23 Sep 2025 Tony Buengo Jackson · Prevention of Future Deaths report East London
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Concerns raised 1
Poor recording of best interest decisions, PEG insertion and subsequent treatment View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Barts Health NHS Trust
Reinforce requirements for clearly documenting best-interest discussions, including participants, reasoning, risks, benefits and outcomes.
View source
Barts Health NHS Trust
Reissue documentation guidance to consultants and trainees and disseminate it through governance meetings and resident doctor teaching.
View source
Barts Health NHS Trust
Roll out e-consent in endoscopy with sections for consent form 4 and best-interest discussions.
View source
Barts Health NHS Trust
Discuss standardising e-consent and expanding Concentric Platform access to improve electronic-record integration and reduce paper consent documentation.
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AI-generated summary
Tony Buengo Jackson · 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
Tony Buengo-Jackson, who had progressive multiple sclerosis and lived in a nursing home, died after a PEG tube inserted on 19 November 2024 passed through his transverse colon, causing bowel perforation, peritonitis and sepsis. The report raises concerns that the injury was not detected until 3 December despite an earlier admission, CT scan and surgical consultation, and that poor records and inadequate Trust governance impeded investigation and learning.
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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 Poor recording of best interest decisions, PEG insertion and subsequent treatment
Wider context from the report “2. Records of, best interest decisions, the PEG insertion and subsequent treatment were so poor as to impede the court’s investigation .
” Source location Tony Buengo Jackson · 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 Reinforce requirements for clearly documenting best-interest discussions, including participants, reasoning, risks, benefits and outcomes.
Verbatim wording from the response “• The Trust has reinforced the requirement that all best-interest discussions are documented in the patient record, clearly recording:
o who was present,
o the clinical reasoning and evidence considered,
o risks and benefits discussed,
o and the agreed outcome.” Source location Response from Barts Health 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 Reissue documentation guidance to consultants and trainees and disseminate it through governance meetings and resident doctor teaching.
Verbatim wording from the response “• Guidance has been re-issued to consultants and trainees regarding documentation standards for capacity assessments and best-interest decisions. This has been discussed in divisional Clinical Governance meetings and included in Resident Doctor teaching.” Source location Response from Barts Health 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 Roll out e-consent in endoscopy with sections for consent form 4 and best-interest discussions.
Verbatim wording from the response “• E-consent has been rolled out in endoscopy in the last 12 months and includes a detailed section for consent form 4 and best interests discussions. Currently only a limited number of clinicians have access to this system.” Source location Response from Barts Health NHS Trust
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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 Discuss standardising e-consent and expanding Concentric Platform access to improve electronic-record integration and reduce paper consent documentation.
Verbatim wording from the response “• E-consent has been rolled out in endoscopy in the last 12 months and includes a detailed section for consent form 4 and best interests discussions. Currently only a limited number of clinicians have access to this system.” Source location Response from Barts Health NHS Trust
Open published response
4 Mar 2025 Mark Anthony Fernandez · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Failure to take account of long-term carers' and social services' views and knowledge in best interest decisions 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
Northern Care Alliance NHS Foundation Trust Oldham Borough Council Oldham Council ASC
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Oldham Borough Council
Work with the commissioned IMCA service to ensure information is shared with decision-makers when interested persons are not invited to medical best-interest meetings.
View source
Oldham Council ASC
Create and disseminate a risk-rating framework for safe attendance decisions at other organisations’ medical best-interests meetings, including information-sharing considerations.
View source
Northern Care Alliance NHS Foundation Trust
Deliver commissioned education sessions on Mental Capacity Act incapacitated-consent requirements and the importance of carers’ views in best-interest decisions.
View source
Northern Care Alliance NHS Foundation Trust
Define Mental Capacity Act and Deprivation of Liberty Safeguards training to support wider practical application beyond DoLS authorisation.
View source
Northern Care Alliance NHS Foundation Trust
Roll out and develop the updated mental-capacity ward audit programme, including training lead nurses and reporting findings through governance groups.
View source See 2 more actions
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Mark Anthony Fernandez · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mark Anthony Fernandez, who had cerebral palsy, complex medical needs and lived in supported accommodation with full-time carers, was admitted to hospital with suspected meningitis and recurring infections and remained there until his death; he was later placed on end-of-life care. The substantive concerns included inadequate information in a referral, failure to use his hospital passport, and a best-interests decision that did not take account of the knowledge and views of his long-term carers and social services.
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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 take account of long-term carers' and social services' views and knowledge in best interest decisions
Wider context from the report “1. The hospital passport was not utilised.
