18 Aug 2025 Emily · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Lack of clinical assessment before discharge home from the Emergency Department View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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
Emily · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Emily died at Bassetlaw DGH on 6 May 2024 after developing unrecognised dehydration, acute kidney injury, ileus and sub-acute small bowel obstruction following bowel surgery for Crohn’s disease. She experienced vomiting, aspiration pneumonitis and cardiac arrest, with the report identifying concerns about inadequate hydration assessment, fluid-balance recording, recognition of deterioration, clinical assessment and escalation, and response to family concerns. The report also raises concerns about clinical assessment in the Emergency Department before mental health referral or discharge home.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clinical assessment before discharge home from the Emergency Department
Wider context from the report “3. That there continues to be a risk that no clinical assessment will be undertaken, in patients attending the Emergency Department at Bassetlaw DGH, prior to referral for a mental health assessment , and that there continues to be a risk that no clinical assessment will occur in Emergency Department prior to a patients discharge home
” Source location Emily · Prevention of Future Deaths report
Open source report
1 Aug 2025 Sidi Chax Bojang · Prevention of Future Deaths report North London
View report summary
Concerns raised 1
Discharge decisions falling to a senior psychiatric nurse View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Sidi Chax Bojang · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 19 July 2024, Sidi Chax Bojang left the platform at Oakleigh Park Railway Station and was struck by a fast train. He had recently attended hospital after reporting self-harm and experiencing a “wooshing” sound and flashes of light, and had called an ambulance on the morning of his death after cutting himself. The concerns included that possible serious mental illness and hallucinations were not recognised, that a psychiatrist did not review him before discharge, and that discharge was left to a senior psychiatric nurse.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Discharge decisions falling to a senior psychiatric nurse
Wider context from the report “Where there is a significant change in presentation when assessed suggesting that the patient is now well, when either the same day, or a short time before presentation, acts of self harm, suicidal behaviour or thoughts were present.
That a psychiatrist did not review the person presenting before discharge.
The discharge of the person in these circumstances fell to a senior psychiatric nurse .
” Source location Sidi Chax Bojang · Prevention of Future Deaths report
Open source report
1 Aug 2025 Brian Thomas RINGROSE · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 5
Discharge documentation liable to be misinterpreted as an official discharge notice View source Failure to provide timely final medical review before formal discharge View source Ambiguous and inadequately communicated discharge criteria View source
Premature discharge of patients who are not medically fit View source Reference in hospital policy to a non-existent police-custody discharge form View source See 2 more concerns
This report raised 17 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Brian Thomas RINGROSE · 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
Brian Thomas Ringrose died on 2 February 2021 after being taken to hospital following an overdose and then subjected to prolonged prone restraint by police. The report identifies concerns about police restraint practices and welfare monitoring, communication and handover, prioritisation of transport over welfare, and the hospital and mental health teams’ assessment, communication and discharge processes.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Discharge documentation liable to be misinterpreted as an official discharge notice
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on . This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Source location Brian Thomas RINGROSE · 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 provide timely final medical review before formal discharge
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged , and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Source location Brian Thomas RINGROSE · 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 Ambiguous and inadequately communicated discharge criteria
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Source location Brian Thomas RINGROSE · 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 Premature discharge of patients who are not medically fit
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Source location Brian Thomas RINGROSE · 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 Reference in hospital policy to a non-existent police-custody discharge form
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Source location Brian Thomas RINGROSE · 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 Amend the police-custody discharge SOP to reflect current Emergency Department and Thames Valley Police processes.
Verbatim wording from the response “This concern refers to a Standard Operating Procedure (Police Custody – Care in and Discharge from ED) which was created using the Royal College of Emergency Medicine Guideline of the same name. I can assure you that it was not created in haste, but had not been updated to reflect work with Thames Valley Police which had continued to evolve and develop local processes and procedures after the guidelines had been published as a local SOP.” Source location Response from Milton Keynes University Hospitals
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Emergency Department adult-discharge SOP defining discharge responsibilities, documentation requirements, safety-netting, and safeguards for higher-risk patients.
