22 Aug 2019 Mr. Christopher Summerhayes · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1
Failure to account for concomitant medications when dosing clozapine View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Cardiff & Vale University LHB
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Cardiff & Vale University LHB
Maintain the Medicines Code and its medicines-reconciliation responsibilities for doctors, pharmacy staff and other prescribers.
View source
Cardiff & Vale University LHB
Provide dedicated pharmacy and specialist mental-health pharmacist support for medicines management and prescribing.
View source
Cardiff & Vale University LHB
Promote polypharmacy reviews through secondary-care pharmacy and primary-care medicines-management teams.
View source
Cardiff & Vale University LHB
Operate the Medicines Management Incentive Scheme to improve recording of medicines across care settings, including staff education and retrospective recording of complex medicines.
View source
Cardiff & Vale University LHB
Develop an interface between PARIS and PMS to improve information transfer and introduce medicines transcribing and electronic discharge using the Welsh Clinical Portal.
View source See 2 more actions
×
AI-generated summary
Mr. Christopher Summerhayes · 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
Mr. Christopher Summerhayes was found deceased at his home address after a significant medical history including double scoliosis, treatment-resistant schizophrenia and a complex regime of around 12 daily medications. The concerns included the prescription of clozapine alongside other medications, substantial weight gain and possible effects on his cardiovascular system, as well as a possible familial lipid disorder. The inquest concluded that the medical cause of death was ischaemic heart disease, with a narrative determination referring to atypical early-onset coronary artery atherosclerosis and complex prescribed medications.
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 Failure to account for concomitant medications when dosing clozapine
Wider context from the report “(1) In relation to Christopher Summerhayes, Clozapine was prescribed as a concomitant medication alongside approximately 11 other drugs including another anti-psychotic medication. Either alone or interaction with other prescribed medication, a large increase in weight occurred to >101kg (BMI 33.1) (reported side effect of clozapine) which had a ‘knock-on’ effect for his cholesterol and lipid levels and cardiovascular system. The usual dose is 200-450mg daily with the maximum dose being 900mg (BNF) which does not consider concomitant medications. Signs of prescription overdose include collapse and hallucinations which could be mistaken for unresolved symptoms of schizophrenia i.e. lack of drug efficacy encouraging dose increase. Blood levels of clozapine may rise in response to smoking cessation which Mr. Summerhayes had advised we was commencing.
(2) He may have suffered from a familial lipid disorder (present in other family members) which had it been confirmed would likely to have contraindicated Clozapine.
” Source location Mr. Christopher Summerhayes · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain the Medicines Code and its medicines-reconciliation responsibilities for doctors, pharmacy staff and other prescribers.
Verbatim wording from the response “The UHB has a Medicines Code in place and this was updated in 2018. It contains a section on medicines reconciliation. It sets out the responsibilities of various healthcare professionals in this process, including doctors, the pharmacy team and other prescribers.” Source location 2019-0263-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide dedicated pharmacy and specialist mental-health pharmacist support for medicines management and prescribing.
Verbatim wording from the response “The Pharmacy Directorate has a system in place of dedicated pharmacists aligned to clinical directorates and Clinical Boards to provide a source of support and expertise in medicines management. A specialist mental health pharmacist supports prescribing in in-patient mental health settings. The Primary Care and Intermediate Care Clinical Board has a Medicines Management and Prescribing Team who support related issues in primary care settings.” Source location 2019-0263-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Promote polypharmacy reviews through secondary-care pharmacy and primary-care medicines-management teams.
Verbatim wording from the response “The All Wales Medicines Strategy Group has produced a number of guidance documents to promote polypharmacy reviews. These documents can be viewed on their website which is www.awmsg.org” Source location 2019-0263-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Medicines Management Incentive Scheme to improve recording of medicines across care settings, including staff education and retrospective recording of complex medicines.