2. A best interest decision was made without taking into account the views of the long-term carers and social services and their knowledge of him as an individual .
” Source location Mark Anthony Fernandez · 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 Work with the commissioned IMCA service to ensure information is shared with decision-makers when interested persons are not invited to medical best-interest meetings.
Verbatim wording from the response “The Council can also confirm that the commissioned IMCA service is able to cover medical best interest decisions. adult social care will work with them to ensure that where they feel interested persons have not been invited to medical best interest decision meetings, they ensure appropriate information is shared with the organisation leading the decision.” Source location Response from Oldham Council
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create and disseminate a risk-rating framework for safe attendance decisions at other organisations’ medical best-interests meetings, including information-sharing considerations.
Verbatim wording from the response “Risk rating framework to support practitioners to make safe and informed decisions regarding attendance at medical best interest’s meetings led by other organisations to be created and disseminated across ASC.” Source location Response from Oldham Council - Action Plan
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver commissioned education sessions on Mental Capacity Act incapacitated-consent requirements and the importance of carers’ views in best-interest decisions.
Verbatim wording from the response “MCA training” Source location Response from Northern Care Alliance 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 Define Mental Capacity Act and Deprivation of Liberty Safeguards training to support wider practical application beyond DoLS authorisation.
Verbatim wording from the response “The Trust Level 3 safeguarding adult mandatory training programme has a significant focus on the MCA and its application in practice. Current organisational compliance with Level 3 Safeguarding adult training is at 95%. MCA and Deprivation of Liberty Safeguards (DoLS) training have been better defined to support the application of MCA beyond the requirement for application of a DoLS authorisation to ensure the MCA is more effectively considered for a wider group of patients, including those with learning disabilities. The application of the MCA is essential to the EPO procedures to ensure the least restrictive option of observation and support is provided.” Source location Response from Northern Care Alliance NHS Foundation Trust
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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 Roll out and develop the updated mental-capacity ward audit programme, including training lead nurses and reporting findings through governance groups.
Verbatim wording from the response “MCA audits” Source location Response from Northern Care Alliance NHS Foundation Trust
Open published response
3 Mar 2025 JAVED IQBAL · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure of staff to understand service users' best interests View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
All Care in One
Provide supervision that develops staff understanding, reflection, performance, policy compliance and responses to deteriorating mental health.
View source
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JAVED IQBAL · 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
Javed died on 1 June 2024 after deliberately igniting his room with flammable liquid and sustaining major burn injuries and smoke inhalation, followed by multi-organ failure. The report identified concerns that staff did not recognise and appropriately act on serious acute mental health issues, including not escalating worsening mood and irrational behaviour to the GP in writing. It also identified the absence of a formal internal post-death investigation and outstanding internal training that had not addressed these concerns.
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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 staff to understand service users' best interests
Wider context from the report “The evidence demonstrated there is a continuing risk that All Care In One Ltd staff will not recognise and take appropriate action when a service user presents with serious acute mental health issues. For example:
(1) At a fundamental level staff did not understand what is in the best interests of a service user :
(a) Carers did not want to embarrass Javed, therefore they felt justified in making repetitive inaccurate contemporaneous records recording behaviour and mood as well despite having serious concerns about his worsening mental health and triggering an urgent call to his GP; (b) Then, having contacted the GP two days before his death, the care co-ordinator did not action the request from the GP to send an email setting out these serious concerns in writing.
(2) There was no formal internal post-death investigation report.
(3) Whilst some post-death internal training has been identified it remains outstanding despite 8 months passing since the death. However, I was not satisfied this training has recognised the above concerns.
” Source location JAVED IQBAL · 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 Provide supervision that develops staff understanding, reflection, performance, policy compliance and responses to deteriorating mental health.
Verbatim wording from the response “Action plan: Guidance and Development: We are Ensuring that carers and coordinators fully understand their duties, including acting in the best interests of service users and recognizing signs of deteriorating mental health.” Source location Response from All Care In One Ltd
Open published response
Concerns raised 2
Insufficient training coverage on capacity and best interests decision making across hospital settings View source Failure to carry out capacity assessments and subsequent best interests decision making View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Janet Rice · 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
Janet Rice, aged 65, died in hospital from pulmonary and cerebral embolism after surgery for a hip fracture sustained in an accidental fall. Anti-coagulant medication was inconsistently administered, including during a period when she was experiencing acute delirium; concerns included the absence of a capacity assessment, best-interests decision, escalation, or consideration of alternative treatment. The report also raised concerns about delays and limitations in the Trust’s patient safety investigation and the limited scope of related training.