Verbatim wording from the response “In the course of investigating Brian’s death and preparing for the inquest, the decision-making, documentation and processes surrounding his discharge were an area of focus for the Trust in the context of the individual decision making and the actions and inactions of the healthcare professionals involved in his care. To be plain, the omissions were felt to be particular to this case and not a systemic issue requiring a change in wider policy and practice. The forensic level of examination of this issue at inquest enabled the Trust to reflect further on this and to consider whether wider change was in fact necessary to improve safety and make professional expectations explicit in a local context. To that end, the Emergency Department has developed and implemented a Standard Operating Procedure for the discharge of adult patients. This is appended at Appendix 2.” Source location Response from Milton Keynes University Hospitals
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out Dynamic Documentation to the Emergency Department with associated discharge-process training and awareness activity.
Verbatim wording from the response “Discharge summaries are also created in eCare for inpatients (adult and paediatric), day-cases and maternity cases. All currently use the older DEPART tool but the creation of the discharge summary and discharging of the patient from the system are carried out separately. Overtime we would expect all areas to migrate onto the newer Discharge Workflow mPage and associated Dynamic Documentation.” Source location Response from Milton Keynes University Hospitals
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue anonymised learning events using Brian’s case in the Emergency Department to improve documentation and communication of risk.
Verbatim wording from the response “This is addressed in the Emergency Department SOP for the discharge of adult patients described above and appended at Appendix 2. The individuals involved in this case have reflected at great length about their actions and inactions. Brian’s death was a seminal event for the Trust and learning from it has been widely shared within the Emergency Department. Further learning events using Brian’s case (anonymised) will continue in the Emergency Department, both to raise awareness of risk of unclear documentation and communication, and to ensure that there is an enduring legacy of improvement following Brian’s death.” Source location Response from Milton Keynes University Hospitals
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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 Share learning from Brian’s case across the Emergency Department to raise awareness of unclear documentation and communication risks.
Verbatim wording from the response “This is addressed in the Emergency Department SOP for the discharge of adult patients described above and appended at Appendix 2. The individuals involved in this case have reflected at great length about their actions and inactions. Brian’s death was a seminal event for the Trust and learning from it has been widely shared within the Emergency Department. Further learning events using Brian’s case (anonymised) will continue in the Emergency Department, both to raise awareness of risk of unclear documentation and communication, and to ensure that there is an enduring legacy of improvement following Brian’s death.” Source location Response from Milton Keynes University Hospitals
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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 Reiterate Toxbase guidance to Emergency Department clinicians and provide a quick guide through the Radar documentation system.
Verbatim wording from the response “Brian should not have been discharged. This is accepted and actions described above have been taken to mitigate the risk of a similar event occurring again. Toxbase guidelines have been reiterated to all Emergency Department clinicians, with a quick guide available on the Radar documentation system.” Source location Response from Milton Keynes University Hospitals
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require escalation to emergency-department clinicians, continued emergency-department medical care and liaison-team availability for reassessment when patients cannot engage or remain medically unfit.
Verbatim wording from the response “b. Inadequate Assessment
Our revised protocol mandates that when a patient cannot engage due to intoxication (alcohol or drugs) or other factors rendering them unfit, the HLT must escalate concerns to the ED team, advise that the patient remains under ED care for ongoing medical management, and the HLT remain available for reassessment. This ensures continuity of care and avoids missed opportunities for intervention. This applies equally in cases where the patient is under police arrest within the ED.” Source location Response from Central and North West London NHS Foundation Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce that emergency-department discharge must not proceed when safety concerns remain, through team meetings and supervision.
Verbatim wording from the response “e. Inappropriate Discharge Recommendation
We have reinforced the principle that discharge from ED should never proceed where there are unresolved concerns about a patient’s safety, whether related to physical or mental health. This has been reiterated in team meetings and supervision sessions. Refresher training and Human Factors Training are taking place to support consistent application of this principle.” Source location Response from Central and North West London 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 Deliver refresher and Human Factors training to support consistent application of safe-discharge principles.
Verbatim wording from the response “e. Inappropriate Discharge Recommendation
We have reinforced the principle that discharge from ED should never proceed where there are unresolved concerns about a patient’s safety, whether related to physical or mental health. This has been reiterated in team meetings and supervision sessions. Refresher training and Human Factors Training are taking place to support consistent application of this principle.” Source location Response from Central and North West London 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 Complete and report an audit of discharge-compliance performance.
Verbatim wording from the response “A recent audit on discharge compliance is included at Appendix 4 for information and assurance.” Source location Response from Milton Keynes University Hospitals
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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 discharge omissions were considered case-specific, not a systemic issue requiring wider policy or practice change.
