20 Oct 2023 Trevor Coy BAILEY · Prevention of Future Deaths report Inner North London
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Concerns raised 2
Failure to elicit smoking status and family history of ischaemic heart disease in the emergency department View source Failure to elicit relevant family medical history View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Church Lane Surgery London North West University Healthcare 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. 4
Church Lane Surgery
Update the NHS health-check template to record negative family history of ischaemic heart disease.
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Church Lane Surgery
Expand family-history updates to annual chronic-disease checks, medication reviews, ECG appointments and standardised templates.
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Church Lane Surgery
Begin updating ischaemic-heart-disease family histories for all patients aged over 25 and inform patients about voluntary updates at registration.
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Church Lane Surgery
Train staff to collect and accurately record family-history information in the clinical system.
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AI-generated summary
Trevor Coy BAILEY · 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
Trevor Bailey attended hospital with chest pain on 19 April 2023 and was discharged after negative test results, without referral to the rapid access chest pain clinic. He subsequently died from a fatal myocardial infarction on 7 May 2023; the concern was that his recent smoking history and family history of ischaemic heart disease were not elicited, which may have prevented an appropriate referral.
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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 elicit smoking status and family history of ischaemic heart disease in the emergency department
Wider context from the report “However, it does not appear that these two pieces of information were elicited by those assessing Mr Bailey in the emergency department of Northwick Park Hospital . I heard evidence that, if they had been, he should have been referred to the rapid access chest pain clinic.
Given the sequence of events, it seems unlikely that such a referral would have resulted in definitive treatment before Mr Bailey’s fatal myocardial infarction, but it could be a life saving referral for another patient in Mr Bailey’s position.
” Source location Trevor Coy BAILEY · Prevention of Future Deaths report
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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 elicit relevant family medical history
Wider context from the report “1. I heard evidence at inquest that Mr Bailey had a family history of ischaemic heart disease – his brother had had two cardiac stents placed in 2006 and two in 2012.
However, this information was not on Mr Bailey’s medical record, it was not elicited at his 2012 or 2018 health checks and it was not elicited when he consulted his general practitioner, ████████
████████, on 19 or 27 April 2023 .
The recording of this information is unlikely to have changed the outcome for Mr Bailey, but it was a vital part of the medical history and it might easily for another patient.
” Source location Trevor Coy BAILEY · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the NHS health-check template to record negative family history of ischaemic heart disease.
Verbatim wording from the response “We have taken the following steps to update the family history of coronary heart disease (IHD).” Source location Response from Chuch Lane Surgery
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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 Expand family-history updates to annual chronic-disease checks, medication reviews, ECG appointments and standardised templates.
Verbatim wording from the response “Currently we assess family history during new patient checks and NHS health checks. We are expanding this practice to include updates on family history at additional points of contact, such as annual chronic disease checks and structured medication reviews, ECG appointments, and have integrated this into our standardised templates.
We have initiated the process of updating family history for all patients aged 25 and above. We have sent the message to all the patients aged >25yrs, to update their family history of IHD. All patients will be informed at registration that they will have to update their family history voluntarily if there are any changes. We have trained the staff to record it in our system. We are going to audit the new entry of family history of IHD every 12 months to assess the progress of our system.” Source location Response from Chuch Lane Surgery
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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 Begin updating ischaemic-heart-disease family histories for all patients aged over 25 and inform patients about voluntary updates at registration.
Verbatim wording from the response “Currently we assess family history during new patient checks and NHS health checks. We are expanding this practice to include updates on family history at additional points of contact, such as annual chronic disease checks and structured medication reviews, ECG appointments, and have integrated this into our standardised templates.
We have initiated the process of updating family history for all patients aged 25 and above. We have sent the message to all the patients aged >25yrs, to update their family history of IHD. All patients will be informed at registration that they will have to update their family history voluntarily if there are any changes. We have trained the staff to record it in our system. We are going to audit the new entry of family history of IHD every 12 months to assess the progress of our system.” Source location Response from Chuch Lane Surgery
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train staff to collect and accurately record family-history information in the clinical system.
Verbatim wording from the response “Currently we assess family history during new patient checks and NHS health checks. We are expanding this practice to include updates on family history at additional points of contact, such as annual chronic disease checks and structured medication reviews, ECG appointments, and have integrated this into our standardised templates.
