Concerns raised 1
Lack of timely cross-local access to relevant electronic patient records View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Jack FARRINGTON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jack Farrington, who had a long history of mental health difficulties and was detained under section 2 of the Mental Health Act, died on 2 January 2020 after running from an emergency department and falling from a road bridge. The report raised concerns about fragmented access to medical records, inadequate handovers and record keeping, insufficient flagging and assessment of absconding and self-harm risks, and the implementation of measures intended to keep him safe.
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× 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 timely cross-local access to relevant electronic patient records
Wider context from the report “I heard evidence that there is no systems or arrangements for the sharing of access to electronic medical records (such as SystmOne and RIO) outside of local areas and the Care and Health Information Exchange (CHIE) operating in the local area contains limited information.
I also received evidence that the new NHS England National Record Locator system only acts as a flag to show who holds records rather than allowing access to clinicians .
This fragmentation of patient records means that medical and mental health practitioners do not have quick access to relevant information about their patients .
” Source location Jack FARRINGTON · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the Integrated Care Board and regional acute trusts towards a paper-free electronic patient record.
Verbatim wording from the response “The Trust fully agrees that the current hybrid between paper and electronic records creates greater complexity and inefficiency, impacting the ability of the multidisciplinary teams to locate all necessary information for each patient. The ambition of PHU and similar NHS Trusts who have not already done so is to move to a true paper free Electronic Patient Record (EPR). We are working with the Integrated Care Board (ICB) and other Acute Trusts in Hampshire and Isle of Wight to achieve that goal over time.” Source location Response from Portsmouth Hospitals University NHS Trust
Open published response
8 Sep 2023 Lynsey Sarah Smalley · Prevention of Future Deaths report North West Wales
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Concerns raised 1
Failure of paper-based medical records to provide all relevant care information to involved individuals and organisations 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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AI-generated summary
Lynsey Sarah Smalley · 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
Lynsey Sarah Smalley, aged 42, set fire to her bed at home during an acute psychotic episode on 8 April 2021. She suffered inhalation injuries, was admitted to intensive care, and died at Ysbyty Gwynedd, Bangor on 16 May 2021. The substantive concerns were conflicting investigation reports, disjointed patient-safety and governance processes, delays in completing actions, and risks arising from paper-based medical records that may impede continuity of care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of paper-based medical records to provide all relevant care information to involved individuals and organisations
Wider context from the report “b. A number of individuals and organisations are involved in the care of those under mental health teams or at times have contact with patients e.g. CMHT, Home Treatment Teams, Psychiatrists, Occupational therapists, Care Coordinators, out of hours crisis service (local authority based in Gwynedd), Police, Ambulance Service etc. As medical records remain paper based not all individuals or organisations who need to understand a patient’s circumstances/care/treatment are privy to all aspects of care/treatment. In addition, where a CMHT patient is receiving in-patient mental heath treatment the paper notes are transferred to the hospital setting. There is a risk that notes will become lost in full / in part. Having medical records electronically will not only allow full access to all notes to those who require which will inform future care/treatment but will also ensure effective continuity of care, without the risk of missing or lost notes. I have previously issued a Prevention of Future Deaths Report on this point, a copy of which was also sent to ████████, Health Minister.
” Source location Lynsey Sarah Smalley · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate in regional and local-authority discussions to assess alternative digital patient-record options for North Wales.
Verbatim wording from the response “Regional meetings are now taking place across Wales to discuss the options that have been presented to them by WG as alternative to WCCIS Care Direct Version 5. BCUHB has met with Local Authorities to discuss implications across health and social care services in order to come to an agreement on the preferred option for North Wales.” Source location Response from Betsi Cadwaladr University Health Board
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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 Develop a Health Board strategic outline case for electronic patient records, incorporating MHLD requirements to address fragmented care records.