Verbatim wording from the response “In the course of investigating Brian’s death and preparing for the inquest, the decision-making, documentation and processes surrounding his discharge were an area of focus for the Trust in the context of the individual decision making and the actions and inactions of the healthcare professionals involved in his care. To be plain, the omissions were felt to be particular to this case and not a systemic issue requiring a change in wider policy and practice. The forensic level of examination of this issue at inquest enabled the Trust to reflect further on this and to consider whether wider change was in fact necessary to improve safety and make professional expectations explicit in a local context. To that end, the Emergency Department has developed and implemented a Standard Operating Procedure for the discharge of adult patients. This is appended at Appendix 2.” Source location Response from Milton Keynes University Hospitals
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10 Jul 2025 Doreen Swann · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Lack of suitable social care placements causing delayed hospital discharges View source
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AI-generated summary
Doreen Swann · 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
Doreen Swann was a patient at Tameside General Hospital whose discharge had been delayed while she awaited a suitable social care placement. She was a high falls risk, fell while unobserved with the bed rails up, suffered a traumatic brain injury and died. The concerns included delayed discharges due to shortages of suitable social care placements, the challenges of managing high falls risk patients in an acute setting, and impacts on hospital bed availability and the Emergency Department.
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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 suitable social care placements causing delayed hospital discharges
Wider context from the report “1. The inquest heard evidence that Doreen Swann was only in hospital at the point of her fall because her discharge had been delayed due to a shortage of a suitable social care placement . The evidence was that nursing/caring for high falls risk patients in an acute setting is challenging and resource intensive.
2. The evidence given to the inquest was that this delayed discharge and the ongoing risk it presents was not an isolated incident at TGH -as an example the evidence given was that there were regularly 30 plus patients with a delayed discharge over 3 weeks due to a lack of social care beds .The evidence indicated that this challenge was not unique to Tameside.
3. The evidence indicated that managing a falls risk and the consequential risk to life is better managed outside an acute setting once the clinical need for a hospital stay has passed .
4. Delayed discharges such as Doreen Swann’s reduces the availability of beds for other patients and creates a knock-on impact across the hospital particularly in relation to the Emergency Department .
” Source location Doreen Swann · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue the Tameside patient-flow and discharge improvement programme, including front-door process mapping and monthly monitoring of delivery targets.
Verbatim wording from the response “As part of a system led improvement programme, there is a continued focus on patient flow and discharge in Tameside covered by the Trust Deputy Chief Operating Officer, Trust Deputy Chief Nurse, and Director of Adult Services for the Local Authority. Progress against the delivery targets within this improvement programme is monitored through a monthly programme group which was established in April 24 and has delivered a significant reduction in patients with a No Criteria to Reside (NCTR) status over recent months. This means that patients who are medically fit for discharge are being discharged to the right place much quicker. This includes process-mapping to support front-door processes to enable deflection to other services.” Source location Response from Greater Manchester Integrated Care
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PFD Monitor interpretation Maintain weekly multidisciplinary oversight of length of stay and delayed transfers to review hospital appropriateness and support discharge.
Verbatim wording from the response “In terms of oversight of discharge planning and patients with NCTR, the Trust’s Chief Operating Officer chairs a weekly meeting to review Length of Stay and Delayed Transfers of Care. Membership includes local stakeholders and the Director of Adult Services to review each patient and ensure appropriateness of care within a hospital setting and aim to support discharge.” Source location Response from Greater Manchester Integrated Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £9 billion through the Better Care Fund to support integrated health and social care and shared discharge-planning accountability.
Verbatim wording from the response “The Better Care Fund (BCF) is a key part of our plan to address these delays, particularly when they are caused by a shortage of suitable social care, by supporting Integrated Care Boards and local authorities to deliver joined-up health and social care. This year, the BCF will provide £9 billion to help ensure patients receive the right care in the right place, with shared accountability for discharge planning.” Source location Response from Department of Health and Social Care
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide over £4 billion in additional adult social care funding by 2028–29 to help local authorities improve services and meet statutory duties.