We have initiated the process of updating family history for all patients aged 25 and above. We have sent the message to all the patients aged >25yrs, to update their family history of IHD. All patients will be informed at registration that they will have to update their family history voluntarily if there are any changes. We have trained the staff to record it in our system. We are going to audit the new entry of family history of IHD every 12 months to assess the progress of our system.” Source location Response from Chuch Lane Surgery
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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 Additional smoking and family-history information would not have triggered rapid access chest pain clinic referral under the HEART scoring system.
Verbatim wording from the response “The point we would like to make is that even if he had not self discharged, based on the information given to the team at the time if the patient underwent a HEART score the patient would score 1.” Source location Response from London North West University Healthcare NHS Trust
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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 established HEART-based chest pain pathway and cardiology governance were considered sufficient to determine appropriate rapid access chest pain referrals.
Verbatim wording from the response “As further evidence we do routinely satisfy our selves that even though this is a well used guideline we are still happy with it. In December 2022 our cardiology team attended the emergency department clinical governance meeting to present data from referrals. The data showed that patients with referrals with a low heart score did not go on to have investigations in the rapid access chest pain clinic and based on this data the cardiology team confirmed that a low heart score did not require a referral to the rapid access chest pain clinic.” Source location Response from London North West University Healthcare NHS Trust
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How this respondent position was interpreted
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PFD Monitor interpretation The acute chest symptoms were appropriately investigated and safety-netted regardless of recorded cardiovascular risk factors.
Verbatim wording from the response “On 19.4.23, during his telephone consultation, Mr. Bailey reported a history of chest pain/tightness intermittently for 2 weeks. If a person has a history of chest tightness, it is important to investigate the acute and high risk causes of the symptoms, regardless of whether they have any risk factors for ischaemic heart disease (IHD). This is because there may be a serious underlying cardiac or non-cardiac condition that needs urgent attention, such as pulmonary embolism, cardiac ischemia, aortic dissection or pericarditis,etc. Mr. Bailey was hence advised to go to the emergency department immediately on April 19, 2023.” Source location Response from Chuch Lane Surgery
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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 family history was not disclosed during prior consultations, so it was unavailable for consideration in risk assessment and prescribing.
Verbatim wording from the response “It has been discovered that the patient's brother had a history of cardiovascular disease in 2006 and 2012, which was not disclosed during previous encounters in 2012, 2018, or recent visits. As a result, it is now clear that the patient had a family history of cardiovascular disease that was not reported in previous encounters. This information was not taken into account, and the patient was not prescribed any cardio protective medication due to the low cardiovascular risk score as per NICE guidelines.” Source location Response from Chuch Lane Surgery
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Concerns raised 1
Lack of structured arrival handover and risk-history enquiry for detained patients 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
Hampshire and Isle of Wight Healthcare NHS Foundation Trust Portsmouth Hospitals University 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. 4
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Work with Portsmouth Hospitals University NHS Trust and continue supporting developments addressing emergency-department handover and shared patient care arrangements.
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Portsmouth Hospitals University NHS Trust
Review the standardised handover, triage and risk-assessment approach to ensure self-harm and absconding risks are considered at handover.
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Portsmouth Hospitals University NHS Trust
Meet with Solent NHS Trust to review transfer-of-care priorities, including clinician-to-clinician discussion before Emergency Department transfer.
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Portsmouth Hospitals University NHS Trust
Agree an implementation timeline with Solent NHS Trust for its electronic handover system.
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AI-generated summary
Jack FARRINGTON · 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
Jack Farrington, who had a long history of mental health difficulties and was detained under section 2 of the Mental Health Act, died on 2 January 2020 after running from an emergency department and falling from a road bridge. The report raised concerns about fragmented access to medical records, inadequate handovers and record keeping, insufficient flagging and assessment of absconding and self-harm risks, and the implementation of measures intended to keep him safe.
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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 structured arrival handover and risk-history enquiry for detained patients
Wider context from the report “I heard that there is no specific structure in place at Queen Alexandra Hospital Emergency Department for ensuring the full and accurate handover of information about a patient who arrives whilst subject to detention under the Mental Health Act. I heard evidence that the receiving staff are not required to ask about a patients history of absconding or self harm . This gives rise to the possibility of a patient’s risk not being properly assessed .