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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 Insufficient training coverage on capacity and best interests decision making across hospital settings
Wider context from the report “(3) Although evidence was heard in relation to the provision of further training in relation to the issues of capacity and best interests decision making , to address the concerns identified in this investigation this was limited to the community hospital setting, when it is known that the issues continued in the acute hospital setting .
” Source location Janet Rice · 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 carry out capacity assessments and subsequent best interests decision making
Wider context from the report “(2) The patient safety investigation report is not a comprehensive and robust review of the omissions in provision of anti coagulant and does not consider or address the omission to administer anti coagulant because the deceased was transferred between hospitals, nor does it detail all of the incidents of missed anti coagulant, some of which only became apparent upon receipt of the independent expert report. It’s remit and action plan are limited to the community hospital only, and do not consider or address the further instances of omission to administer anti coagulant in the acute hospital setting, where there was a continued failure to carry out a capacity assessment and any subsequent best interests decision making process , failure to escalate these issues, and/or to consider any alternative treatment to reduce the high risk of DVT/PE.
” Source location Janet Rice · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update the patient safety investigation report and action plan to cover the patient’s acute and community care.
Verbatim wording from the response “The patient safety investigation report is not a comprehensive and robust review of the omissions in provision of anti-coagulant and does not consider or address the omission to administer anti-coagulant because the deceased was transferred between hospitals, nor does it detail all of the incidents of missed anti-coagulant, some of which only became apparent upon receipt of the independent expert report. It’s remit and action plan are limited to the community hospital only, and do not consider or address the further instances of omission to administer anti-coagulant in the acute hospital setting, where there was a continued failure to carry out a capacity assessment and any subsequent best interests decision making process, failure to escalate these issues, and/or to consider any alternative treatment to reduce the high risk of DVT/PE.” Source location Response from Durham and Darlington NHS
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17 Jul 2022 Darren Jones · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to put an IMCA in place to safeguard best interests 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
NHS Greater Manchester Integrated Care Board
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AI-generated summary
Darren 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
Darren Jones, who had severe learning disabilities, a long-term catheter and chronic kidney disease, was admitted to Stepping Hill Hospital after unsuccessful catheter changes in the community and Emergency Department. He deteriorated despite treatment for sepsis and died at the hospital on 22 October 2021. The concerns included pressures on community district nursing services, insufficient recognition of his learning difficulties and support needs in hospital, a dispute between Local Authorities affecting respite care and catheter-care training, and the absence of a commissioned LeDeR review.
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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 put an IMCA in place to safeguard best interests
Wider context from the report “2. Mr Jones had significant learning difficulties which were not fully recognised at the hospital to ensure that he was provided with support and that an IMCA was put in place to ensure his best interests were met . The Inquest heard evidence that it was important that all clinicians and health care professionals were clear and understood how to effectively support someone with a learning disability to ensure they were given the best and most appropriate care;
” Source location Darren Jones · Prevention of Future Deaths report
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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 safeguarding processes for patients with learning difficulties are considered robust, despite failing on this occasion.
Verbatim wording from the response “We are satisfied that there is a robust process in place for the support of patients with learning difficulties but acknowledge that the process failed on this occasion which is highly regrettable. Appropriate steps have been taken to ensure wider team awareness for the benefit of future patients.” Source location Response from NHS Greater Manchester
Open published response
28 May 2021 KEVIN JOHN FITTON · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 1
Failure to use best interests policy appropriately View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
KEVIN JOHN FITTON · 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
Kevin Fitton suffered a catastrophic stroke in 2010 and died after a cardiac arrest following fluid overload during his final hospital admission on 12 July 2019. The report identified longstanding concerns about inadequate assessment and support for his acquired brain injury, poor coordination and communication, ineffective implementation of care assessments, and failures to recognise and respond to his substance use, self-neglect and deteriorating health. The inquest concluded that a failure to obtain an urgent echocardiogram represented a missed opportunity to diagnose and treat his cardiac condition, and that the outcome may have been different with a correct diagnosis and more controlled fluid administration.
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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 use best interests policy appropriately
Wider context from the report “(1) There was an almost complete reliance of assumption of capacity. The lack of capacity assessments resulted in failure to identify the area and support needed by Mr Fitton and a failure to use best interests policy appropriately .
” Source location KEVIN JOHN FITTON · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and refresh Mental Capacity Act training, monitor attendance and refresher completion, and communicate attendance requirements to frontline teams.