Verbatim wording from the response “Additionally, the Spending Review includes over £4 billion additional funding for adult social care by 2028-29, compared to 2025-26, helping local authorities improve services and meet their duties under the Care Act 2014.” Source location Response from Department of Health and Social Care
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20 Jun 2025 Finlay Joshua ROBERTS · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to complete final nursing observations before discharge View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Finlay Joshua ROBERTS · 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
Finlay’s parents took him to Whittington Hospital the night before he died, during an extremely busy and understaffed night in the paediatric emergency department. The report describes failures to conduct serial nursing observations, complete appropriate tests, and obtain specialist advice before Finlay was discharged home. The principal concerns were that missing nursing observations may be a wider issue and that medical staff failed to recognise that the observations had not been carried out.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to complete final nursing observations before discharge
Wider context from the report “The lack of serial nursing observations was a fundamental omission from Finlay’s care. I heard at inquest that there have been many improvements in the paediatric emergency department at the Whittington since his death, not least of which has been the addition of more nursing staff.
However, a lack of paediatric nursing observations is a subject about which I wrote a PFD report on 13 March 2025 to a different hospital (the Royal Free) following the death of Billie Wicks.
I remain concerned on two counts:
1. A lack of nursing observations may be a much wider issue than is recognised. In my experience there is nothing about the Whittington and the Royal Free that stands out as unusual.
2. The medical staff at the Whittington did not recognise the lack of nursing observations.
• Observations were thought to be acceptable because they were not reported as otherwise, when in fact they were absent.
• The discharging doctor decided that, if his final observations were normal Finlay could go home. Those observations were never carried out, but Finlay was nevertheless discharged.
” Source location Finlay Joshua ROBERTS · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide vital-signs, escalation, local-induction and policy training to nurses and other clinical staff, including triage competency training.
Verbatim wording from the response “• Training & Induction Enhancements:
◦ All new nurses now receive training on vital signs monitoring and escalation during induction and in-house triage training. This ensures that all new starters have a foundational understanding of the importance of recording and escalating abnormal observations from the outset. All clinical staff are also required to familiarise themselves with the department’s common presentation policies during their induction.” Source location 2025-0316 Response from Whittington 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 Require paediatric clerking documentation to specify the frequency of observations.
Verbatim wording from the response “We acknowledge that staff failed to identify that vital observations were incomplete and not repeated at the time of Finlay’s discharge. In response:” Source location 2025-0316 Response from Whittington 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 Require review of vital signs before paediatric discharge through the ED discharge checklist and audit its use regularly.
Verbatim wording from the response “◦ The ED paediatric discharge checklist now requires that there is a review of patient’s vital signs prior to discharge. This has been implemented since Finlay’s death and its use will be audited regularly.” Source location 2025-0316 Response from Whittington 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 Disseminate the ED paediatric discharge checklist at emergency, surgical and paediatric inductions and thereafter at future medical inductions.
Verbatim wording from the response “◦ The discharge checklist will be disseminated at ED and surgical induction in August and paediatric induction in September and at all future medical inductions thereafter.” Source location 2025-0316 Response from Whittington 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 Conduct quarterly audits of paediatric discharge-checklist compliance and present results to the divisional quality meeting.
Verbatim wording from the response “◦ Audits will be conducted and will be presented at the division’s quality meeting on a quarterly basis.” Source location 2025-0316 Response from Whittington 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 Continue staff training and induction on complete observations and escalation, including the content in paediatric emergency simulation training.
Verbatim wording from the response “• Ongoing training and induction for all staff in regard to the importance of complete observations and their escalation. This training will also be part of all simulation training in PED” Source location 2025-0316 Response from Whittington Health NHS Trust
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Concerns raised 1
Failure to record an inpatient fall on the discharge letter View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Hazel Gambles · 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
Hazel Gambles was admitted to hospital after a fall at home and was later found to have sustained a brain bleed in an unwitnessed in-patient fall. She died on 27 January 2025, and the report states that the head injury more than minimally contributed to her death. The principal concerns were failures to complete and implement falls assessments and prevention measures, delay in medical review, inadequate communication with her family, failure to report and investigate the fall, and omission of the fall from the discharge letter.
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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 record an inpatient fall on the discharge letter
Wider context from the report “There are several areas of concern around failures in documentation and failures to follow Trust policy, namely:
1. Lying and standing Blood Pressure was not recorded on admission.
2. There was no documentation of any falls prevention measures at the time of the first falls assessment.
3. There is no evidence of falls prevention measures being put in place following the first falls assessment.
4. There was no falls assessment done at the time of transfer to ward B4. There should have been a falls assessment within six hours of transfer but that did not happen. The assessment took place some 23 hours after admission to the ward, by which time Mrs Gambles had already fallen.