Verbatim wording from the response “In addition I am pleased to report that a Strategic Outline Case for an Electronic Patient Record system(s) is being developed on a Health Board wide level to address the issue of fragmented care records; the deadline for the strategic outline case is the end of January 2024. MHLD are taking a key role in shaping the outline case to ensure that the Division’s needs are considered as part of the Health Board wide proposal.” Source location Response from Betsi Cadwaladr University Health Board
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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 Chief Information Officer to consider options for a more timely MHLD digital-record solution.
Verbatim wording from the response “Whilst MHLD are keen to support and progress the processes outlined above, we are mindful of the scale of the task for agreeing a national solution and are therefore working with BCUHBs Chief Information Officer to consider options which may bring MHLD a more timely solution. This remains a major priority for the Division and is supported by the Health Board.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implementation of the planned MHLD digital records system cannot proceed as expected because national arrangements changed following a Welsh Government decision.
Verbatim wording from the response “Within the notice, you also raised your continued concerns about the implementation of digital patient records for MHLD. In previous correspondence with you, the Health Board has reported significant delays with the development and implementation of a suitable system at a national level. I understand that you have raised your concerns about the delays with the Health Minister directly. We now know that following a decision made by WG the national system will not be progressing in the way that was previously expected. This has significantly altered MHLD divisional plans for digital transformation as these were dependent upon the use of the WCCIS Care Director Version 5 product, with a pilot having been due to start in September 2023, and the expectation that a wider adoption across all applicable MHLD services would follow.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
14 Aug 2023 Linda Oldland · Prevention of Future Deaths report Surrey
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Concerns raised 2
Failure to pass pertinent information to the ambulance service View source Failure to pass pertinent clinical information to the GP View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Linda Oldland · 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
Linda Oldland died at Hydon Hill Nursing Home on 3 January 2022 from a urinary tract infection that infected both kidneys and resulted in sepsis. Concerns included failures to share information about positive urine tests and the GP’s treatment plan, delayed antibiotics, failure to recognise cardiac arrest, and incorrectly informing ambulance staff that a valid DNAR form was in place.
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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 pass pertinent information to the ambulance service
Wider context from the report “Hydon Hill Nursing Home:
- Did not pass on pertinent information to the GP about the positive dip stick test on 30 December 2021;
- Delayed the start of the stand-by oral antibiotics from the evening 31 December 2021 until Midday on 2 January 2022;
- Did not pass on pertinent information to the ambulance service on 2 January 2022 about Mrs Oldland’s wishes and the GP plan should she deteriorate with suspected sepsis ;
- Did not recognise that Ms Oldland was in a state of cardiac arrest on 3 January 2022;
- Incorrectly informed the ambulance service that Mrs Oldland had a valid DNAR in place on 3 January 2022.
The Coroner considers that consideration ought to be given to updating policies and procedures in respect of the sharing and documentation of information relating to residents and/or in relation to training of clinical staff to address the above matters.
” Source location Linda Oldland · 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 pass pertinent clinical information to the GP
Wider context from the report “Hydon Hill Nursing Home:
- Did not pass on pertinent information to the GP about the positive dip stick test on 30 December 2021 ;
- Delayed the start of the stand-by oral antibiotics from the evening 31 December 2021 until Midday on 2 January 2022;
- Did not pass on pertinent information to the ambulance service on 2 January 2022 about Mrs Oldland’s wishes and the GP plan should she deteriorate with suspected sepsis;
- Did not recognise that Ms Oldland was in a state of cardiac arrest on 3 January 2022;
- Incorrectly informed the ambulance service that Mrs Oldland had a valid DNAR in place on 3 January 2022.
The Coroner considers that consideration ought to be given to updating policies and procedures in respect of the sharing and documentation of information relating to residents and/or in relation to training of clinical staff to address the above matters.
” Source location Linda Oldland · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold a daily flash meeting to discuss activities, concerns, changes in behaviour, illness and professional contacts.