Verbatim wording from the response “The Primary Care and Intermediate Care team established a Medicines Management Incentive Scheme with GPs to ensure that medicines prescribed across care settings are added to the GP record so there is a complete medicines record for patients on the GP systems. The driver for this project was to promote patient safety but it has seen cost-benefits. Education is provided to staff within GP practices who are then required to identify their local process to ensure that a patient’s medication history is accurately updated prospectively. Practices have also been asked to retrospectively add certain complex medicines to the GP systems to ensure they are clearly recorded.” Source location 2019-0263-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an interface between PARIS and PMS to improve information transfer and introduce medicines transcribing and electronic discharge using the Welsh Clinical Portal.
Verbatim wording from the response “A project proposal is in development by Mental Health Clinical Board, Pharmacy and Information Technology to develop an interface between PARIS (patient management and information software in use in Mental Health and community services) and PMS (patient management system) to improve the transfer of information. The project aims to improve the interface between these systems and introduce Medicines Transcribing and e-Discharge to mental health wards with use of the Welsh Clinical Portal.” Source location 2019-0263-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing medicines reconciliation, pharmacist support, NICE monitoring and promoted polypharmacy reviews address medication interaction and prescribing risks.
Verbatim wording from the response “The UHB has a Medicines Code in place and this was updated in 2018. It contains a section on medicines reconciliation. It sets out the responsibilities of various healthcare professionals in this process, including doctors, the pharmacy team and other prescribers.” Source location 2019-0263-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mandated Clozapine monitoring, ZTAS reporting and primary-care record checks are considered sufficient for shared prescribing and information exchange.
Verbatim wording from the response “I am able to advise that there is a requirement for patients taking Clozapine to be registered with a service to monitor the medicine during the course of their treatment with it. Additionally, when a patient who is taking Clozapine dies or ceases to take it, the manufacturer supplying the medication must be informed. The monitoring service currently in place for Cardiff and Vale University Health Board is via the Zaponex Treatment Access System (ZTAS) which is provided by the medicine’s manufacturer that we currently use, called Leyden Delta. The necessary information was shared at the time via ZTAS.” Source location 2019-0263-Response-by-University-Health-Board
Open published response
23 May 2019 Sasha Sabrina FORSTER · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 1
Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Sasha Sabrina FORSTER · 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
Sasha Sabrina FORSTER, a 20-year-old woman with a lengthy history of mental health disorders, self-harm and overdoses, died by suicide following deliberate ingestion of a fatal overdose of Propranolol tablets. The inquest identified concerns that hospitals and police forces were not always aware of their powers and responsibilities when her section 17 leave was revoked, or had not agreed and updated a common plan, resulting in inconsistent actions and an increased risk to Sasha.
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 access to relevant psychiatric and prescribing history when prescribing Propranolol
Wider context from the report “Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use it.
” Source location Sasha Sabrina FORSTER · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate relevant prescribing guidance extracts to support safe prescribing and patient safety.
Verbatim wording from the response “With regards to prescribing, the GMC’s guidance is clear that a doctor must only prescribe when they have adequate knowledge of the patient’s health. This will involve making an assessment, together with the patient, of their condition and having, or taking, an adequate history.” Source location Sasha-Forster-R2019-01694
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refer information about the private GPs to an Assistant Registrar to determine whether the investigation threshold is met.
Verbatim wording from the response “Conduct of individual doctors
When a doctor fails to adhere to our ethical guidance the GMC must establish whether our threshold for investigation has been met; namely, whether the doctor’s conduct, if proven, is capable of amounting to impaired fitness to practise to a degree warranting action on their registration.” Source location Sasha-Forster-R2019-01694
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore Graphnet as an integrated care record providing organisations read-only access to legal status, risks and contemporaneous care plans.
Verbatim wording from the response “There is a long term goal to create a platform that will allow NHS organisations to have read only access to key information pulled from a service user’s internal record keeping platforms. Graphnet is currently being explored to provide an integrated care record across Surrey. This will potentially be able to show that a person is currently detained in hospital allowing other organisations to see their legal status, as well as associated risks. Were a system such as this in place in early 2017 this would have allowed staff at the acute hospitals to view Sasha’s legal status and contemporaneous care plans; this would have assisted their decision making and meant that the system would have had read only access to the notes from her interactions with other services.” Source location Sasha-Forster-R2019-01692
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing GMC prescribing guidance, when followed, is considered sufficient to ensure safe practice and protect patient safety.