5. Following the in-patient fall there was a delay of over 5 hours before a medical review took place. The note recording the request for medical review is not timed.
6. There was no discussion with Mrs Gambles' family explaining the findings of the CT scan and they were not told about the bleed on the brain.
7. No Datix report was done following the in-patient fall leading to a delay in investigation.
8. The in-patient fall is not mentioned on the Discharge letter.
I am concerned that these failures suggest a lack of awareness of, and lack of compliance with, the Trust’s processes on falls assessment and record keeping.
” Source location Hazel Gambles · 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 Add a mandatory discharge-summary question covering inpatient falls and other safety incidents, and monitor it during implementation.
Verbatim wording from the response “As a Trust, we have now added a mandatory question to the inpatient discharge summary to ask whether the patient has had a fall, VTE (Venous Thromboembolism), pressure ulcer or any other incident. This will prompt clinicians to consider whether any of these have occurred and if so, it will be clear on the discharge summary. This will be monitored throughout the implementation stage, to ensure effectiveness.” Source location Response from Rotherham NHS Foundation Trust
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5 Jun 2025 Cain Alex River Donald · Prevention of Future Deaths report Oxfordshire
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Concerns raised 4
Discharge policy failing to specifically address Tribunal discharge directly from PICU to the community View source Failure to involve the Probation Service in discharge planning View source Failure to engage family members effectively in discharge planning View source
Failure to rapidly coordinate complex discharge arrangements View source See 1 more concern
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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Each statement is shown once, even when linked to more than one concern.
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Cain Alex River Donald · 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
Cain Alex River Donald died by hanging on 29 July 2022 after being discharged from Ashurst PICU directly into the community on 19 July 2022. The principal concerns were deficiencies in discharge planning and communication with his family and Probation Services, and failure by the Crisis Home Treatment Team to supervise medication administration and escalate concerns about compliance.
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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 Discharge policy failing to specifically address Tribunal discharge directly from PICU to the community
Wider context from the report “Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community.
(1) The evidence revealed deficiencies in the way Mr Donald's discharge was planned and executed, specifically that his family and the Probation Services were not properly engaged in the discharge planning process when they were considered important mitigations in any risk Mr Donald posed to himself.
(2) There was insufficient communication and liaison with family members, including explaining Mr Donald's condition and risks on discharge and providing support to his partner as a carer. The Probation Service was not informed of the discharge meeting and should have been invited and participated; and Mr Donald’s family were unable to contribute effectively to the discharge process.
My principal concern was that the Trust's Discharge Policy did not seem to specifically envisage discharge to the community by a Tribunal directly from the PICU . Such a decision necessitates rapid coordination of complex discharge arrangements and effective engagement of relevant agencies and the family, which was absent in Mr Donald's discharge. Whilst the Trust has taken some action to acknowledge these issues, I remain concerned that the specific issues outlined above have not been adequately addressed.
” Source location Cain Alex River Donald · 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 involve the Probation Service in discharge planning
Wider context from the report “Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community.
(1) The evidence revealed deficiencies in the way Mr Donald's discharge was planned and executed, specifically that his family and the Probation Services were not properly engaged in the discharge planning process when they were considered important mitigations in any risk Mr Donald posed to himself.
(2) There was insufficient communication and liaison with family members, including explaining Mr Donald's condition and risks on discharge and providing support to his partner as a carer. The Probation Service was not informed of the discharge meeting and should have been invited and participated ; and Mr Donald’s family were unable to contribute effectively to the discharge process.
My principal concern was that the Trust's Discharge Policy did not seem to specifically envisage discharge to the community by a Tribunal directly from the PICU. Such a decision necessitates rapid coordination of complex discharge arrangements and effective engagement of relevant agencies and the family, which was absent in Mr Donald's discharge. Whilst the Trust has taken some action to acknowledge these issues, I remain concerned that the specific issues outlined above have not been adequately addressed.
” Source location Cain Alex River Donald · 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 engage family members effectively in discharge planning
Wider context from the report “Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community.
(1) The evidence revealed deficiencies in the way Mr Donald's discharge was planned and executed, specifically that his family and the Probation Services were not properly engaged in the discharge planning process when they were considered important mitigations in any risk Mr Donald posed to himself.
(2) There was insufficient communication and liaison with family members, including explaining Mr Donald's condition and risks on discharge and providing support to his partner as a carer. The Probation Service was not informed of the discharge meeting and should have been invited and participated; and Mr Donald’s family were unable to contribute effectively to the discharge process .