” Source location Jack FARRINGTON · 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 Work with Portsmouth Hospitals University NHS Trust and continue supporting developments addressing emergency-department handover and shared patient care arrangements.
Verbatim wording from the response “I hope that my letter has addressed the concerns raised from Mr Farrington’s inquest. I have noted that there were concerns addressed to both NHS England and Portsmouth Hospitals University NHS Trust in addition to Solent NHS Trust. I am pleased to report that our service has been working with Portsmouth Hospitals University NHS Trust to address the concern raised regarding handover on arrival at the Emergency Department and will continue to support Portsmouth Hospitals University NHS Trust in future developments and care arrangements for our shared patient groups.” Source location Response from Solent NHS 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 Review the standardised handover, triage and risk-assessment approach to ensure self-harm and absconding risks are considered at handover.
Verbatim wording from the response “The Trust uses a Mental Health Primary Risk Assessment Survey Tool to assess patients on arrival to ED, this has been updated following this incident (see response to Q3). In addition, the use of a standardised handover triage and risk assessment tool are in review to ensure that patients’ risk of self-harm or absconding are considered at the point of handover.” Source location Response from Portsmouth Hospitals University NHS 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 Meet with Solent NHS Trust to review transfer-of-care priorities, including clinician-to-clinician discussion before Emergency Department transfer.
Verbatim wording from the response “A meeting has been arranged with Solent NHS Trust on 9 January 2024 to review transfer of care priorities which will include clinician to clinician discussion prior to a patient’s transfer to the Emergency Department.” Source location Response from Portsmouth Hospitals University NHS 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 Agree an implementation timeline with Solent NHS Trust for its electronic handover system.
Verbatim wording from the response “In addition to a proposed clinician-to-clinician discussion, our colleagues at Solent NHS Trust are working on developing an electronic handover system. This system will provide the ED team with more information about the patient’s needs and risks before they arrive. We will agree the timeline for implementing this system at the scheduled meeting on January 9, 2024.” Source location Response from Portsmouth Hospitals University NHS Trust
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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 Solent NHS Trust is developing the electronic handover system, with implementation timing to be agreed jointly.
Verbatim wording from the response “In addition to a proposed clinician-to-clinician discussion, our colleagues at Solent NHS Trust are working on developing an electronic handover system. This system will provide the ED team with more information about the patient’s needs and risks before they arrive. We will agree the timeline for implementing this system at the scheduled meeting on January 9, 2024.” Source location Response from Portsmouth Hospitals University NHS Trust
Open published response
Concerns raised 1
Failure to incorporate family concerns and available information into ongoing treatment and clinical assessment View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Hampshire and Isle of Wight Healthcare NHS Foundation Trust NHS Hampshire and Isle of Wight Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Progress Triangle of Care accreditation from Star 2 toward Star 3.
View source
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Introduce Esther Improvement Coaches to reinforce person-centred carer and family engagement.
View source
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Employ carer leads, honorary carer leads and dedicated Carer Support Workers across the Trust.
View source
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Embed information-sharing principles through policies, protocols, annual information-governance training and carer materials.
View source
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Expand feedback routes through carer groups, forums, storytelling events, surveys and a funded BAME carers group.
View source
NHS Hampshire and Isle of Wight Integrated Care Board
Maintain an ongoing focus on improving engagement with families and carers using learning from this case.
View source See 3 more actions
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AI-generated summary
Kirsty Clare TAYLOR · 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
Kirsty Clare TAYLOR, aged 33, was found dead in the garage at her family home on 25 June 2022 after taking her own life by hanging in the early hours. The report identified concerns about fragmented mental and physical health services, insufficiently developed personality disorder provision, inadequate communication with and listening to families, and insufficient information and support for families of patients with neurodiversity.
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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 incorporate family concerns and available information into ongoing treatment and clinical assessment
Wider context from the report “3. I remain concerned (as it is a matter I have raised on many occasions at inquest and again as a result of the experiences of the family in this case), that communication with the families of patients with mental health difficulties is still not being effectively achieved. Nor are such families being sufficiently, effectively and meaningfully listened to or understood when they voice concerns, based on their experience of the patient outside of a treatment or assessment environment. Consequently, I am concerned that such matters are not being reflected sufficiently or frequently enough in the onward treatment of those patients or in the clinical curiosity afforded to their conditions .
