16 Oct 2017 Jeremy Michael Holt · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 1
Failure to specify and record timely review points for critically ill patients View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Jeremy Michael Holt · Prevention of Future Deaths report
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Report summary
Jeremy Michael Holt Marshall developed a small bowel obstruction and other complications after elective surgery for colonic adenocarcinoma, deteriorated in hospital, and died on 17 November 2016 after life support was withdrawn. Concerns included delays in escalating his deteriorating condition, insufficiently specified review and fallback arrangements, and inadequate recording of observations for a critically ill patient with a high NEWS score.
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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 specify and record timely review points for critically ill patients
Wider context from the report “2. Review Point and fall back position when no further action is forthcoming – ████████ and also ████████ care plan at midnight provided for action to be undertaken but neither care plan provided for a specific timescale for any further review in respect of a patient who was quite clearly critically ill. Both ████████ indicated that with the benefit of hindsight that such a timescale would have been desirable. I am concerned that if there is not a review or further action undertaken and noted within a period of time which at the end of the day has to be reasonable but given the critical nature of patient scoring 7 and above should be relatively short , that if nothing happens that the nursing staff are empowered to refer the matter now to the Critical Care Outreach Team. My concern goes further than that. If hypothetically the Critical Care Outreach Team at a time of significant demand were unable to assess a patient then there needs to be built into that system a fallback position similar to the same fallback position that is available to the doctors ie that the nursing team can contact ITU or even as a last resort on the call Consultant. I am satisfied and I have no doubt in my similar situation that ████████ would have no hesitation in making such a call but I am concerned as to whether or not other members of the nursing team would be aware of those options and that is of concern to me as well as the reinforcement of a review point for a critically ill patient to be actually recorded in the care plan .
” Source location Jeremy Michael Holt · 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 Update the junior surgical doctors’ handbook to cover delegation responsibilities and documented follow-up plans.
Verbatim wording from the response “The Trust has considered your view and is of the belief there is no single solution to this. The omissions most likely stemmed from human factors rather than a system failing. Therefore a multidisciplinary approach is being taken strengthening personal accountability including updates to a handbook, simulation training and Adult Basic Life Support training.” Source location 2017-0296-Response-by-The-Great-Western-Hospital-NHS-Trust
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4 Oct 2017 Sofia Ann Legg · Prevention of Future Deaths report Somerset
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Concerns raised 1
Insufficient detail in care plans to record safeguarding requirements View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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Sofia Ann Legg · Prevention of Future Deaths report
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Report summary
Sofia Ann Legg had a history of low mood and self-harm, received care from CAMHS, and was placed on a six-month waiting list for CBT. On 26 September 2016, her mother discovered her hanging at home, and the inquest concluded that her death was suicide. Concerns included access to CAMHS, delays in CBT, the lack of urgent psychiatric input, shortcomings in the recording and follow-up of a critical CAMHS meeting, and inappropriate language in the SIRI 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 Insufficient detail in care plans to record safeguarding requirements
Wider context from the report “4. The recollections of Sofia’s care co-ordinator and Sofia’s mother as to the meeting of the 19th September were at odds with each other. Sofia’s care co-ordinator recollected in her evidence telling Sofia’s mother that Sofia was not to be left alone. Sofia’s mother deemed the impression from Sofia’s care co-ordinator's evidence as of Sofia being an extremely vulnerable and dangerous position but this was not reflected in Sofia’s care plan which made no mention of her not being left alone and it was not reflected in the care co-ordinator’s actions in not urgently contacting Sofia’s school, where she would be during the following days to a psychiatrist. Her care plan appears to be the critical written record of the outcomes of this meeting as it was not of sufficient detail to safeguard Sofia.
” Source location Sofia Ann Legg · 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 CAMHS care plans are explicit and communicate information clearly, with implementation monitored through clinical supervision.