My principal concern was that the Trust's Discharge Policy did not seem to specifically envisage discharge to the community by a Tribunal directly from the PICU. Such a decision necessitates rapid coordination of complex discharge arrangements and effective engagement of relevant agencies and the family, which was absent in Mr Donald's discharge. Whilst the Trust has taken some action to acknowledge these issues, I remain concerned that the specific issues outlined above have not been adequately addressed.
” Source location Cain Alex River Donald · 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 rapidly coordinate complex discharge arrangements
Wider context from the report “Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community.
(1) The evidence revealed deficiencies in the way Mr Donald's discharge was planned and executed, specifically that his family and the Probation Services were not properly engaged in the discharge planning process when they were considered important mitigations in any risk Mr Donald posed to himself.
(2) There was insufficient communication and liaison with family members, including explaining Mr Donald's condition and risks on discharge and providing support to his partner as a carer. The Probation Service was not informed of the discharge meeting and should have been invited and participated; and Mr Donald’s family were unable to contribute effectively to the discharge process.
My principal concern was that the Trust's Discharge Policy did not seem to specifically envisage discharge to the community by a Tribunal directly from the PICU. Such a decision necessitates rapid coordination of complex discharge arrangements and effective engagement of relevant agencies and the family, which was absent in Mr Donald's discharge . Whilst the Trust has taken some action to acknowledge these issues, I remain concerned that the specific issues outlined above have not been adequately addressed.
” Source location Cain Alex River Donald · 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 Produce and circulate additional discharge guidance for staff through the discharge checklist.
Verbatim wording from the response “The Trust accepts of course that we must be prepared for a Tribunal to take a different view to the Trust’s view and the period of time to discharge being limited. You expressed concern that – faced with a very short period between the Tribunal’s decision and the date of Mr Donald no longer being lawfully detainable – there were deficiencies in the discharge process. Our Associate Director of Nursing has reviewed the Trust’s Discharge Policy and has recommended some amendments to the policy. The proposed amendments include a new section headed “Unplanned discharge”. We had previously produced some additional guidance to staff in the discharge checklist, which was completed and circulated before your letter. The proposed amendments were taken on 26 June 2025 to the relevant committee for discussion and approval of final wording.” Source location Response from Oxford 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 Review the Discharge Policy and recommend amendments, including a new section on unplanned discharge.
Verbatim wording from the response “The Trust accepts of course that we must be prepared for a Tribunal to take a different view to the Trust’s view and the period of time to discharge being limited. You expressed concern that – faced with a very short period between the Tribunal’s decision and the date of Mr Donald no longer being lawfully detainable – there were deficiencies in the discharge process. Our Associate Director of Nursing has reviewed the Trust’s Discharge Policy and has recommended some amendments to the policy. The proposed amendments include a new section headed “Unplanned discharge”. We had previously produced some additional guidance to staff in the discharge checklist, which was completed and circulated before your letter. The proposed amendments were taken on 26 June 2025 to the relevant committee for discussion and approval of final wording.” Source location Response from Oxford 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 Obtain approval and publish the revised Discharge Policy, then brief ward teams on its requirements.
Verbatim wording from the response “The Trust accepts of course that we must be prepared for a Tribunal to take a different view to the Trust’s view and the period of time to discharge being limited. You expressed concern that – faced with a very short period between the Tribunal’s decision and the date of Mr Donald no longer being lawfully detainable – there were deficiencies in the discharge process. Our Associate Director of Nursing has reviewed the Trust’s Discharge Policy and has recommended some amendments to the policy. The proposed amendments include a new section headed “Unplanned discharge”. We had previously produced some additional guidance to staff in the discharge checklist, which was completed and circulated before your letter. The proposed amendments were taken on 26 June 2025 to the relevant committee for discussion and approval of final wording.” Source location Response from Oxford 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 Implement family and carer engagement changes using the triangle of care model in the Psychiatric Intensive Care Unit.