There remains an over-focus on patient centric assessments and patient only responses. It is recognised that patients can present quite differently to and in the presence of their families, who know them intimately, to how they may (or may be able to) present to assessing clinicians - with or without the intent to mask their condition.
Whilst consent to share is an understandable barrier in some cases, there should not be a bar to listening to or to actively encouraging feedback and input from families, especially where a family's concerns are heightened by any sudden or marked changes in the behaviours, mood or presentation of their relative outside of the clinical/assessment environment - particularly in the case of neurodiversity.
Unless all concerns are heard and considered and all available information is taken on board, holistically , there is a continuing risk that the masking of mental health conditions and the deterioration of them may occur or that significant red flags are missed . In this case, the family's increasing desperate concerns voiced about their daughter's evident mental health deterioration in her final days went un-responded.
” Source location Kirsty Clare TAYLOR · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Progress Triangle of Care accreditation from Star 2 toward Star 3.
Verbatim wording from the response “In June of this year we were delighted to be awarded Triangle of Care Star 2 accreditation and we are now working towards Star 3 to complete the process. In order for a mental health trust to achieve star 2 status, it must not only have completed the self-assessment for inpatient wards and crisis services, but also provision of support within community mental health services.” Source location Response from Southern Health NHS 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 Introduce Esther Improvement Coaches to reinforce person-centred carer and family engagement.
Verbatim wording from the response “The introduction of Esther coaching this year will further enhance and reinforce the Triangle of Care principles. Esther Improvement Coaches are specially trained dedicated members of staff who support the development of other staff to create a culture of continuous” Source location Response from Southern Health NHS 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 Employ carer leads, honorary carer leads and dedicated Carer Support Workers across the Trust.
Verbatim wording from the response “There are 152 carer leads in teams across the Trust with an additional 63 honorary Carers Leads – influencers and ambassadors. These are members of the team with a responsibility to champion family and carer engagement as part of their wider clinical role. We have also employed 22 staff in the roles of Carer Support Workers across the Trust. These are paid roles exclusively for working with carers.” Source location Response from Southern Health NHS 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 Embed information-sharing principles through policies, protocols, annual information-governance training and carer materials.
Verbatim wording from the response “Policies and protocols with regards to information sharing (including the issue of capacity) are also in place. The Trust promotes the importance of both the 7th and 8th principles of the UK Caldicott Guardian Council in recognising the importance of the duty to share information being as important as the duty to protect patient confidentiality. They are included with our Triangle of Care work and information governance (IG) training. IG training is completed annually by every member of staff which will help to embed these principles further.” Source location Response from Southern Health NHS 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 Expand feedback routes through carer groups, forums, storytelling events, surveys and a funded BAME carers group.
Verbatim wording from the response “The Trust has increased the number of ways that people can give feedback and opportunities to share their experience. This includes Carers groups, storytelling events, carers forums, surveys etc. We have a number of carers groups across the Trust, as well as supporting external groups. Most recently, the Trust has funded and supported the setting up of a BAME carers group in Southampton. Feedback and issues highlighted from these different platforms is reported to the Carers, Family and Friends group and the Patient Experience and Caring group as part of our business-as-usual reporting.” Source location Response from Southern Health NHS 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 Maintain an ongoing focus on improving engagement with families and carers using learning from this case.
Verbatim wording from the response “Whilst there is more to be done to ensure that feedback from families and carers is heard and acted on and informs the delivery of care and decision-making for those in receipt of services, the trust has demonstrated its commitment to deliver continuous improvements in this area.” Source location Response from Hampshire and Isle of Wight
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Concerns raised 1
Difficulty obtaining an accurate clinical picture from patients with learning disabilities View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Shane Luke West · 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
Shane Luke West was pronounced dead on 17 August 2018 at Morriston Hospital after multi-organ failure caused by cardiorespiratory arrest associated with abdominal distention from chronic constipation and fluid build-up from laxative treatment. The principal concerns were inconsistent records of laxative administration, difficulty assessing his condition due to his learning disability, and whether the risks of further abdominal distention and respiratory compromise were sufficiently appreciated when administering laxatives.