Verbatim wording from the response “4.1 It has been recognised that the recollections of Mrs Legg and Sofia’s care co-ordinator are not in agreement with regards to the level of detailed safety advice given. Mrs Legg herself has told us that we, as a service, may not fully understand how challenging this situation was for her as a parent. She was being asked to absorb new information about her daughter’s mental state and her risk of ending her life, which was new and shocking for her. I extend again my own and the Trust’s sincere apologies to Mrs Legg for this. The Trust appreciates and fully understands this feedback given by Sofia’s mother and realises that services need to work much harder to help families understand the impulsive and fluctuating nature of suicide risk in young people. CAMHS practitioners have been made aware of the importance of ensuring care plans are explicit and information is written clearly.” Source location 2017-0293-Response-by-Somerset-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 risk training and team meetings to reinforce clear crisis plans explaining supervision requirements to young people and parents.
Verbatim wording from the response “4.3 It has been fully recognised that family members need to be involved at the earliest stage when young people are expressing suicidal ideation and given time to absorb information and to process advice. The CAMH service is continuing to work with staff through risk training and via local team business meetings to emphasise the importance of crisis plans which give advice to both the young” Source location 2017-0293-Response-by-Somerset-NHS-Trust
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11 Sep 2017 Janet WILLIAMS · Prevention of Future Deaths report Inner North London
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Concerns raised 2
Failure to detect missing computer records of CPA care plans View source Failure to record CPA care plans in the computer system View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Janet WILLIAMS · Prevention of Future Deaths report
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Report summary
Janet Williams became ill in early 2016 and received mental health care, including admission and home treatment. She died by suicide at home on 8 March 2017 while suffering late onset paranoid schizophrenia. Concerns included failures to record and monitor her care plan, insufficient reviews and medical follow-up, inadequate response to family concerns, and retrospective entries in her medical records.
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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 detect missing computer records of CPA care plans
Wider context from the report “1. Ms Williams’ care plan approach (CPA) was not recorded on the computer system and so there were no automatic alerts generated when she was not seen for review at the appropriate times. The lack of computer record of her CPA was never noted .
” Source location Janet WILLIAMS · 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 record CPA care plans in the computer system
Wider context from the report “1. Ms Williams’ care plan approach (CPA) was not recorded on the computer system and so there were no automatic alerts generated when she was not seen for review at the appropriate times . The lack of computer record of her CPA was never noted.
” Source location Janet WILLIAMS · Prevention of Future Deaths report
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1 Sep 2017 Mohammad Ismaeel Ashraf · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 4
Delays in issuing care plans for children with allergies View source Failure to provide issued care plans to the food provider View source Lack of care plans for all pupils who require them View source
Inaccurate care plans View source See 1 more concern
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Birmingham Community Healthcare NHS Foundation Trust The Olive School, Small Heath
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Birmingham Community Healthcare NHS Foundation Trust and The Olive School, Small Heath
Review and rectify Health Care Plan inaccuracies, update medical records, and provide signed, dated plans to catering staff.
View source
Birmingham Community Healthcare NHS Foundation Trust and The Olive School, Small Heath
Establish a Central Medical Register tracking Health Care Plans, medication, medicine locations, outstanding issues, and incomplete actions.
View source
Birmingham Community Healthcare NHS Foundation Trust and The Olive School, Small Heath
Require written, signed medical notifications, promptly refer them to the SENCO and school nurse, and record notification handling.
View source
Birmingham Community Healthcare NHS Foundation Trust and The Olive School, Small Heath
Conduct routine half-term checks comparing displayed and catering-held Health Care Plans with the central master list.
View source
Birmingham Community Healthcare NHS Foundation Trust and The Olive School, Small Heath
Implement allergy lunchtime controls requiring daily pre-orders, allergy-specific meal preparation, staff-supervised collection, and documented communication of allergy information.
View source
Birmingham Community Healthcare NHS Foundation Trust and The Olive School, Small Heath
Request parental updates on pupils’ medical conditions once each term in addition to annual updates.
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Mohammad Ismaeel Ashraf · 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
Mohammad Ismaeel Ashraf, a nine-year-old boy with multiple food allergies, suffered an anaphylactic reaction at school after eating lunch and died later that day following unsuccessful resuscitation. Concerns included failures and delays in care plans, ineffective communication about allergy information, unsafe allergy-identification lanyards, and failure to administer his epipen promptly despite his deteriorating condition.