Verbatim wording from the response “Turning to the matter of concern relating to the prescribing of propranolol. My officials have made enquiries and I am aware that the General Medical Council (GMC) has responded to you to explain that its prescribing guidance² is clear that a doctor must only prescribe when they have adequate knowledge of the patient’s health. This should involve making an assessment together with the patient of their condition and having, or taking, an adequate history. A patient’s consent to contact their GP should be sought if more information, or confirmation of the information available, is needed before prescribing. The GMC is confident that its guidance, when followed, ensures safe practice and protects patient safety.” Source location Sasha-Forster-R2019-0169
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing prescribing guidance is considered sufficient to ensure safe prescribing and protect patient safety when followed.
Verbatim wording from the response “I have enclosed extracts of the relevant sections of our ethical guidance at Annex A of this letter; and, we consider that this guidance, when followed, ensures safe prescribing and protects patient safety.” Source location Sasha-Forster-R2019-01694
Open published response
24 Apr 2019 Ioannis AVGOUSTI · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 1
Failure to prevent prescribing and administration of a documented allergenic medication View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
University Hospitals Sussex NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
University Hospitals Sussex NHS Foundation Trust
Implement redesigned prescription charts displaying medication, reaction and allergy-safety decision information.
View source
University Hospitals Sussex NHS Foundation Trust
Finalise the EPMA specification and secure funding to purchase an electronic prescribing and medicines administration package incorporating allergy safeguards.
View source
University Hospitals Sussex NHS Foundation Trust
Undertake medicines reconciliation for every patient as soon as possible after admission.
View source
University Hospitals Sussex NHS Foundation Trust
Trial a single red allergy wristband system in the Acute Admissions Unit and Emergency Department, supported by compliance audits.
View source
University Hospitals Sussex NHS Foundation Trust
Deliver bespoke Acute Admissions Unit training on penicillin allergy risks and co-amoxiclav use.
View source See 2 more actions
×
AI-generated summary
Ioannis AVGOUSTI · 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
Ioannis Avgousti died after an episode involving documented allergy to Co-Amoxiclav, during which the medication was prescribed and administered. The report identified concerns about failure to follow allergy guidance, inadequate communication, failure to act on elevated NEWS observations or escalate care, and staffing pressures during the relevant shift.
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 Failure to prevent prescribing and administration of a documented allergenic medication
Wider context from the report “(2) On the 6th October 2018 although the hospital had noted that he was allergic to Co-Amoxiclav and although the paper medication notes noted that fact he was written up for that medication and it was administered to him .
I saw evidence of a poorly documented, from the point of view of time, NEWS observation. Although at the top of the chart there were the numbers 2 0 (20) I found on the balance of probabilities that set of observations had more likely been taken at about 20:10 or 20:15 hours.
The observations were added up to 9. In fact the total was 13.
NEWS is a tool to ensure that the deteriorating patient is recognised and given help and escalated, if appropriate, to Intensive Care.
This set of observations was not acted on in accordance with the directions and no escalation was made. There should have been a MET call then i.e., at around 20:15 hours to a specialist registrar (there was one on duty)
If this call had been made and if the appropriate doctor had been called to see Mr. Avgousti it is possible that although the sepsis protocol would I believe have been implemented, it would have been realised that he had an allergy to Co-Amoxiclav and he would have been given an appropriate alternative.
Whilst I cannot say categorically that this would have been the case I believe it is highly likely.
NEWS is an important tool and should not be ignored as it was on Vallance Ward on the night of the 6th October 2018.
” Source location Ioannis AVGOUSTI · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement redesigned prescription charts displaying medication, reaction and allergy-safety decision information.