Verbatim wording from the response “• We will review our existing Mental Capacity Act (In Practice) training which includes the Code of Practice, and guidance on use of the Best Interests process and refresh the message on ensuring good practice of this. We will monitor practitioner take up of the training, percentage attended and those who have refreshed, and communicate with front line teams to ensure practitioners attend these and refresh regularly.” Source location 2021-0169-Responses-from-Sussex-NHS-Commissioners-and-Brighton-and-Hove-City-Council_Published
Open published response
Concerns raised 4
Inadequate detail in best-interests documentation View source Failure of clinical teams to seek the patient's views View source Failure to treat best-interests decisions as specific individual decisions View source
Failure to distinguish clinical decisions from supported or best-interests decision-making View source See 1 more concern
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Sheffield Teaching Hospitals 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. 4
Sheffield Teaching Hospitals NHS Foundation Trust
Run MCA and Best Interests audits to assess practical application, recording, patient and family involvement, and Health Passport use.
View source
Sheffield Teaching Hospitals NHS Foundation Trust
Strengthen MCA training so all front-line clinical staff have the required knowledge.
View source
Sheffield Teaching Hospitals NHS Foundation Trust
Roll out advanced MCA training to senior decision-makers, initially targeting Clinical Directors, and monitor uptake.
View source
Sheffield Teaching Hospitals NHS Foundation Trust
Provide accessible intranet resources covering MCA guidance, staff awareness and specialist support contacts.
View source See 1 more action
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AI-generated summary
Laura Booth · 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
Laura Booth died at the Royal Hallamshire Hospital on 19 October 2016 after becoming unwell during an admission for a routine procedure. The inquest found that inadequate management of her nutritional needs led to malnutrition, which contributed to her death, and that clinical decisions about her care were made without properly involving her or her parents under the Mental Capacity Act. The report also raised concerns about staff understanding and application of the Mental Capacity Act and the use of Laura’s hospital passport.
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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 detail in best-interests documentation
Wider context from the report “(7) There was evidence in the clinical notes of one best interests form completed for Laura's admission for her eye surgery. The completion of this form, whilst a positive that it had been completed and is evidence that best interests had been considered, remains woefully inadequate in details and upon further exploration it was apparent that no attempt had been made to engage Laura in the decision making.
” Source location Laura Booth · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of clinical teams to seek the patient's views
Wider context from the report “(6) Laura was non verbal but she could communicate. There was no evidence of anyone seeking Laura's parents' views in a way which would be compliant with the Mental Capacity Act and were worryingly, no evidence of clinical teams seeking Laura's views at all .
” Source location Laura Booth · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to treat best-interests decisions as specific individual decisions
Wider context from the report “(5) There appears to be a lack of understanding that decisions, when referred to in a best interests sense, are specific . This is not an overall catch all care plan . For example, the decision about whether Laura should receive an NG tube is one specific decision it is not bound up with ceilings of care decisions or any other decisions to be made with and for Laura.
” Source location Laura Booth · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to distinguish clinical decisions from supported or best-interests decision-making
Wider context from the report “(8) There appeared to be a view that although there was no formal best interests meeting for decisions about Laura's nutrition, clinical discussions were taking place with the right clinicians and therefore the decisions would not be changed by a best interests meeting. This is a fundamental misunderstanding about the requirements of the Mental Capacity Act and best interests, clinical decisions are not a substitute for the individual being supported to decide for themselves or for a decision made in their best interests to be reflective of their own views . In the same way as an individual with capacity may decline a treatment, even where it is recommended by a clinician in the highest possible terms, a treatment or intervention can be declined on Ps behalf where that decision is made in their best interests in accordance with the requirements of the Mental Capacity Act. Where necessary this may require application to the Court of Protection where there is a dispute.
” Source location Laura Booth · 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 Run MCA and Best Interests audits to assess practical application, recording, patient and family involvement, and Health Passport use.
Verbatim wording from the response “In order to assess the impact of this training, the following measures have been put in place and are on-going:” Source location 2021-0137-Response-from-Northern-General-Hospital_Published
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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 Strengthen MCA training so all front-line clinical staff have the required knowledge.
Verbatim wording from the response “Over the past few years the Trust has undertaken a wide range of actions to embed the requirements of the Mental Capacity Act (MCA) and ensure that there is proactive support for learning disability patients, and other patient groups who may lack full capacity. Prior to the inquest into Laura’s death, we had started to give this area of work greater emphasis and the conclusions that you reached give further weight to the importance of this work, which includes:” Source location 2021-0137-Response-from-Northern-General-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out advanced MCA training to senior decision-makers, initially targeting Clinical Directors, and monitor uptake.