Verbatim wording from the response “More broadly, the Psychiatric Intensive Care Unit has implemented changes since Mr Donald’s death in relation to how they engage with carers and family using the triangle of care model. Our Associate Director of Nursing provided some evidence to you on this work.” Source location Response from Oxford Health NHS Foundation Trust
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Concerns raised 3
Failure to establish and communicate accurate baseline presentation and inpatient mobility information for discharge care planning View source Failure to maintain accurate information about baseline presentation for discharge planning and risk assessment View source Failure to arrange follow-up appointments after discharge View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Esther Jane Lancaster Byrne · 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
Esther Jane Lancaster Byrne, who had vascular dementia and was extremely frail, died at her care home on 18 December 2024 after deterioration following a fall, a neck of femur fracture, surgery and discharge back to the care home. Concerns included poor communication with the family and power-of-attorney holder, misunderstandings about her baseline and mobility affecting discharge planning, failure to arrange follow-up, and doubts about the quality and accuracy of outsourced radiological reporting.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to establish and communicate accurate baseline presentation and inpatient mobility information for discharge care planning
Wider context from the report “2. There were numerous discrepancies in the evidence demonstrating a misunderstanding by various medical staff as to the deceased's baseline presentation, and the extent to which she had or had not mobilised whilst an inpatient which were pertinent to care planning upon discharge and to any handling required to be risk managed by the care home.
” Source location Esther Jane Lancaster Byrne · 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 maintain accurate information about baseline presentation for discharge planning and risk assessment
Wider context from the report “1. Poor communication and liaison with family generally, and in particular with a family member who held a health and welfare power of attorney, led to important information being incorrect, including about such issues as the deceased's baseline presentation which was pertinent to safe discharge planning and risk assessment. It was accepted that there was no communication with the family member who held power of attorney regarding diagnosis and treatment options, the rationale for these, or the discharge plan.
” Source location Esther Jane Lancaster Byrne · 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 arrange follow-up appointments after discharge
Wider context from the report “3. It was accepted that a follow up appointment should have been arranged for the deceased after discharge and there was no explanation for why this was not arranged .
” Source location Esther Jane Lancaster Byrne · 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 Ensure physiotherapists attend orthopaedic ward rounds and access electronic clinical records for mobility-related decision-making.
Verbatim wording from the response “Although there was a plan for the patient to be discharged back to her care home, the physiotherapists were planning to complete further mobility assessments including considering using a hoist for transfers. Unfortunately this assessment did not take place prior to Ms Byrne’s discharge back to the care home. The patient had not returned to her baseline level of mobility and therefore a further discussion with the family care home should have taken place to ensure the care home could meet Ms Byrne’s care needs.
As a result of this the ward has made adjustments to ensure the physiotherapy team attend orthopaedic ward rounds and have access to electronic clinical records to ensure they are involved in decision making and contribute to discussion regarding the mobility status of patients.” Source location Response from County Durham and Darlington 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 Record patients’ mobility status in discharge letters through physiotherapy and occupational therapy input.
Verbatim wording from the response “As a further action physio and occupational therapist will input to patient’s discharge letter to record patients mobility status.” Source location Response from County Durham and Darlington 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 Use a discharge process requiring follow-up appointments when needed and documenting confirmation in patient records.
Verbatim wording from the response “The accountable doctor, ████████ accepts that the lack of a scheduled follow up appointment was an error on his part. A discharge process is in place to include scheduling a follow up appointment for every patient (if required) and confirmation is documented in the patient records. To ensure compliance with this process regular ward audits will be completed to provide assurance.” Source location Response from County Durham and Darlington 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 Conduct regular ward audits to monitor compliance with the follow-up appointment process.
Verbatim wording from the response “The accountable doctor, ████████ accepts that the lack of a scheduled follow up appointment was an error on his part. A discharge process is in place to include scheduling a follow up appointment for every patient (if required) and confirmation is documented in the patient records. To ensure compliance with this process regular ward audits will be completed to provide assurance.” Source location Response from County Durham and Darlington NHS Foundation Trust
Open published response
Concerns raised 1
Failure to further explore a patient's decision not to involve a relevant family member in discharge notification View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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
Callum James Hargreaves · 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
Callum James Hargreaves, who had substance misuse issues and was sleeping rough, was removed from a cliff edge on 19 January 2024 and underwent a mental health assessment before being discharged to emergency accommodation. His body was recovered from the sea the following day, and the inquest concluded that he died from suicide due to multiple injuries. Concerns included unrecorded reasons for not detaining him, insufficient exploration of his wish not to inform his mother, incomplete nearest-relative details, and gaps in record keeping.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to further explore a patient's decision not to involve a relevant family member in discharge notification
Wider context from the report “At inquest, the court heard from Gail Ashton who was the AMHP involved in the mental health act assessment conducted overnight on 19 & 20 January 2024.