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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 Difficulty obtaining an accurate clinical picture from patients with learning disabilities
Wider context from the report “I am concerned that in cases involving patients with learning disabilities (who commonly suffer from chronic constipation) the management of laxative treatment was not monitored closely enough to ensure a safe dosage of laxatives.
1. There was a contradiction between the nursing notes and the prescription charts as to the amount of laxatives administered on the 15th and 16th of August 2018.
2. Shane was known to hide his physical condition on questioning due to his learning disabilities and saying what he thought people wanted to hear. As such it was difficult for staff to get a true picture of Shane's condition .
3. Shane had ongoing respiratory compromise due to his abdominal distension pressing against his diaphragm therefore further distention posed a risk of further loss of respiratory function.
4. It was not clear whether medical professionals appreciated this risk and whether the administering of the laxatives ought to be staggered to allow Shane to receive the prescribed dose but not to the extent of overloading his already distended abdomen with fluid
” Source location Shane Luke West · Prevention of Future Deaths report
Open source report
13 Jun 2023 Raquel Mellonie Harper · Prevention of Future Deaths report East London
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Concerns raised 1
Lack of thorough history taking and verification of baseline oxygen saturation 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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Raquel Mellonie Harper · 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
Raquel Mellonie Harper attended Whipps Cross Hospital with shortness of breath and difficulty breathing, but a D Dimer test was not carried out and her condition later deteriorated. She suffered a cardiac arrest and died at the hospital on 25 June 2021. Concerns included inadequate history taking, failure to escalate monitoring after a high NEWS score, and disagreement or unclear wording in the Trust’s pulmonary embolism policy.
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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 thorough history taking and verification of baseline oxygen saturation
Wider context from the report “1. There was a lack of thorough history taking and a number of assumptions were made on the basis of Raquel’s high BMI . There was an assumed chronic low oxygen saturation with no evidence that the doctors had checked the records available or asked the patient about her baseline . The oxygen saturations recorded in the Barts sleep apnoea clinic in 2015 and 2016 were noted to be 99% and 100%.
” Source location Raquel Mellonie Harper · Prevention of Future Deaths report
Open source report
26 Apr 2023 Mrs Elsie Leaver · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Failure by SGH doctors to take a reasonable psychiatric history during clerking 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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Mrs Elsie Leaver · 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
Mrs Elsie Leaver died on 23 August 2020, aged 89, from multiple organ failure following a mixed drug overdose. The report raised concerns about missing psychiatric history, inadequate psychiatric assessment and risk assessment, failure to access available health information, and the lack of formal psychiatric liaison cover at QMH.
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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 by SGH doctors to take a reasonable psychiatric history during clerking
Wider context from the report “2. That doctors at SGH do not take a reasonable psychiatric history as part of their clerking and thus fail to make a proper holistic assessment of the patient and potentially miss the opportunity to manage risks such as those in this case which may lead to death.
” Source location Mrs Elsie Leaver · Prevention of Future Deaths report
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28 Mar 2023 Louis James Rogers · Prevention of Future Deaths report Surrey
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Concerns raised 1
Failure to undertake a detailed history and full neurological examination in general practice 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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Louis 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
Louis James Rogers died after being found unresponsive at home following a period of clinical illness and was pronounced dead on 18 June 2021 despite resuscitation attempts. Autopsy identified a viral infection, and genetic studies confirmed Dravet’s Syndrome. The report raised concerns about the management and investigation of febrile seizures, information provided to parents, paramedic and general practice guidance, and the lack of a coordinated febrile seizure pathway.
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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 a detailed history and full neurological examination in general practice
Wider context from the report “4. General Practice -
At his mother’s request after the possibility of a further seizure, Louis was reviewed by his general practitioner on the 13th May 2021 following which Louis’s mother was reassured without a detailed history from Louis’s mother or a full neurological examination and in the absence of documentation in circumstances whereby it was acknowledged there was sufficient information at that time to refer Louis to secondary services for the management of children with febrile seizures. It would therefore be appropriate to consider providing robust national guidance and education to general practitioners to ensure appropriate history, examination, investigation are undertaken to allow timely referrals to secondary medical services to be undertaken.
” Source location Louis James Rogers · 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 Ask colleagues from seven NHS regions to share learning and available guidance with Integrated Care Boards for cascading to relevant healthcare professionals.