Verbatim wording from the response “We are committed to rolling out this more advanced training to all senior decision makers. This will initially be targeted at Clinical Directors who will then be tasked with deciding how best to deliver this within their directorates, which cover a wide variety of services. This approach will enable us to ensure training is tailored to the intended audience and that uptake is high. The progress of this advanced training will be monitored by the Mental Health Steering Group to ensure that all appropriate staff groups receive this training.” Source location 2021-0137-Response-from-Northern-General-Hospital_Published
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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 accessible intranet resources covering MCA guidance, staff awareness and specialist support contacts.
Verbatim wording from the response “Over the past few years the Trust has undertaken a wide range of actions to embed the requirements of the Mental Capacity Act (MCA) and ensure that there is proactive support for learning disability patients, and other patient groups who may lack full capacity. Prior to the inquest into Laura’s death, we had started to give this area of work greater emphasis and the conclusions that you reached give further weight to the importance of this work, which includes:” Source location 2021-0137-Response-from-Northern-General-Hospital_Published
Open published response
4 May 2020 Barry Wayne Preston · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure of care coordinators to lead support and best-interests processes in acute settings View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Bolton Borough Council Bolton NHS Foundation Trust Department of Health and Social Care Greater Manchester Mental Health 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. 8
Bolton NHS Foundation Trust
Provide assessment wards and the Emergency Department with a full Integrated Discharge Team service and assign a lead care coordinator for each patient's discharge planning.
View source
Bolton NHS Foundation Trust
Provide a single hospital-based care coordinator for each patient and record coordination input in electronic and social services records.
View source
Greater Manchester Mental Health NHS Foundation Trust
Use the care coordinator as the single mental health contact for hospital admissions and require re-entry into hospital care to maintain communication and consistency.
View source
Greater Manchester Mental Health NHS Foundation Trust
Advise care coordinators to proactively contact acute trusts and coordinate care when service users move between wards, hospitals or care settings.
View source
Greater Manchester Mental Health NHS Foundation Trust
Communicate expectations to staff that significant changes require consideration and recording of capacity assessments and Best Interest meetings, with care-plan liaison monitored through supervision.
View source
Greater Manchester Mental Health NHS Foundation Trust
Have Team Managers proactively review cases involving admission to other care settings during supervision to check care coordination and consideration of capacity and Best Interest meetings.
View source
Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust
Establish a single care-coordinator point of contact, with care coordinators providing hospital in-reach for involved service users.
View source
Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust
Provide the Integrated Discharge Team across all assessment wards and the Emergency Department, assigning a lead care coordinator from admission through discharge.
View source See 5 more actions
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AI-generated summary
Barry Wayne Preston · 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
Barry Wayne Preston, who lacked capacity and lived in supported accommodation, suffered a series of falls and traumatic brain injuries before developing urosepsis associated with a catheter that was not replaced within the guidance period, followed by bronchopneumonia. The report identified concerns about inaccurate documentation, unsuitable placement and wards, inadequate coordination and ownership of care, failures to hold best interests meetings, and insufficient understanding of his lack of capacity.
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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 care coordinators to lead support and best-interests processes in acute settings
Wider context from the report “3. The inquest heard that he had a care coordinator in the community. However the care coordinator did not take a lead in ensuring he was being supported in the acute settings or that best interests meetings were taking place . There was a lack of understanding between agencies of roles and responsibilities under the integrated care model.
” Source location Barry Wayne Preston · 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 Provide assessment wards and the Emergency Department with a full Integrated Discharge Team service and assign a lead care coordinator for each patient's discharge planning.
Verbatim wording from the response “At the time of this incident the IDT did not provide a comprehensive service to inpatient assessment areas such as ward D2, operating an in-reach model which was reliant on other professionals to identify those patients who had existing social care needs prior to admission to hospital. The team has been reconfigured to ensure that patients with complex health and social needs are identified through the same multi-disciplinary team process that has been in place on base ward areas. Since May 2020, all assessment wards, as well as the Emergency Department are provided a full service and a lead care coordinator is assigned to oversee the coordination of the discharge planning process from admission to discharge.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
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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 a single hospital-based care coordinator for each patient and record coordination input in electronic and social services records.
Verbatim wording from the response “The IDT has identified that the role of a seconded mental health post within the team was a key omission in the management of Mr Preston’s journey. The use of different organisation’s case recording systems also resulted in the failure to identify that the patient already had a care coordinator in the community and the needs to identify an IMCA to represent the patient’s best interest. Since this incident the IDT has in conjunction with GMMHFT, removed this role from the service in order to provide a single care coordinator (this will either be a social worker or discharge nurse) for each patient who is hospital based and will liaise with other organisations where needed. All input will be recorded in the patient’s electronic patient record and social services case recording systems.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the care coordinator as the single mental health contact for hospital admissions and require re-entry into hospital care to maintain communication and consistency.