Verbatim wording from the response “████████ Head of Nursing for Quality Improvement has undertaken work in conjunction with the Pharmacy team to ensure that the Trust is fully compliant with these NICE guidelines. ████████ has confirmed that the Trust is currently compliant with most of the guidelines and has produced an action plan for the remaining guidelines. This includes a tool, to describe reactions and to determine actual allergy status, which has been developed and this tool will be incorporated into the new design of the Trust’s Prescription chart. The next print run of our newly designed Prescription charts will include:” Source location 2019-0135-Response-by-Brighton-and-Sussex-University-Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Finalise the EPMA specification and secure funding to purchase an electronic prescribing and medicines administration package incorporating allergy safeguards.
Verbatim wording from the response “All of the above will be incorporated into the EPMA (Electronic Prescribing and Medicines Administration) system. The business case for this package has been approved and the specification is currently being finalised. We are waiting for an imminent NHS England allocation of funding decision in order to purchase the EPMA package. Once commenced we our aim is for 80% of wards to have EPMA within 2 years. The Chief of Pharmacy and his team are leading on this work.” Source location 2019-0135-Response-by-Brighton-and-Sussex-University-Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake medicines reconciliation for every patient as soon as possible after admission.
Verbatim wording from the response “Medicines reconciliation is now undertaken for every patient as soon as possible after they have been admitted to hospital.” Source location 2019-0135-Response-by-Brighton-and-Sussex-University-Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trial a single red allergy wristband system in the Acute Admissions Unit and Emergency Department, supported by compliance audits.
Verbatim wording from the response “We have undertaken extensive investigation into the use of red allergy wrist bands, led by the Head of Nursing - Quality Improvement. We have conducted three audits of the appropriate use of red wristbands since January 2019 and there has been 10% improvement on compliance. In addition, our Acute Admissions Unit and Emergency Department are trialing a single coloured wristband system whereby if a patient has an allergy, they will only wear a red wristband with their details on it, and not an additional white wristband. The aim of this trial is to see if it reduces the risk of the red wristband not being seen when checking patients’ details prior to medication administration and our patients like Mr Avgousti who I gather did not like wearing multiple wristbands and would sometimes pull them off, being more comfortable and reducing the risk of removal.” Source location 2019-0135-Response-by-Brighton-and-Sussex-University-Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver bespoke Acute Admissions Unit training on penicillin allergy risks and co-amoxiclav use.
Verbatim wording from the response “To supplement this trial, the Acute Admissions Unit team have put in a place a bespoke training programme for staff in order to highlight the risk of penicillin allergy and the use of co-amoxiclav. I am delighted to say that over the last month there have been no penicillin related incidents on the Acute Floor at the Royal Sussex County Hospital. These improvements will then be extended to other areas of the Trust.” Source location 2019-0135-Response-by-Brighton-and-Sussex-University-Hospitals
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Purchase of the EPMA package cannot proceed until NHS England decides its funding allocation.
Verbatim wording from the response “All of the above will be incorporated into the EPMA (Electronic Prescribing and Medicines Administration) system. The business case for this package has been approved and the specification is currently being finalised. We are waiting for an imminent NHS England allocation of funding decision in order to purchase the EPMA package. Once commenced we our aim is for 80% of wards to have EPMA within 2 years. The Chief of Pharmacy and his team are leading on this work.” Source location 2019-0135-Response-by-Brighton-and-Sussex-University-Hospitals
Open published response
Concerns raised 1
Failure to prescribe intravenous hydrocortisone when vomiting prevents oral steroid administration View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Terence Bradfield · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Terence Bradfield entered Derriford Hospital on 1 December 2013 with gastric bleeding and died on 17 December 2013, primarily from the consequences of his gastrointestinal bleed. The report raised concerns that his long-term steroid medication was not given or adequately managed, including when he was vomiting, and about staff training and the absence of policies for steroid management and “Nil by Mouth” patients with co-morbidities.
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 Failure to prescribe intravenous hydrocortisone when vomiting prevents oral steroid administration
Wider context from the report “(1) They are :
1. Mr. Bradfield was not given his steroids on 2.12.13
2. Mr. Bradfield was not prescribed intravenous hydrocortisone on 4th and 5th December 2013 when Mr. Bradfield had reported vomiting
3. Mr. Bradfield was not put on a stress dose of steroids whilst in Derriford hospital
4. The awareness and training of staff on the issue of steroid management.
5. The lack of a policy on the administration of steroids generally and their use in situations where a number of co – morbidities are present despite this death having arisen in 2013.