Verbatim wording from the response “Action | Impact | Expected Completion
Manager’s daily walkaround | The service manager’s now carry out a daily walkaround which is documented, following a standardised format. This ensures that they are visible, speak with staff and people being supported. | Completed
Daily ‘flash’ meeting | This is a 10-20 minute meeting held daily in the morning, chaired by the Service Manager/Deputy Manager or Nurse in Charge, its attended by key staff: Domestic, Maintenance, Activities, Nurses – at the meeting the daily activities are discussed along with any concerns regarding people using the service, changes in behaviour, signs of illness, external professionals visiting, GP contact | Completed
Weekly clinical governance meeting | These meetings are held with the clinical team, going into detail about clinical concerns within the service, any further support the people we support may need.” Source location Response from Leonard Cheshire
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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 Maintain a robust handover process for communicating concerns about supported people.
Verbatim wording from the response “In addition to the action plan above, we have a robust handover process which is an opportunity to discuss any concerns the nurses and carers have with people, which people have a Respect document in-situ and who does not want to be resuscitated. Hydon Hill specifically have implemented an additional system to identify discreetly who does not want to be resuscitated, this ensures that if a person is not in their bedroom but around the home in their wheelchair, staff can easily identify them, should they need to.” Source location Response from Leonard Cheshire
Open published response
19 Jul 2023 Michael Kevin Amesbury · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure of inter-trust referral systems to provide timely electronic transfer of clinical information, images and notes View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Michael Kevin Amesbury · 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
Michael Kevin Amesbury had extensive cardiac disease and became increasingly unwell while awaiting assessment for severe mitral regurgitation. He died in hospital after becoming unresponsive and undergoing cardiopulmonary resuscitation; post-mortem examination identified bilateral bronchopneumonia and aspiration of gastric contents, with heart failure contributing to reduced physiological reserves. The concerns included delays and problems in referrals between secondary and tertiary services, information-sharing and transfer of clinical records and images, and delays in cardiology assessment and trans-oesophageal echocardiography due to resource and appointment constraints.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of inter-trust referral systems to provide timely electronic transfer of clinical information, images and notes
Wider context from the report “1. The inquest heard evidence that Mr Amesbury needed to be referred from secondary to tertiary services within Greater Manchester. The inquest heard evidence that the speed and quality of that referral was impacted by the way in which information was shared between clinicians in different trusts within Greater Manchester . The use of different systems and reliance on postal services and lack of a clear, effective electronic system of referrals including transfer of images /notes meant there were delays in assessing patients which led to a delay in formulating a treatment plan in tertiary services;
” Source location Michael Kevin Amesbury · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore extending referral-platform benefits to other Greater Manchester services.
Verbatim wording from the response “exploring. Attached as appendix 1 is a briefing note which outlines how a secondary to tertiary referral platform (Patient Pass) has been used to excellent effect in Renal, Neurosurge████████ Northern Care Alliance (NCA). There are significant benefits for outcomes re safety and productivity. We are looking at how we can bring the benefits of this type of technology to other services.” Source location Response from Greater Manchester Integrated Care
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss with information officers and the Digital Delivery Executive how to develop the referral-platform proposal into a funded project.
Verbatim wording from the response “Work to resolve this aligns closely with the GM digital strategy, the opportunities that the ICB brings for visibility, spread and scale. GM ICB commits to exploring and as appropriate, implementing this across other GM services. We will be progressing this with chief information officers across the integrated care system for an outline discussion to consider how this could be worked up into a funded project within the strategy delivery plan.” Source location Response from Greater Manchester Integrated Care
Open published response
14 Jul 2023 PETER MARTIN AARON FLEMING · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2
Delays in primary care organisations providing important patient updates to GPs View source Failure of digital systems used by different health organisations to communicate View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
PETER MARTIN AARON FLEMING · 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
Peter Martin Aaron Fleming was found deceased in his flat on 10 November 2022 after taking a deliberate overdose of prescribed medication; his cause of death was confirmed as carbamazepine toxicity and the conclusion was suicide. The report raised concerns about inadequate mental health resources, ineffective communication between specialist teams and health organisations, delays in medication provision, and shortcomings in medication management and monitoring.