Verbatim wording from the response “A review of the mental health practitioner role within the Integrated Discharge Team had commenced prior to the death of Mr Preston, however following a subsequent review with the Local Authority and Bolton Foundation Trust, taking into consideration the concerns noted within the inquest, the decision has been taken to end the secondment of the mental health social worker and return the practitioner to their substantive post within Greater Manchester Mental Health. Going forward there is now one point of contact with mental health services, the care coordinator, who will on re-arch into the hospital when any service user they are involved with is admitted, to provide consistency and ensure hospital staff are aware of any input from mental health services.” Source location 2020-0110-Response-from-Greater-Manchester-Mental-Health-Trust_Redacted.pdf
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 Advise care coordinators to proactively contact acute trusts and coordinate care when service users move between wards, hospitals or care settings.
Verbatim wording from the response “• Care coordinators have been advised that as part of their role, they are expected to proactively in-reach into acute trusts, to ensure effective communication is facilitated, to mitigate risks of individuals being moved between wards / hospitals / other care settings without the care coordinator being informed; this will enable to care coordinator to appropriately coordinate care, taking into account an individual's holistic needs. (This is outlined with the Older Adult Service Operational Procedure and the Policy for the Transfer of Service Users to Acute Care).” Source location 2020-0110-Response-from-Greater-Manchester-Mental-Health-Trust_Redacted.pdf
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 Communicate expectations to staff that significant changes require consideration and recording of capacity assessments and Best Interest meetings, with care-plan liaison monitored through supervision.
Verbatim wording from the response “• Team Managers have discussed the expectations with all staff, that every time there is a significant change in an individual's circumstance, that capacity assessments & Best Interest Meetings are considered and clearly recorded, and that care coordinators ensure they proactively liaise with other care providers to ensure any changes to the care plan can be reviewed and updated appropriately, and this is being monitored via supervision.” Source location 2020-0110-Response-from-Greater-Manchester-Mental-Health-Trust_Redacted.pdf
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 Have Team Managers proactively review cases involving admission to other care settings during supervision to check care coordination and consideration of capacity and Best Interest meetings.
Verbatim wording from the response “Through supervision and team meetings, all staff have been informed of the expectations of a care coordinator when patients are admitted to alternative care settings, such as acute trusts, and informed that they must consider support from advocacy / IMCA. Team Managers will proactively review cases where individuals have been admitted to other care settings in supervision to ensure that care coordinator are proactively coordinating the individuals care, and consideration has been given to Capacity and Best Interest meetings, where appropriate.” Source location 2020-0110-Response-from-Greater-Manchester-Mental-Health-Trust_Redacted.pdf
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 Establish a single care-coordinator point of contact, with care coordinators providing hospital in-reach for involved service users.
Verbatim wording from the response “A review of the mental health practitioner role within the IDT had commenced prior to the death of Mr Preston, however following a subsequent review with the Local Authority and BNFT, taking into consideration the concerns noted within the inquest, the decision has been taken to end the secondment of the mental health social worker and return the postholder to Greater Manchester Mental Health. There is now one point of contact, which is the care coordinator, who will in-reach into the hospital when any service user they are involved with is admitted.” Source location 2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
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 the Integrated Discharge Team across all assessment wards and the Emergency Department, assigning a lead care coordinator from admission through discharge.
Verbatim wording from the response “At the time of this incident the IDT did not provide a comprehensive service to inpatient assessment areas such as ward D2, operating an in-reach model which was reliant on other professionals identify those patients who had existing social care needs prior to admission to hospital. The team has been reconfigured to ensure that patients with complex health and social needs are identified through the same multi-disciplinary team process that has been in place on base ward areas. Since May 2020, all assessment wards as well as the Emergency Department are provided a full service and a lead care coordinator is assigned to oversee the coordination of the discharge planning process from admission to discharge.” Source location 2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
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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 Bolton Council and GMMHFT will provide the full response to concerns about community care coordination and agency roles.
Verbatim wording from the response “Section 5 (3) The inquest heard that he had a care coordinator in the community. However, the care coordinator did not take a lead in ensuring he was being supported in the acute settings or that best interest meetings were taking place. There was a lack of understanding between agencies of role and responsibilities under the integrated care model.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
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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 Greater Manchester Mental Health Foundation Trust addresses care coordinator responsibilities.
Verbatim wording from the response “The point regarding care coordinator responsibilities is addressed in point (4) by GMMH. However, with regard to the lack of understanding of roles and responsibilities under the integrated care model, we have made some changes following the inquest which should provide assurance.” Source location 2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
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 Bolton NHS Foundation Trust, Greater Manchester Mental Health NHS Foundation Trust and Bolton Council are responsible for responding to the report’s specific concerns.