6. The training and awareness of staff on the meaning of “Nil by Mouth “ in patients who are suffering from a number of co –morbidities and are on important prescribed medication which needs to be taken regularly notwithstanding any planned necessary procedures .
” Source location Terence Bradfield · Prevention of Future Deaths report
Open source report
11 Mar 2019 Margaret Bernadette WILSON · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1
Prescribing antibiotics that mask Endocarditis View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Margaret Bernadette WILSON · 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
Margaret Bernadette Wilson was admitted with swelling, pain and bruising, and was provisionally diagnosed with cellulitis and treated with antibiotics without prior blood tests. She later developed chest pain, was diagnosed with endocarditis, did not respond to treatment and died. The report identified concern that the absence of a blood test and the prescribing of antibiotics masked the endocarditis, and stated that earlier diagnosis and treatment would more likely than not have resulted in a different outcome.
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 Prescribing antibiotics that mask Endocarditis
Wider context from the report “1. A blood test should have been done, in compliance with national guidelines, which would have confirmed Endocarditis. The absence of such test and the prescribing of antibiotics masked the disease .
2. Earlier diagnosis and treatment would more likely than not have resulted in a different outcome.
In addition it was later recognised that the finger symptoms were most likely due to Endocarditis.
” Source location Margaret Bernadette WILSON · Prevention of Future Deaths report
Open source report
7 Mar 2019 CHAND ALI · Prevention of Future Deaths report City of London
View report summary
Concerns raised 1
Failure to require individualized risk-benefit justification for cyclizine prescribing in severe heart failure View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
CHAND ALI · 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
Chand Ali, a 78-year-old man with severe end-stage heart failure and diabetes, was admitted to hospital with fluid overload and decompensated heart failure and died later that day. Cyclizine was administered intravenously despite cautions concerning its use in severe heart failure. Concerns included its routine use without individual risk-benefit assessment, the lack of monitoring of deaths following recent cyclizine use, and the absence of a comprehensive review of alternative antiemetics.
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 Failure to require individualized risk-benefit justification for cyclizine prescribing in severe heart failure
Wider context from the report “As stated above, cyclizine is an antiemetic which, according to the British National Formula, must be used with caution for patients suffering severe heart failure, especially if it is administered intra-venously.
The evidence revealed that cyclizine is administered to heart failure patients at St. Bartholomew’s Hospital, including those suffering severe heart failure, as the routine or standard antiemetic and without consideration of its likely effect on the individual patient in question . There is no system in place in the hospital requiring the prescriber to balance any risk to the patient arising from the use of cyclizine against the patient’s clinical need for it, in order to justify its prescription .
Further, whilst it was said that the Hospital was not aware of any pattern or trend of deaths following the administration of cyclizine, it was accepted that the actual incidence of such deaths was not, in fact, known. It was accepted that monitoring and analysis of all deaths following the recent use of cyclizine would be needed in order to establish a reliable picture.
It was also apparent from the evidence that there had been no comprehensive review of other available antiemetics in order to explore whether there exists and effective alternative antiemetic which is not subject to a caution in the British National Formula as to its use.
” Source location CHAND ALI · Prevention of Future Deaths report
Open source report
20 Feb 2019 Malcolm John Rathmell · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1
Failure to identify incorrect warfarin prescribing View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Malcolm John Rathmell · 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 Rathmell was admitted after a fall and his pelvic fracture was not diagnosed until several days later. He was incorrectly given warfarin intended for another patient, subsequently suffered retroperitoneal bleeding, and died after developing bronchopneumonia. Concerns included failures to identify the incorrect prescription, the absence of a ward-based pharmacy review, and insufficient implemented action to address the risk of future deaths.
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 Failure to identify incorrect warfarin prescribing
Wider context from the report “(1) Mr Rathmell was treated and reviewed by a number of medical professionals from various disciplines between 14.03.18 and 22.03.18. No one identified during that time that he was being prescribed warfarin incorrectly.