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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 Delays in issuing care plans for children with allergies
Wider context from the report “2. That there are delays in issuing care plans . Care plans need to be issued quickly where a child has an allergy.
” Source location Mohammad Ismaeel Ashraf · 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 provide issued care plans to the food provider
Wider context from the report “3. All issued care plans had not been provided to Caterlink by the school and communication between the school and Caterlink was not as effective as they could be .
” Source location Mohammad Ismaeel Ashraf · 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 Lack of care plans for all pupils who require them
Wider context from the report “1. That care plans are not in place for all pupils that require them . Evidence was heard at the Inquest that the deceased’s sister’s care plan is still inaccurate, despite this having been identified to the school.
” Source location Mohammad Ismaeel Ashraf · 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 Inaccurate care plans
Wider context from the report “1. That care plans are not in place for all pupils that require them. Evidence was heard at the Inquest that the deceased’s sister’s care plan is still inaccurate , despite this having been identified to the school .
” Source location Mohammad Ismaeel Ashraf · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and rectify Health Care Plan inaccuracies, update medical records, and provide signed, dated plans to catering staff.
Verbatim wording from the response “The School was very concerned to hear the evidence given by the uncle of the deceased at the inquest that the Health Care Plan for Ismael’s sister was inaccurate. At the time of the inquest the pupils were on the six week summer holiday and so neither pupil nor any other pupils were being put at risk at the time the evidence came to light. The School took immediate steps, before the school re-opened in September 2017, to review and rectify any inaccuracies.” Source location 2017-0243-Response-by-Al-Hijrah-School
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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 Establish a Central Medical Register tracking Health Care Plans, medication, medicine locations, outstanding issues, and incomplete actions.
Verbatim wording from the response “The School has established a Central Medical Register which provides instant access to the status of a pupil’s Care Plan, all medication issued to a pupil and the location of the medicine. The Central Medical Register provides instant information to highlight any outstanding issues and the actions that are yet to be completed, including receipt of the Health Care Plan.” Source location 2017-0243-Response-by-Al-Hijrah-School
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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 written, signed medical notifications, promptly refer them to the SENCO and school nurse, and record notification handling.
Verbatim wording from the response “All notifications made to the School regarding a pupil’s medical condition, including allergies, must be provided by the parent/guardian to the School in writing using the data information sheet. The data information sheet must be signed by a parent/guardian of the pupil and counter signed by the staff member at the School accepting the document. The notification ensures that an accurate record is made of a pupil’s medical condition before a referral is made to the Birmingham Health Care Trust, who will issue a Health Care Plan if required.” Source location 2017-0243-Response-by-Al-Hijrah-School
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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 routine half-term checks comparing displayed and catering-held Health Care Plans with the central master list.
Verbatim wording from the response “The School has implemented a routine half termly check of all Health Care Plans displayed at key locations and held by the catering teams, which are cross checked against the master list held centrally at the school.” Source location 2017-0243-Response-by-Al-Hijrah-School
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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 allergy lunchtime controls requiring daily pre-orders, allergy-specific meal preparation, staff-supervised collection, and documented communication of allergy information.
Verbatim wording from the response “Aside from the monthly meetings the School has implemented a robust system to ensure that the catering staff are notified of any new allergy information as soon as the School is notified. The pupil is added to the pre-order list and a prepared lunch is provided to the pupil by the catering team. The pupil is accompanied to lunch by a member of staff. A record is kept of all notifications made to the catering team. The pupil is issued once a Health Care Plan has been issued by the School, which is signed by both the catering manager and a signed record kept of delivery and receipt of the Health Care Plan to the catering manager.” Source location 2017-0243-Response-by-Al-Hijrah-School
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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 Request parental updates on pupils’ medical conditions once each term in addition to annual updates.