Verbatim wording from the response “As a result of your Report, we will also be asking colleagues from each of the seven NHS regions to share the learnings from this matter and the guidance available with their Integrated Care Boards for cascading to relevant healthcare professionals.” Source location Response from 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 Replace the epilepsy guideline with updated recommendations on referral and information and support after a first seizure.
Verbatim wording from the response “We believe that our guideline on epilepsies: diagnosis and management [CG137], which was in place at the time of Louis’ death, is directly relevant to this case. The guideline covered diagnosing, treating and managing epilepsy and seizures in children, young people and adults in primary and secondary care and made recommendations on what should happen following a first seizure (section 1.4), diagnosis (section 1.5) and investigations (sections 1.6).” Source location Response from NICE
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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 NICE is responsible for producing clinical guidance on the diagnosis, treatment and management of febrile seizures.
Verbatim wording from the response “The National Institute for Health and Care Excellence (NICE) are responsible for producing clinical guidance for health and care practitioners on the issue of febrile seizures. Their guidance on Epilepsies in children, young people and adults (NG127) covers the diagnosis, treatment and management, referral recommendations and information and support for the management of epilepsy and seizures in children:” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing national guidance is considered sufficient for managing febrile seizures.
Verbatim wording from the response “NHS England has been sighted on the response to your Report from NICE, who have advised that there is sufficient national guidance regarding the management of febrile seizures.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing national guidance and the Clinical Knowledge Summary are considered sufficient to support timely assessment, investigation and referral for febrile seizures.
Verbatim wording from the response “We believe that our guideline on epilepsies: diagnosis and management [CG137], which was in place at the time of Louis’ death, is directly relevant to this case. The guideline covered diagnosing, treating and managing epilepsy and seizures in children, young people and adults in primary and secondary care and made recommendations on what should happen following a first seizure (section 1.4), diagnosis (section 1.5) and investigations (sections 1.6).” Source location Response from NICE
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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 RCEM will not lead development of further guidance because the project would be a significant undertaking, but can contribute with other organisations.
Verbatim wording from the response “RCEM would be happy to work with NHS England / National Institute for Healthcare Excellence, Royal Colleges and other interested parties to help develop further evidence based or consensus guidance in this complex area of clinical practice. We are mindful that this would be a significant undertaking and that it would therefore not be appropriate for RCEM to take the lead on such a project.” Source location Response from Emergency Care Committee
Open published response
Concerns raised 1
Failure to ask about family history of sudden cardiac death during reception health screening View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
NHS England
Refresh the secondary health screening template to add a specific prompt about family history of sudden cardiac death.
View source
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AI-generated summary
Joseph Andrew Price · 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
Joseph Andrew Price was found dead in his cell at HMP Durham on 20 September 2020, after being remanded there ten days earlier. The pathologist concluded that the medical cause of death was Sudden Cardiac Death, following evidence of a paternal family history of premature cardiac-related deaths. The principal concern was that this family history had not been recorded or elicited during healthcare assessments, making it unavailable to inform possible genetic screening; symptoms before death were also potentially confusable with drug withdrawal and mental or emotional distress.
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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 ask about family history of sudden cardiac death during reception health screening
Wider context from the report “The best, in some cases the only, way to predict a pre-disposition to a death of this nature is by reference to family medical history of such, or similar, occurrences. Once this is known, the person can then be referred for genetic screening. Sadly, in Andrew`s case no one in healthcare, some of whom had been familiar with him for years from previous terms of imprisonment, had any knowledge of the family history, as it did not feature on system one, and Andrew had never volunteered it. Equally, he had never been asked about it. This is not a criticism, simply a statement of fact made starkly relevant by the circumstances, unusual though they are.
The head of healthcare at HMP Durham gave evidence, when asked directly by me, that provision for a question in the reception health screen template about any family history of sudden cardiac death could help to prevent deaths of this kind recurring at the prison . She, with the health care provider for HMP Durham (Spectrum Community Health), has helpfully and very pro-actively put this into immediate effect locally (at HMP Durham and those other prisons covered by the health care provider). Specifically, the second health screen template (see attached - at pages 7 and 8) now shows that a question with regards family history (FH) of a ‘FH: Cardiac Disorder (incl. Sudden Cardiac Death)’ has been added to the second reception screen. The updating of the first reception health screen template is currently in hand.