” Source location Malcolm John Rathmell · Prevention of Future Deaths report
Open source report
29 Jan 2019 Sophie Holman · Prevention of Future Deaths report London (East)
View report summary
Concerns raised 1
Inadequate asthma safety-netting advice and reliance on unlicensed high-dose salbutamol weaning plans View source
This report raised 23 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Sophie Holman · 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
Sophie Holman, a 10-year-old girl with chronic asthma, died on 13 December 2017 after collapsing during a severe asthma attack while being taken to hospital. The report identifies concerns about inadequate long-term management, fragmented records, failure to recognise the cumulative severity and risks of her asthma, lack of a coordinated asthma action plan and safety-netting, and missed opportunities for specialist referral.
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 Inadequate asthma safety-netting advice and reliance on unlicensed high-dose salbutamol weaning plans
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions: in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Source location Sophie Holman · Prevention of Future Deaths report
Open source report
11 Jan 2019 Jacqueline Marie Elliott · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2
Failure to document and justify the volume of tramadol prescribed despite recorded non-compliance and self-medication View source Failure to explore alternatives to repeated painkiller prescribing for persistent back pain View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
NHS Greater Manchester Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
NHS Greater Manchester Integrated Care Board
Document follow-up plans and dosage advice whenever medication is started.
View source
NHS Greater Manchester Integrated Care Board
Provide GPs and non-medical prescribers with tools, information and education on safer prescribing and medication review.
View source
NHS Greater Manchester Integrated Care Board
Audit practices against repeat-prescribing and medication-review standards to support and maintain safety improvements.
View source
NHS Greater Manchester Integrated Care Board
Add patient alerts for concerns about overuse of painkillers or other medicines.
View source
NHS Greater Manchester Integrated Care Board
Share learning from the practice improvement plan with all Trafford practices to improve prescribing and repeat prescribing.
View source
NHS Greater Manchester Integrated Care Board
Provide and document advice on non-pharmacological treatments when prescribing analgesia.
View source
NHS Greater Manchester Integrated Care Board
Share learning on medication follow-up, dosage advice and non-pharmacological pain treatment with GPs through training and newsletters.
View source
NHS Greater Manchester Integrated Care Board
Consider running education sessions on non-pharmacological pain management and referral criteria for musculoskeletal services.
View source See 5 more actions
×
AI-generated summary
Jacqueline Marie Elliott · 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
Jacqueline Marie Elliott, who had a long-standing history of back pain, was found deceased at home on 9 August 2018. Post-mortem and toxicology findings identified reduced liver function and significant toxicity from a combination of drugs. Concerns included inaccurate prescription records, insufficient clinical notes and medication-review detail, prescribing of 100 tramadol tablets despite a recorded history of non-compliance and self-medication, and a lack of continuity of care.
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 Failure to document and justify the volume of tramadol prescribed despite recorded non-compliance and self-medication
Wider context from the report “4. There was a recorded history of non-compliance and deliberate self-medication of painkillers by Mrs Elliott. Despite that a GP immediately before her death in a telephone consultation prescribed her with 100 tramadol tablets whilst recording that she needed an urgent review. The rationale for prescribing this volume of medication was unclear from the notes ;
” Source location Jacqueline Marie Elliott · 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 explore alternatives to repeated painkiller prescribing for persistent back pain
Wider context from the report “5. There was a lack of continuity of care. Mrs Elliott saw a variety of different locum GPs. This meant that no clinician had an overview of her and her health. As a result, painkillers were repeatedly prescribed and other potential ways of managing her persistent back pain were not explored . This led to a significant reliance by Mrs Elliott on painkillers to manage her on going back problems. The inquest was told that the lack of continuity of care was due to a national shortage of GPs and was a national not local issue.
” Source location Jacqueline Marie Elliott · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Document follow-up plans and dosage advice whenever medication is started.
Verbatim wording from the response “Actions agreed with the CCG and in progress” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide GPs and non-medical prescribers with tools, information and education on safer prescribing and medication review.