Verbatim wording from the response “The School will continue with its policy, as it has for many years, to send the existing medical details (including allergy details), out to every parent at the end of the school year. The information is sent to the parents for them to check and report back any changes at the start of the new academic year. The School now requests parental updates once a term in addition to the annual requests.” Source location 2017-0243-Response-by-Al-Hijrah-School
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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 School does not issue Health Care Plans; responsibility for issuing them rests with the Trust’s school nurse.
Verbatim wording from the response “The School is not responsible for issuing a pupil’s Health Care Plan. The School nurse employed by the Trust is the person responsible for issuing the Health Care Plans. The School immediately informs the School nurse of the pupil’s medical condition. The School nurse will then issue the pupil’s Health Care Plan, within seven days. It is not” Source location 2017-0243-Response-by-Al-Hijrah-School
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4 Jul 2017 Janet Silva Müller · Prevention of Future Deaths report West Sussex
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Concerns raised 1
Failure to maintain complete, sufficient and consistent nursing records, handovers, risk assessments and care plans View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Janet Silva Müller · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Janet Silva Müller, a patient detained under Section 2 of the Mental Health Act 1983 at Millview Hospital, died on 13 March 2015 after being found in the boot of a burning car; the circumstances were recorded as unlawful killing following her absconding from hospital. The principal concerns were incomplete and contradictory records, handovers, risk assessments and care plans, inadequate staffing, and insufficient measures to prevent detained patients from absconding.
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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 complete, sufficient and consistent nursing records, handovers, risk assessments and care plans
Wider context from the report “1. Nursing records, handovers, risk assessments and care plans were often incomplete, insufficient and at times contradictory . Whilst we were told that regular auditing is carried out by the Trust of nursing records it is clear that this is not fit for purpose as it is did not identify the fact that there were gaps in Janet’s nursing records and other key documents . The lack of proper record keeping increased Janet’s risk.
” Source location Janet Silva Müller · Prevention of Future Deaths report
Open source report
12 May 2017 Nasar AHMED · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to maintain accurate allergy action plans with medication-use instructions View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Bow School Compass Wellbeing CIC The British Society For Allergy & Clinical Immunology The Bromley by Bow Health Partnership
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 11
The British Society For Allergy & Clinical Immunology
Promote personalised written emergency plans for anaphylaxis and provide adaptable templates for healthcare professionals.
View source
The Bromley by Bow Health Partnership
Work with the borough safeguarding team to determine whether school nurses can access the community patient-record system for shared care-plan information.
View source
The Bromley by Bow Health Partnership
Investigate whether secondary-care anaphylaxis care plans are already in place and used.
View source
Compass Wellbeing CIC
Implement a centralised IHCP database with renewal flags, notifications, data-team management and clinical oversight.
View source
Compass Wellbeing CIC
Complete the whole-service IHCP Quality Standards Audit and extend the annual audit schedule to biannual IHCP audits.
View source
Compass Wellbeing CIC
Rewrite the IHCPs prepared by the involved nurse at Bow School to correct identified errors.
View source
Compass Wellbeing CIC
Implement measures requiring school nurses to follow up and update IHCP meeting actions routinely.
View source
Bow School
Review all pupil Individual Health Care Plans and verify that emergency-box medicines are prescribed and in date.
View source
Bow School
Implement monitored procedures for arranging and following up Individual Health Care Plan and medication reviews, including senior oversight and deadline reminders.
View source
Bow School
Use Safeguarding Committee governance, scheduling, spot checks and compliance reporting to monitor Individual Health Care Plans and medicines.
View source
Bow School
Attach Individual Health Care Plans and medical alerts to electronic pupil records and add allergy alerts to the cashless catering system.
View source See 8 more actions
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Nasar AHMED · Prevention of Future Deaths report
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Report summary
Nasar died following an anaphylactic reaction contributed to by asthma while he was in the internal exclusion room at school. The concerns included delayed or inappropriate advice about using his adrenaline auto-injector, discrepancies and gaps in asthma and allergy care planning, unsuitable emergency inhaler equipment, inadequate medication review systems, and shortcomings in staff awareness, training and emergency procedures.