Verbatim wording from the response “I expect the Bolton NHS Foundation Trust, the Greater Manchester Mental Health NHS Foundation Trust and Bolton Council to carefully consider and respond to the specific concerns highlighted by your report. I am advised that Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust have apologised for the lack of co-ordination in Mr Preston’s care while he was in hospital and the failure to conduct a formal assessment of Mr Preston’s mental capacity. You will know from the responses of the NHS trusts and Bolton Council to your report that they have worked together to resolve the matters of concern highlighted, with several actions taken to improve the co-ordination and quality of care for people with physical and mental health problems. I am pleased to see that learnings are being taken from the circumstances around Mr Preston’s care.” Source location 2020-0110-Response-from-Department-of-Health-and-Social-Care.pdf
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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 Local authorities, service providers and the Care Quality Commission are responsible for acting on allegations of poor care, neglect or abuse.
Verbatim wording from the response “The Government is committed to preventing and reducing the risk of harm to adults in vulnerable situations. Under the Care Act 2014, we expect local authorities to ensure that the services they commission are safe, effective and of high quality. We also expect those providing the service, local authorities and the Care Quality Commission (CQC) to take swift action where anyone alleges poor care, neglect or abuse.” Source location 2020-0110-Response-from-Department-of-Health-and-Social-Care.pdf
Open published response
24 Dec 2019 Julie Helen Taylor · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2
Failure to document decision-making rationales in inpatient notes View source Failure to hold formal best interests meetings for key inpatient decisions 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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AI-generated summary
Julie Helen 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
Julie Helen Taylor, who had Down syndrome and significant learning disabilities, died at Stepping Hill Hospital on 23 September 2018 from pneumonitis following a chicken pox virus infection contracted while awaiting discharge. The concerns included inadequate reasonable-adjustment planning, lack of best-interests meetings and documented decision-making, poor communication between agencies, limited access to suitable learning-disability beds and support, information-sharing difficulties, and delayed recognition of chicken pox.
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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 document decision-making rationales in inpatient notes
Wider context from the report “2. No formal best interests meeting(s) was/were held whilst Julie Taylor was an inpatient at the acute hospital. Key decisions were taken regarding what tests to carry out; whether to nurse her and whether to place her on End of Life care without the benefit of a best interests meeting. Decisions were taken with no rationale for them being documented in her notes . The inquest heard that the trust had taken steps to promote the use of best interests meetings/improved documentation in similar cases in the future but that nationally there was a lack of consistency around the use of best interests meetings/documentation of decision making and rationales for those decisions ;
” Source location Julie Helen Taylor · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to hold formal best interests meetings for key inpatient decisions
Wider context from the report “2. No formal best interests meeting(s) was/were held whilst Julie Taylor was an inpatient at the acute hospital. Key decisions were taken regarding what tests to carry out; whether to nurse her and whether to place her on End of Life care without the benefit of a best interests meeting . Decisions were taken with no rationale for them being documented in her notes. The inquest heard that the trust had taken steps to promote the use of best interests meetings/improved documentation in similar cases in the future but that nationally there was a lack of consistency around the use of best interests meetings/documentation of decision making and rationales for those decisions;
” Source location Julie Helen Taylor · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit use of Best Interest Meetings following the October 2019 launch of Trust guidelines.
Verbatim wording from the response “The Trust launched guidelines for Best Interest Decisions and Best Interest Meetings in October 2019.” Source location 2019-0454-Response-from-Greater-Manchester-Health-and-social-Care-Partnership-Redacted
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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 local NHS is expected to reflect on the LeDeR findings and address local failings in care for people with learning disabilities.
Verbatim wording from the response “I am advised by NHS England and NHS Improvement that Ms Taylor’s death is currently being reviewed under the LeDeR process and I expect the local NHS to reflect on the findings of the review and take action to address any failings in the care provided locally for people with a learning disability. I have also asked officials to bring your report to the attention of the National Director for Learning Disabilities, Ray James, who is leading work nationally to improve services for people with learning disabilities and/or autism.” Source location 2019-0454-Response-from-the-Department-of-Health-and-Social-Care
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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 A formal best-interests meeting is not a statutory duty, although decision-makers must comply with the Mental Capacity Act consultation requirements.