Verbatim wording from the response “As a CCG we will offer advice to all GPs and Non-Medical Prescribers around these actions, this will be in the role of an enabler by providing appropriate tools and information/education. Our Medicines Optimisations team will continue to support practices to achieve and maintain the changes through an ongoing system of audit, against the Gold Standard Repeat Prescribing guidelines and medication review.” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit practices against repeat-prescribing and medication-review standards to support and maintain safety improvements.
Verbatim wording from the response “As a CCG we will offer advice to all GPs and Non-Medical Prescribers around these actions, this will be in the role of an enabler by providing appropriate tools and information/education. Our Medicines Optimisations team will continue to support practices to achieve and maintain the changes through an ongoing system of audit, against the Gold Standard Repeat Prescribing guidelines and medication review.” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add patient alerts for concerns about overuse of painkillers or other medicines.
Verbatim wording from the response “Actions agreed with the CCG and in progress” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning from the practice improvement plan with all Trafford practices to improve prescribing and repeat prescribing.
Verbatim wording from the response “The learning that the CCG has gained in working with Delamere practice on their improvement plan will be shared with all practices across Trafford to highlight the risks that have been identified in this case. This should also improve the quality of prescribing and repeat prescribing across all Trafford GP practices. Currently we are not aware of any other GP practices with the same level of risk. However to mitigate any potential risk we have now included the risks of repeat prescribing within our level three safeguarding training this commenced on 7th March 2019.” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide and document advice on non-pharmacological treatments when prescribing analgesia.
Verbatim wording from the response “Actions agreed with the CCG and in progress” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning on medication follow-up, dosage advice and non-pharmacological pain treatment with GPs through training and newsletters.
Verbatim wording from the response “1. When medication is started document the plan for follow-up/review and any advice given relating to the dose to take.” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider running education sessions on non-pharmacological pain management and referral criteria for musculoskeletal services.
Verbatim wording from the response “Increase awareness of and consider running GP, nurse and pharmacist education sessions regarding non-pharmacological management of pain and criteria for referral to MSK service.” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
Open published response
6 Dec 2018 John Michael KIRBY · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 2
Inappropriate ADHD assessment and prescribing suggestion View source Prescribing Concerta without further clinical review View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
John Michael KIRBY · 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
John Michael KIRBY took his own life, according to the conclusion of the inquest. The concerns included delays in his care, the handling of an ADHD diagnosis and Concerta prescribing, inadequate monitoring, and failures to respond appropriately to information about suicidal thoughts, a reported suicide attempt, substance use and an A&E admission.
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 Inappropriate ADHD assessment and prescribing suggestion
Wider context from the report “(1) The delay in dealing with Mr Kirby between August 2017 and March 2018.
(2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta .
(3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin.
(4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E.
This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE.
(5) Why was Mr Kirby prescribed Concerta without any (further) review?
(6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too?
(7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”.
(8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke?
” Source location John Michael KIRBY · 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 Prescribing Concerta without further clinical review
Wider context from the report “(1) The delay in dealing with Mr Kirby between August 2017 and March 2018.
(2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta.
(3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin.
(4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E.
This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE.
(5) Why was Mr Kirby prescribed Concerta without any (further) review?
(6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too?
(7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”.
(8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke?
” Source location John Michael KIRBY · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a senior medical decision-making group to review ADHD assessment, diagnosis, questionnaire use and prescribing practice.
Verbatim wording from the response “As your concern centres on clinical decision-making I asked the Trust’s Chief Medical Officer ████████ to set up a group of senior medical colleagues to review ████████ medical practice in relation to ADHD. The terms of reference of that medical decision-making group (DMG) included consideration of the use of ADHD questionnaires for diagnosis as well as consideration of the assessment and diagnosis of ADHD and recommended prescribing.” Source location 2018-0379-Response-by-Sussex-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a clinical review of ADHD prescribing within the relevant team.
Verbatim wording from the response “An immediate action that was taken was to ensure that all ████████ ADHD patients were co-managed with the Neurobehavioural Team. Additionally, a clinical review of all ADHD prescribing within the relevant team was completed which, I am pleased to say, did not identify any concerns.” Source location 2018-0379-Response-by-Sussex-NHS-Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.