” Source location Joseph Andrew Price · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refresh the secondary health screening template to add a specific prompt about family history of sudden cardiac death.
Verbatim wording from the response “In relation to your concern raised over a lack of appropriate read code for sudden cardiac death, there is no specific read code for sudden death syndrome on any clinical system, which is likely due to the fact there is no evidence to screen for it. NHS England is however refreshing the secondary health screening template to include a specific prompt for users to ask relevant questions relating to family history.” Source location Response from NHS England
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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 No specific read code for sudden death syndrome is provided because there is no evidence supporting screening for the condition.
Verbatim wording from the response “In relation to your concern raised over a lack of appropriate read code for sudden cardiac death, there is no specific read code for sudden death syndrome on any clinical system, which is likely due to the fact there is no evidence to screen for it. NHS England is however refreshing the secondary health screening template to include a specific prompt for users to ask relevant questions relating to family history.” Source location Response from NHS England
Open published response
1 Jul 2022 Daniel Xavier · Prevention of Future Deaths report East London
View report summary
Concerns raised 1
Failure to account for learning disability when taking a clear clinical history 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
Barts Health NHS Trust Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Department of Health and Social Care
Require CQC-registered service providers to ensure employees receive role-appropriate learning disability and autism training.
View source
Department of Health and Social Care
Make the first e-learning component of Oliver McGowan Mandatory Training available.
View source
Department of Health and Social Care
Publish a Code of Practice covering mandatory training requirements, content, delivery, monitoring and evaluation.
View source
Department of Health and Social Care
Carry out a public consultation on the Code of Practice for mandatory learning disability and autism training.
View source
Barts Health NHS Trust
Apply a vulnerable-patient flag to all emergency-department patients with a learning disability.
View source
Barts Health NHS Trust
Require senior-clinician discussion and early review for all emergency-department patients with a learning disability through the SOP and induction package.
View source
Barts Health NHS Trust
Provide learning-disability training for hospital specialties during governance days.
View source
Barts Health NHS Trust
Add a learning-disability section to statutory and mandatory training.
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AI-generated summary
Daniel Xavier · 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
Daniel Xavier attended the emergency department on 21 October 2021 with a history of painful haemorrhoids and an accompanying history of constipation. A venous blood gas showed an abnormally high creatinine level, but the result was not considered before he was discharged; he later became increasingly unwell, suffered a cardiac arrest, and could not be resuscitated. The report identified concerns about the failure to act on the blood result, a chaotic referral and inadequate handover, and insufficient consideration of his learning disability when taking his history.
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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 account for learning disability when taking a clear clinical history
Wider context from the report “3. Due regard was not given to Mr Xavier’s learning disability during his admission on 21st October 2021. Insufficient time and care was taken to establish a clear history from the patient , most pertinently his 7-day history of constipation.
” Source location Daniel Xavier · 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 CQC-registered service providers to ensure employees receive role-appropriate learning disability and autism training.
Verbatim wording from the response “Introducing mandatory training is an important way in which we can address persistent disparities in health and care outcomes for people with a learning disability and autistic people as evidenced from LeDeR reports. That is why the Government have now introduced a requirement for CQC registered service providers to ensure their employees receive learning disability and autism training appropriate to their role, as set out in the Health and Care Act 2022, which came into force on 1 July 2022.” Source location Response from Department of Health and Social Care
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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 Make the first e-learning component of Oliver McGowan Mandatory Training available.
Verbatim wording from the response “To support this new training requirement, the government have made significant progress on the Oliver McGowan Mandatory Training which was trialled in England during 2021 with over 8000 people. Part one of the training – an e-learning package – is now available.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a Code of Practice covering mandatory training requirements, content, delivery, monitoring and evaluation.
Verbatim wording from the response “Furthermore, the Secretary of State will publish a Code of Practice that will outline how to meet the new requirement for mandatory training including its content, delivery, ongoing monitoring and evaluation. The government will carry out a public consultation on the Code of Practice and timings for this consultation are currently being considered.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Carry out a public consultation on the Code of Practice for mandatory learning disability and autism training.
Verbatim wording from the response “Furthermore, the Secretary of State will publish a Code of Practice that will outline how to meet the new requirement for mandatory training including its content, delivery, ongoing monitoring and evaluation. The government will carry out a public consultation on the Code of Practice and timings for this consultation are currently being considered.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Apply a vulnerable-patient flag to all emergency-department patients with a learning disability.