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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 allergy action plans with medication-use instructions
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” Source location Nasar AHMED · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Promote personalised written emergency plans for anaphylaxis and provide adaptable templates for healthcare professionals.
Verbatim wording from the response “In addition, we have promoted the use of written personalised emergency management plans for anaphylactic reactions. We have developed templates which can be used by all healthcare professionals available on the BSACI website and these can be tailored to each individual’s personal circumstances and allergies.” Source location Response from British Society for Allergy and Clinical Immunology
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the borough safeguarding team to determine whether school nurses can access the community patient-record system for shared care-plan information.
Verbatim wording from the response “We are currently in contact with our borough children’s safeguarding team to determine whether School nurses have access to the community version of our patient record system so that information about care plans can be input into this and this can be shared between us and the school nurses. Some hospital departments also have limited access to our patient record system- this may be a good way to share information. There needs to be borough wide (and national consideration around this). From a practice level, our clinical teams are checking for up to date and accurate care plans during asthma reviews- however, this case has further highlighted the importance of this.” Source location Response from St Andrews Health Centre
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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 Investigate whether secondary-care anaphylaxis care plans are already in place and used.
Verbatim wording from the response “All our staff receives yearly BLS training and training around anaphylaxis. During this training the points above may or may not be emphasised by the trainer. We would share our learning around this at our bough with the safeguarding children team and discuss whether change can be implemented such that trainers organised to deliver this training emphasise the points highlighted if they also agree with these. By the end of September 2017, our nursing team will investigate whether there are anaphylaxis care plans that are already in place and being used by secondary care. We will then be incorporating these into care plans when seeing patients with asthma and allergies who have adrenaline prescriptions.” Source location Response from St Andrews Health Centre
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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 a centralised IHCP database with renewal flags, notifications, data-team management and clinical oversight.
Verbatim wording from the response “An IHCP improvement plan was subsequently implemented to identify, review and monitor all IHCPs across the service using a centralised database. This will support the identification of IHCPs requiring review which will be automatically flagged to the senior management team by an identified data manager. The database has been designed with a flagging system in it. The system counts down in days when an IHCP is due to be renewed and turns the date yellow 60 days prior to the expiry date and red once the date has arrived. The database will be managed by a data team on a daily basis and details of IHCP due (within 60 days) sent via email to the individual nurse responsible for the school and their line manager. This will be overseen by the clinical lead for the service and monitored as part of the performance data for the service.” Source location Response from Compass Wellbeing
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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 the whole-service IHCP Quality Standards Audit and extend the annual audit schedule to biannual IHCP audits.
Verbatim wording from the response “A full Quality Standards Audit was commenced in June 2017 for IHCPs and is due to be completed in August 2017. This audit will review all IHCPs across the whole service. Once this audit has been completed, the annual audit schedule will be extended to include IHCP audits on a bi-annual basis. We will put in place a robust action plan to deal with any deficiencies identified.” Source location Response from Compass Wellbeing
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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 Rewrite the IHCPs prepared by the involved nurse at Bow School to correct identified errors.
Verbatim wording from the response “As part of CWB's investigation, each of the IHCPs prepared by this Nurse at Bow School were reviewed. CWB's investigation found that IHCPs prepared by the Nurse had errors in them and were required to be re-written. That process has now been completed.” Source location Response from Compass Wellbeing
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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 measures requiring school nurses to follow up and update IHCP meeting actions routinely.
Verbatim wording from the response “CWB have implemented additional measures to ensure that the checking and updating of actions from IHCP meetings are routinely followed up by all school nurses and to prevent this event from happening again.” Source location Response from Compass Wellbeing
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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 all pupil Individual Health Care Plans and verify that emergency-box medicines are prescribed and in date.
Verbatim wording from the response “The Coroner also raised concerns that the system in place for ensuring that actions arising from individual health plans (‘IHP’) and medication reviews were undertaken was not sufficiently robust. Since Nasar’s death, the school’s Safeguarding Committee has undertaken a thorough review of all IHPs for pupils in the school. This included ensuring that all medicines kept within emergency boxes at the school are as prescribed and in date.” Source location Response from Bow School
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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 monitored procedures for arranging and following up Individual Health Care Plan and medication reviews, including senior oversight and deadline reminders.
