional networks of local government officers with an interest in public parks and environment services to share this information with their members.” Source location 2019-0296-Response-by-Local-Government-Association
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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 Publish the event outcomes, anonymised Section 28 report and good practice on tree management and reducing harm on the LGA website.
Verbatim wording from the response “To raise and discuss the findings of your review directly with local authorities, the LGA will set up an event with relevant officers by the end of December 2019, using online/webinar technology to ensure that it is available to a wide range of locations. The outcomes of the event will be made available on the LGA website along with a link to the anonymised Section 28 report and good practice on tree management and reducing the risk of harm. We will ask relevant professional networks of local government officers with an interest in public parks and environment services to share this information with their members.” Source location 2019-0296-Response-by-Local-Government-Association
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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 Ask relevant professional networks to share the information with local government officers involved in public parks and environmental services.
Verbatim wording from the response “To raise and discuss the findings of your review directly with local authorities, the LGA will set up an event with relevant officers by the end of December 2019, using online/webinar technology to ensure that it is available to a wide range of locations. The outcomes of the event will be made available on the LGA website along with a link to the anonymised Section 28 report and good practice on tree management and reducing the risk of harm. We will ask relevant professional networks of local government officers with an interest in public parks and environment services to share this information with their members.” Source location 2019-0296-Response-by-Local-Government-Association
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for spending on parks, including responding to the concern, lies with local authorities.
Verbatim wording from the response “You have asked for action to be taken nationally, to stop such an accident happening again. Spending on parks is a matter for local authorities. We acknowledge that local authorities are working under financial pressure, that’s why this year the Chancellor has announced the biggest year-on-year real terms increase in spending power for local government in almost a decade. Core Spending Power (CSP) is expected to rise from £46.2 billion to £49.1 billion in 2020-21, an estimated 4.3% real terms increase.” Source location 2019-0296-Response-by-Ministry-of-Housing-Communities-Local-Government
Open published response
29 Jul 2019 Alistair Patrick McDonald · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1
Lack of a specific action plan for failed communication with the patient or family View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Herefordshire and Worcestershire Health and Care NHS Trust
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AI-generated summary
Alistair Patrick McDonald · 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
Alistair Patrick McDonald, who had disclosed suicidal thoughts and a history of deliberate self-harm, was found dead on 14 May 2018, hanging by a ligature secured to a door frame. The concerns included the assessment and management of his suicidal ideation and self-harm, lack of follow-up and clear referral plans, communication with him and his family, and failure to recognise the wider significance of his presentation.
Read the report on judiciary.uk
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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 a specific action plan for failed communication with the patient or family
Wider context from the report “1. Whether or not the specific deliberate self-harm or suicidal ideation criteria need to be reviewed and redrafted
2. The lack of a specific plan for referrals to other services which proved unsuccessful
3. The opportunity to take a broader view of the whole position and have an assessment by an experienced psychiatrist.
4. Ensuring a proper line of communication with the patient and the patient’s family to ensure appropriate reviews if the patient’s mental state deteriorates
5. Obtaining detailed feedback from services the patient is referred to, to check on attendance and progress
6. Recognising that some patients will only make partial disclosure of their true symptomology and history.
7. Loss of opportunity to see the bigger picture, which was of an academically bright student but who nonetheless was disclosing physical self-harm and suicidal intent, as well as an inability to deal with stress or pressure; and have a plan to review and deal with this
8. Ensuring if there were any failed communications with the patient or the family, to have a plan to take specific action to deal with this .
” Source location Alistair Patrick McDonald · 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 The assessment and communication arrangements were considered reasonable and proportionate, so no further action was identified.
Verbatim wording from the response “The Choice assessment was attended by the mother of Mr Alastair McDonald, and the detailed assessment notes that her views were taken into consideration in line with the overall formulation of the assessment and outcome.” Source location 2019-0257-Worcestershire-Health-and-Care-NHS-Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.