Verbatim wording from the response “Within ED, all patients with a learning disability will have the vulnerable patient flag applied to them on the electronic patient records system to raise awareness. As part of an SOP, all patients with a learning disability will be discussed with by a senior clinician (ST3 plus) as a minimum and prioritised for early review. The SOP is part of the induction package.” Source location Response from Barts Health NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require senior-clinician discussion and early review for all emergency-department patients with a learning disability through the SOP and induction package.
Verbatim wording from the response “Within ED, all patients with a learning disability will have the vulnerable patient flag applied to them on the electronic patient records system to raise awareness. As part of an SOP, all patients with a learning disability will be discussed with by a senior clinician (ST3 plus) as a minimum and prioritised for early review. The SOP is part of the induction package.” Source location Response from Barts Health NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide learning-disability training for hospital specialties during governance days.
Verbatim wording from the response “Across the hospital, all specialties will be asked to have learning disability (LD) training during their governance days this year. The hospital currently has a LD nurse on site 2 days a week and with future appointments will have one 4-5 days a week. There will be a LD section as part of statutory and mandatory training by the end of the year.” Source location Response from Barts Health NHS
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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 Add a learning-disability section to statutory and mandatory training.
Verbatim wording from the response “Across the hospital, all specialties will be asked to have learning disability (LD) training during their governance days this year. The hospital currently has a LD nurse on site 2 days a week and with future appointments will have one 4-5 days a week. There will be a LD section as part of statutory and mandatory training by the end of the year.” Source location Response from Barts Health NHS
Open published response
Concerns raised 1
Inadequate questionnaire on the person's medical history View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Jamie Francis O'Connor · 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
Jamie O’Connor was found deceased in the garden of his home in Leicester on 14 October 2018 after his mother became concerned that he was not responding to phone calls. The report identified concerns about online prescribing, including the lack of central tracking, limited information sharing with GPs, no required face-to-face consultation, limited questionnaires, patients requesting specific drugs, and limited regulation; the inquest concluded that this was a drug-related death and recorded the cause as ████████ toxicity.
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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 Inadequate questionnaire on the person's medical history
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” Source location Jamie Francis O'Connor · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish high-level principles for safe remote consultations and online prescribing with healthcare organisations.
Verbatim wording from the response “We have also worked with other healthcare organisations including regulators, royal colleges and faculties and have jointly-agreed High level principles for good practice in remote consultations and prescribing that set out the good practice of healthcare professionals when prescribing medication online. The ten principles, underpinned by existing expected standards and guidance, include that healthcare professionals are expected to:” Source location 2021-0363-Response-from-GPC_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 Launch a call for evidence on remote consultations and prescribing to assess whether existing guidance remained appropriate for changing practice and technology.
Verbatim wording from the response “I appreciate that the events giving rise to this inquest date from several years ago. In late 2019 we launched a call for evidence in relation to remote consultations and prescribing. This explored whether our existing guidance, which was last updated in 2013 and which applied at the time of Mr O’Connor’s death, had kept pace with changes in practice and the use of technology.” Source location 2021-0363-Response-from-GMC_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 Publish updated prescribing guidance covering remote consultation suitability, information sharing, patient dialogue, and safeguards for controlled or potentially addictive medicines.
Verbatim wording from the response “Following this exercise, we published updated guidance for doctors on prescribing in February 2021. This now places a greater emphasis on following the principles of good practice regardless of the medium through which a consultation is taking place, face to face or online.” Source location 2021-0363-Response-from-GMC_Published
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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 Online consultations and prescribing without face-to-face assessment can be safe where appropriate safeguards, history-taking, GP engagement and monitoring exist.
Verbatim wording from the response “Through our regulation of independent online primary medical services, CQC has identified gaps in the regulatory framework for independent online providers. We continue to have concerns about safety gaps, which generally align to those you have identified. We do however recognise there are benefits in the provision of online services, and for consultations and prescribing without the need for a face to face consultation where there are appropriate safeguards in place. These include history taking, engagement with the registered GP, and monitoring, as well as a risk assessing those medicines that are prescribed by a service. Our specific concerns are in the following areas:” Source location 2021-0363-Response-from-CQC_Published
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.