Verbatim wording from the response “The Executive Headteacher, along with Headteacher representatives from across the area, has been invited by the Local authority to meet to discuss the school nursing service as part of a scheduled contract renewal process. This meeting is due to take place later this year, but it is understood that the concerns identified during the Inquest will inform that process. In the interim the school has been working with Compass Wellbeing to clarify the procedure for setting up IHP meetings and medication reviews. The school has had additional processes to ensure this procedure is robustly monitored at senior level. The procedure requires that, in all cases an update of the pupil’s medical need is required at each review.” Source location Response from Bow School
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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 Safeguarding Committee governance, scheduling, spot checks and compliance reporting to monitor Individual Health Care Plans and medicines.
Verbatim wording from the response “The Safeguarding Committee⁵ has developed a flowchart to outline the responsibilities under the ‘Support students with medical needs’ policy. The committee has an agenda item ‘IHP and medication reviews’ so that effectiveness of managing medical needs is considered at each meeting. It is responsible for setting the schedule of meetings for all IHP or medication reviews on a half termly basis. The school administrator is required to liaise with Compass Wellbeing and the YLM to ensure all parties are present at meetings. The Designated Safeguarding Lead (‘DSL’) also receives details of IHP meetings and the decisions made and conducts spot checks on the IHPs and medicines so that compliance with expectations can be maintained. The DSL provides a compliance report each half term to the safeguarding committee.” Source location Response from Bow School
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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 Attach Individual Health Care Plans and medical alerts to electronic pupil records and add allergy alerts to the cashless catering system.
Verbatim wording from the response “In addition, all IHPs are being scanned and attached to the relevant child’s electronic record (the SIMS profile) so that it can be viewed quickly by staff. An alert symbol has also been added to relevant pupils’ SIMS profiles so that it is immediately visible if a child has an IHP. Alerts have also been added to the school’s Cashless Catering System to flag students with allergies so that staff are aware of those children. Catering staff are encouraged to liaise with the relevant pastoral team or Compass Wellbeing to check if unsure and continue to challenge if they feel a pupil’s choice may place them at risk. There is also a procedure for catering staff to report concerns where children with allergies regularly seek to purchase food containing allergens.” Source location Response from Bow School
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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 Schools share responsibility for preparing and updating IHCPs and ensuring an appropriate school representative attends review meetings.
Verbatim wording from the response “CWB recognises and understands the importance of the collaborative working arrangements involved in preparing IHCPs and the ongoing support, communication and processes for children in schools with medical conditions. The Supporting Medical Needs Policy clearly sets out that a number of organisations have roles and responsibilities and that school staff, school nurses and parents must work in partnership to ensure that the needs of pupils with medical conditions are met effectively.” Source location Response from Compass Wellbeing
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16 Mar 2017 James Charles MALLETT · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Absence of patient care plans View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
James Charles MALLETT · 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
James Charles Mallett, aged 93, was admitted to hospital after a fall at home and later sustained a fatal head injury in a further inpatient fall. Concerns included delayed medical attendance, unclear and untimely neurological observations, inadequate contemporaneous records, insufficient falls prevention, and nursing staff training and experience that were considered inadequate.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Absence of patient care plans
Wider context from the report “4) The nursing staff on duty do not appear to have the requisite knowledge or experience to nurse patients such as Mr Mallett. There was no falls planning or prevention, there was no care plan in place on this ward . There was no use of items such as sensor.crash pads, or equipment which can be attached to patients to warn of movement. The nurse who was stationed in that 6 bed bay because Mr Mallett and others in there were at particular risk, left her post and then Mr Mallett was found on the floor.
” Source location James Charles MALLETT · Prevention of Future Deaths report
Open source report
16 Feb 2017 ETHELINE DE-GALE · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 1
Lack of sufficiently specific care plans for required assistance View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Ambassador House
Update care plans to require that residents using bedrails are not left unattended when rails are lowered for assistance.