Verbatim wording from the response “Your report explains that a best interests meeting was not held while Ms Taylor was an inpatient at Stepping Hill Hospital. While a formal best interests meeting is not a duty, under section 4 of the Mental Capacity Act (2005)⁶ (MCA), the decision maker must take into account, if it is practicable and appropriate to consult them, the views of anyone named by the person as someone to be consulted; anyone engaged in caring for the person or interested in their welfare; and any person with lasting power of attorney or a deputy appointed by a court.” Source location 2019-0454-Response-from-the-Department-of-Health-and-Social-Care
Open published response
17 Dec 2019 Lewis Victor Mendelson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2
Failure to hold a formal best interests meeting during hospital treatment View source Failure to hold a best interests meeting for End of Life Care View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Helen Whatley MP Stockport Borough Council
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AI-generated summary
Lewis Victor Mendelson · 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
Lewis Victor Mendelson, who had profound learning and physical disabilities, became unwell after vomiting on 8 May 2019, was taken to hospital, later received end-of-life care, and died at home on 16 May 2019. The concerns included the absence of a DoLS authorisation, statutory care review and allocated social worker, as well as hospital treatment and end-of-life decisions without a formal best interests meeting or IMCA involvement.
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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 hold a formal best interests meeting during hospital treatment
Wider context from the report “2. He was treated in hospital with no IMCA in place or formal best interests meeting taking place. As a result it was unclear if the treating physicians understood the complexity of his learning disability and communication issues that flowed from his disability. The inquest heard that repeated attempts were made to insert a nasogastric tube causing him great distress and where there was limited evidence that it would be beneficial;
” Source location Lewis Victor Mendelson · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to hold a best interests meeting for End of Life Care
Wider context from the report “3. He was placed on End of Life Care with no best interests meeting taking place or discussion with an IMCA or assessment of what should happen if he rallied – as he did.
” Source location Lewis Victor Mendelson · Prevention of Future Deaths report
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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 Medical treatment decisions fall outside the Council’s responsibility, so it cannot comment on the individual’s hospital treatment.
Verbatim wording from the response “This response solely addresses the concerns under paragraph 1, “The MATTER OF CONCERN”. Stockport Metropolitan Borough Council are unable to comment in respect of paragraph 2 which refers to the individual’s hospital treatment as, in accordance with the Mental Capacity Act 2005, the decision maker for best interest decisions in relation to medical treatment had been the NHS Trust. The arrangement of an IMCA and formal best interests meeting had been the responsibility of the Trust as this had concerned medical decisions. In this instance the NHS Trust would have been under a duty to consult with Stockport Council as stated in the Mental Capacity Act “...anyone engaged in caring for the person or interested in his welfare...”. Ultimately, if the matter had gone to the Court of Protection, the NHS Trust would have been the applicant.” Source location 2019-0434-Response-from-Stockport-Council_Redacted
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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 NHS Trust was responsible for arranging an IMCA and formal best-interests meeting concerning medical treatment.
Verbatim wording from the response “This response solely addresses the concerns under paragraph 1, “The MATTER OF CONCERN”. Stockport Metropolitan Borough Council are unable to comment in respect of paragraph 2 which refers to the individual’s hospital treatment as, in accordance with the Mental Capacity Act 2005, the decision maker for best interest decisions in relation to medical treatment had been the NHS Trust. The arrangement of an IMCA and formal best interests meeting had been the responsibility of the Trust as this had concerned medical decisions. In this instance the NHS Trust would have been under a duty to consult with Stockport Council as stated in the Mental Capacity Act “...anyone engaged in caring for the person or interested in his welfare...”. Ultimately, if the matter had gone to the Court of Protection, the NHS Trust would have been the applicant.” Source location 2019-0434-Response-from-Stockport-Council_Redacted
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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 A formal best-interests meeting is not legally required; decision-makers must consult appropriate people where practicable and appropriate.
Verbatim wording from the response “I share your concern that no best interests’ meetings were held to consider Mr Mendelson’s care in hospital. While a formal best interests meeting is not a duty, under section 4 of the Mental Capacity Act (2005)⁶ (MCA) the decision maker must take into account, if it is practicable and appropriate to consult them, the views of anyone named by the person as someone to be consulted, anyone engaged in caring for the person or interested in their welfare, any person with lasting power of attorney or a deputy appointed by a court.” Source location 2019-0434-Response-from-the-Department-of-Health-and-Pensions-1
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 The local NHS is expected to reflect on the LeDeR findings and address identified local failings in care.
Verbatim wording from the response “The Programme systematically reviews the deaths of all people with a learning disability, aged four years and above, that are notified to it. The Programme enables a detailed picture to be built of key improvements that are needed both locally and at a national level, to reduce the inequality in life expectancy between people with a learning disability, and those without.” Source location 2019-0434-Response-from-the-Department-of-Health-and-Pensions-1
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.