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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 primary care organisations providing important patient updates to GPs
Wider context from the report “4. The deceased’s GP raised concerns that different health organisations use different digital systems that do not communicate with each other. Further, GPs often do not get important patient updates from primary care organisations for many days or weeks . (See examples above: the GP did not pick up the carbamazepine prescription, and could not prescribe the medication in October 2022). My concern is communication between different health organisations is not as effective as it could be and important information is being missed , and consequently a material delay in treatment is occurring .
” Source location PETER MARTIN AARON FLEMING · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of digital systems used by different health organisations to communicate
Wider context from the report “4. The deceased’s GP raised concerns that different health organisations use different digital systems that do not communicate with each other . Further, GPs often do not get important patient updates from primary care organisations for many days or weeks. (See examples above: the GP did not pick up the carbamazepine prescription, and could not prescribe the medication in October 2022). My concern is communication between different health organisations is not as effective as it could be and important information is being missed, and consequently a material delay in treatment is occurring.
” Source location PETER MARTIN AARON FLEMING · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the Shared Care Platform to enable participating organisations to access clinical information and improve information exchange.
Verbatim wording from the response “Following the introduction of the shared electronic system across Birmingham, Sandwell and Solihull areas through Your Care Connected some years ago, the Trust could access some clinical information from primary care services. However, in the last 12 months this has been enhanced, and is now known as the Shared Care Platform. This allows a number of different organisations to access different clinical information across the system, including investigation results, thus improving the exchange of clinical information and thus improving patient care.” Source location Response from Birmingham and Solihull Mental Health Foundation Trust
Open published response
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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 Improve digital capability so relevant information is automatically added to GP patient records.
Verbatim wording from the response “Current GP systems are designed to be interoperable before being allowed to be used for patient care and as such are accredited under the Digital Care Services Catalogue which requires suppliers to meet relevant standards, including interoperability with other systems, which is a pre-requisite of being included on the catalogue. This has enabled almost all GPs (99%) to have the digital capability to share and receive medical information from a variety of care providers within the NHS. This quick and efficient way of relaying and transmitting information between clinicians should address the sharing of important clinical information. The NHS is working to further improve this capability to enable information to be automatically added into the GP Patient record as appropriate.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop interoperable shared care records to enable safe and secure information sharing across NHS and social care services.
Verbatim wording from the response “In addition, NHS England is also undertaking a programme of work that will enable the safe and secure sharing of an individual’s health and care information as they move between different parts of the NHS and social care. A shared care record joins up” Source location Response from NHS England
Open published response
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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 Accredited interoperable GP systems and widespread digital capability should address the sharing of important clinical information.
Verbatim wording from the response “Current GP systems are designed to be interoperable before being allowed to be used for patient care and as such are accredited under the Digital Care Services Catalogue which requires suppliers to meet relevant standards, including interoperability with other systems, which is a pre-requisite of being included on the catalogue. This has enabled almost all GPs (99%) to have the digital capability to share and receive medical information from a variety of care providers within the NHS. This quick and efficient way of relaying and transmitting information between clinicians should address the sharing of important clinical information. The NHS is working to further improve this capability to enable information to be automatically added into the GP Patient record as appropriate.” Source location Response from NHS England
Open published response
22 Jun 2023 Lucy Anne Walles · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 1
Failure of systems to make involved agencies aware of safeguarding referrals and concerns View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Lucy Anne Walles · 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
Lucy Anne Walles died in hospital on 23 February 2022 after jumping from a bridge on 16 February 2022. She had mild learning disabilities and a history of self-harm, and had recently disclosed thoughts of jumping from the bridge. The principal concerns related to safeguarding, mental health provision, and inter-agency communication, including the handling of safeguarding referrals and the provision of support after her contact with mental health services.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of systems to make involved agencies aware of safeguarding referrals and concerns
Wider context from the report “Reading Borough Council
1) Time scales for review and triage of safeguarding referrals.
2) Requirements to speak to the individual about whom safeguarding concerns have been raised.
3) Training around Section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a Section 42 enquiry.