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ETHELINE DE-GALE · 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
Etheline De-Gale fell while mobilising from bed at a care setting on the night of 7/8 March 2016. Hospital admission was declined, follow-up with a doctor did not occur as recommended, and an ambulance attended the following afternoon; she later underwent surgery, contracted bronchopneumonia and died from a pulmonary embolism on 16 March 2016. Concerns included an insufficiently clear care plan, inadequate guidance on risk assessments, limited staffing, and the apparent failure to follow paramedic recommendations.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of sufficiently specific care plans for required assistance
Wider context from the report “(1) The care plan was too vague to be of assistance to the carers. The carer understood that the deceased required 2 carers to assist her to the commode, but interpreted that as being limited to walking across the floor, but not sitting up in bed with the sides removed or sitting on the side of the bed.
” Source location ETHELINE DE-GALE · 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 Update care plans to require that residents using bedrails are not left unattended when rails are lowered for assistance.
Verbatim wording from the response “The care plan should stipulate that when bedrails are used for any resident and they are lowered for assistance to the resident, the resident must not be left unattended. This will be in place by 3rd March 2017.” Source location 2017-0058-Response-Ambassador-House-Home
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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 Policies and procedures were followed; the incident resulted from a senior staff member’s negligence.
Verbatim wording from the response “Based on the information from statements, staff interview, care plans, risk assessments and LR’s personnel file, we have concluded that in this case we have acted in accordance with our policies and procedures. The incident occurred, we believe, because of the negligence of a senior staff member (LR).” Source location 2017-0058-Response-Ambassador-House-Home
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14 Feb 2017 Derek LEE · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 2
Failure to make mobility central to the care plan View source Lack of a coherent, considered and reviewed care plan View source
This report raised 24 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Derek LEE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Derek LEE died on 5 June 2016 following an admission to Brunswick Ward. The report identified numerous concerns about his care, including medication management, incomplete assessments and documentation, falls and pressure-sore prevention, delayed referrals and treatment, nutrition, mobility, and the absence of a care co-ordinator. The inquest concluded that the death was from natural causes, and the report stated that the identified failings did not change the outcome.
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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 make mobility central to the care plan
Wider context from the report “(3) His Falls Risk Assessment was flawed in that it failed to take into account information from his wife and son as to how he was mobilising at home. Mobilisation in Mr Lee’s case should have been at the core of the Care Plan because he was suffering from Parkinson’s Disease, where if possible, it is important to maintain mobility. Brunswick Ward should know that.
” Source location Derek LEE · 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 Lack of a coherent, considered and reviewed care plan
Wider context from the report “(13) There was no coherent and carefully considered and reviewed Care Plan.
” Source location Derek LEE · Prevention of Future Deaths report
Open source report
27 Nov 2016 Matthew RUSSELL · Prevention of Future Deaths report Surrey
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Concerns raised 1
Lack of structured care plans for each patient View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
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Matthew RUSSELL · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Matthew Russell was a serving prisoner who was found hanging by a ligature from his cell door and died in hospital the following day. The jury concluded that multiple failures in the management and application of the ACCT plan procedure materially contributed to his death, including concerns about medication monitoring, care planning, multidisciplinary reviews, staff training, risk assessment and communication.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of structured care plans for each patient
Wider context from the report “b. The preparation of structured care plans for each patient .
” Source location Matthew RUSSELL · 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 Launch the Offender Care Psychosocial Strategy to support psychologically informed care and reduce reliance on dependence-forming medication where appropriate.
Verbatim wording from the response “A key element of the new CNWL model in the Surrey prisons is based on Medicines Optimisation for all patients, with pharmacy services focused on delivering individual” Source location 2016-0430-Response-by-Central-and-North-West-London-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 Provide Best Practice Care Plan training to HMP Highdown staff.
Verbatim wording from the response “A Care Plan audit was undertaken in October 2016. The audit identified that 100% of patients on the In-reach caseload had care plans in place. The team is monitored on a monthly basis on:” Source location 2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.