1) One issue that arose was whether Callum presented with an imminent and significant risk of harm to justify a short-term admission into hospital as is provided for in NICE guidance. Ms Ashton said this was expressly discussed by the clinicians concerned. It was felt he was likely to be withdrawing and there were no resuscitation facilities available in Longreach. She also said the vulnerabilities of others on the ward needed to be considered all of which contributed to the decision not to detain Callum in hospital. She accepted that this rationale was not recorded in the notes.
2) Callum was asked whether he wanted his mother (who he described as his rock) notified of his discharge. He said that he did not. This was not tested or challenged where GMC guidance is that it may be appropriate to do so.
The Nearest Relative details on the MH 1 form were not completed.
The expert who reviewed the case felt there were ‘obvious gaps’ in the record keeping and that as Callum’s mother was one of the few levers available to the assessing team, Callum’s decision not to involve her should have been explored further.
You may feel these omissions should be learned from when assessments are conducted in the future and, in particular, when notes of an assessment are subsequently recorded.
” Source location Callum James Hargreaves · Prevention of Future Deaths report
Open source report
21 May 2025 Malcolm Morris · Prevention of Future Deaths report Northumberland
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Concerns raised 1
Failure to transfer comprehensive discharge and ongoing treatment information to community nursing services View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Malcolm Morris · 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
Malcolm Morris developed lymphoedema after surgery for penile cancer and died on 5 January 2024 after collapsing with right-thigh pain. The report raises concerns about hospitals being unable to electronically refer patients living outside their usual catchment area to community nursing services, resulting in inadequate discharge information and delayed or absent support for wound and catheter care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to transfer comprehensive discharge and ongoing treatment information to community nursing services
Wider context from the report “Upon discharge from hospital in Sunderland, staff were unable to refer him electronically to district nursing services in Northumberland. They had to resort to telephoning the service to make a referral and were unable by this route to pass the necessary information to the service .
As a consequence, Mr Morris left hospital requiring catheter care and wound management. He did not initially receive district nursing support. His wound became infected and required readmission to hospital. His catheter bag became full and he, nor his family had any guidance on what action to take.
Evidence I heard at inquest described that hospital systems were unable to communicate with healthcare systems outside of the immediate geographical area and as such efficient referrals to district nursing services were not possible.
This meant detailed information on Mr Morris's discharge arrangements and ongoing treatment could not be passed and ultimately district nurses relied on inadequate brief paper-based discharge documents .
In Mr Morris's case he was supported and cared for by his wife and family. They sought advice and made contact with the district nursing services themselves to affect a referral, after the absence of nursing support following his first discharge from hospital.
My concern is, had Mr Morris been discharged without any support from his family, lived alone or been vulnerable in some way, he may have not been able to access nursing services.
Even with family support, his wound became infected and required readmission to hospital. My concern is other persons may be at risk of death if discharging hospitals cannot efficiently, comprehensively and in a timely fashion refer patients to ongoing care in the community.
The evidence I have heard is this is an issue which is not confined to individual hospital trusts and is based on the ability of technology to ‘talk to each other’ across various NHS services. Given Sunderland Royal Hospital is a regional centre for penile cancer it means patients are treated there who are not living in the usual catchment area for the trust, and as such situations such as this with patients living out of the area must occur regularly.
” Source location Malcolm Morris · 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 Develop and lead the Frontline Digitisation Programme to support adoption and safe deployment of electronic patient record systems.
Verbatim wording from the response “Over the past three years, NHS England has developed and led ‘The Frontline Digitisation’ (FLD) Programme, which has supported trusts in adopting electronic patient record (EPR) systems, and which nationally supports increased consistency in digital maturity and improves information sharing between and within organisations.” 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 Develop and implement the national Booking and Referral Standard to digitise and standardise referrals and bookings across care settings.
Verbatim wording from the response “To further support more consistent interoperability across the NHS, NHS England has developed the ‘Booking and Referral Standard’ (BaRS), which is a national framework designed to help digitise and standardise referrals and bookings across care settings, including urgent and emergency care (UEC), general practice, hospital, and community services.” Source location Response from NHS England
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Includes failures in hospital discharge planning, readiness decisions, multidisciplinary or receiving-service coordination, safety planning, execution and directly required follow-up.