4) Systems for making other involved agencies aware of safeguarding referrals and concerns.
5) In relation to each of the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training.
6) Improving interaction amongst agencies involved, and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is now being actively encouraged. Should there be written guidance about this somewhat subjective issue ?
7) Whether they consider that the resourcing of this service is adequate and safe.
8) Systems for auditing, and what will happen if the auditing reveals ongoing issues.
” Source location Lucy Anne Walles · Prevention of Future Deaths report
Open source 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 Implement the One Team community mental health model with multi-agency working, clear safety plans, named workers, feedback, and wider community support.
Verbatim wording from the response “NHS Trusts are changing and improving the way mental health services are provided in the community to support people with mental illness. In Berkshire Health Care we are calling this programme of work “One Team”. This transformation of services is happening across the country following the publication of the Community Mental” Source location Response from Berkshire Healthcare NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make the Integrated Multi-Disciplinary Team operational to discuss complex cases, share information, formulate risk, and determine suitable pathways and care plans.
Verbatim wording from the response “• Integrated Multi-Disciplinary Team
Complex cases can be discussed to enable a clear formulation of risk and needs. This forum will ensure the person gets the most suitable pathway and care plan to enable the patient to achieve their personal and treatment goals. It is also a place where important information can be shared across agencies pathways, for example,the ARRs worker could present a case here to ensure the correct pathway is in place, adult social care staff can attend to share any concerns. This function will be operational by December 2023.” Source location Response from Berkshire Healthcare NHS Foundation Trust
Open published response
11 Jun 2023 Marlene McCabe · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 2
Difficulty sharing information between service providers using different databases View source Inconsistent availability of access to mental health records across service providers View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Marlene McCabe · 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
Marlene McCabe was unlawfully killed in her own home on 4 September 2019 after being struck repeatedly on the head and face with a doorstop, causing catastrophic injuries. The concerns included urgent mental-health referral processes, inconsistent access to and sharing of mental-health records, the risk of substance misuse obscuring mental-health diagnoses, non-communication of material information, and delayed assessment of apparently intoxicated patients.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Difficulty sharing information between service providers using different databases
Wider context from the report “2) There is inconsistent availability of access to mental health records across the service providers and information sharing between service providers using different data bases is difficult .
” Source location Marlene McCabe · 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 Inconsistent availability of access to mental health records across service providers
Wider context from the report “2) There is inconsistent availability of access to mental health records across the service providers and information sharing between service providers using different data bases is difficult.
” Source location Marlene McCabe · Prevention of Future Deaths report
Open source report
26 May 2023 Conrad Richard James Colson · Prevention of Future Deaths report East London
View report summary
Concerns raised 1
Failure to share risk information and coordinate risk management planning between specialist and stepdown services at discharge View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England North East London NHS Foundation Trust South London and Maudsley 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. 6
South London and Maudsley NHS Foundation Trust
Update and ratify the CADAT discharge policy to require liaison, joint risk planning, and communication with skin clinics about aesthetic treatment.
View source
North East London NHS Foundation Trust
Develop a joint working protocol between CADAT and NELFT step-down services covering risk information sharing, joint risk management and discharge planning.
View source
North East London NHS Foundation Trust
Share the joint working protocol with staff and discuss it in team business meetings.
View source
North East London NHS Foundation Trust
Deliver a learning event on completing and updating risk assessments, including relevant assessment parameters.
View source
North East London NHS Foundation Trust
Undertake a quality improvement project to identify and address structural, process and cultural gaps in risk assessment and risk management.
View source
North East London NHS Foundation Trust
Develop risk formulation to support robust risk assessment and risk management processes and improve patient safety.
View source See 3 more actions
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Conrad Richard James Colson · 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
Conrad Colson, who had severe body dysmorphic disorder and a previous serious suicide attempt, was found deceased at home on 2 March 2022 after friends became concerned for his welfare. The inquest concluded that he took his own life while accessing aesthetic dermatology treatment, without therapeutic medication or professional mental health support, and after discharge without a robust risk assessment or relapse risk-management plan. Concerns included insufficient liaison and information sharing between mental health services, inadequate consideration of risks associated with aesthetic dermatology treatment, and training and resource gaps relating to body dysmorphic disorder.
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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 share risk information and coordinate risk management planning between specialist and stepdown services at discharge
Wider context from the report “1. A concern arose at the Inquest hearing in relation to the absence of liaison between the highly specialist services of the CADAT team and the stepdown services provided by NELFT . There was a lack of full information sharing around risk and risk assessment/risk management planning on discharge .
” Source location Conrad Richard James Colson · 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 and ratify the CADAT discharge policy to require liaison, joint risk planning, and communication with skin clinics about aesthetic treatment.
Verbatim wording from the response “The Centre for Anxiety Disorders and Trauma (‘CADAT’) has updated its discharge policy (enclosed with this letter), to explicitly state the expectations of liaison between local teams and CADAT. The updates to this policy confront the issues faced in Conrad’s case. The updated policy was circulated to all team members at CADAT and was discussed in the clinic’s team meeting on 1 June 2023. This” Source location Response from South London and Maudsley NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a joint working protocol between CADAT and NELFT step-down services covering risk information sharing, joint risk management and discharge planning.
Verbatim wording from the response “1) Improve working relationship between the highly specialised services of the CADAT team and the stepdown services provided by NELFT. This should include the need for full information sharing around risk and joint risk/management planning and discharge.” Source location Response from NELFT
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the joint working protocol with staff and discuss it in team business meetings.
Verbatim wording from the response “• Joint working protocol to be developed between the CADAT team and the stepdown services provided by NELFT. This should highlight the need for full information sharing around risk and joint risk/management planning and discharge.” Source location Response from NELFT
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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 Deliver a learning event on completing and updating risk assessments, including relevant assessment parameters.
Verbatim wording from the response “• Learning event on completing risk assessments arranged for 05/07/2023. This learning event will cover updating risk, the parameters to consider when completing a risk assessment and when to update a risk assessment.” Source location Response from NELFT
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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 Undertake a quality improvement project to identify and address structural, process and cultural gaps in risk assessment and risk management.
Verbatim wording from the response “• The Trust is planning to undertake a Quality Improvement Project on understanding why there are gaps in risk assessment and risk management processes (a couple of examples of reoccurring themes), particularly when there are poor outcomes associated with care provided. The project will focus on working with users of service, clinical and operational teams, as well as senior leadership and other identified key stakeholders to understand the structural, process and cultural factors which contribute to poor outcomes and use improvement methodology and frameworks to address the areas which can result in process changes to improve outcomes. It may be that a break through series collaborative methodology could be used across various teams at NELFT.” Source location Response from NELFT
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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 Develop risk formulation to support robust risk assessment and risk management processes and improve patient safety.
Verbatim wording from the response “This approach could potentially standardise variation through testing a change package which includes evidence based approaches to ensure care provision meets those standards and teams have a realistic chance of providing the care that is required to avoid future untoward outcomes. There is also a workstream which is leading on the development of risk formulation to ensure the implementation of robust risk assessment and risk management process to improve patient safety and move away from the current risk stratification model.” Source location Response from NELFT
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation SLAM and NELFT are responsible for addressing liaison, communication, information sharing and staff training concerning Conrad’s care.
Verbatim wording from the response “In terms of the matters of concern specific to Conrad, NHS England are unable to comment on the absence of liaison between the Centre for Anxiety Disorders and Trauma (CADAT) team at SLAM and the stepdown services provided by North East London NHS Foundation Trust (NELFT), nor the adequacy of communication, information sharing between the two Trusts or the training of staff employed by NELFT, who are the appropriate organisations to respond to your concerns. NHS England has however been sighted on NELFT’s Serious Incident Report into the matters surrounding Conrad’s death and note that there have been learnings and recommendations made, including improvements to information sharing. We have also asked to be sighted on the response to you Report from both NELFT and SLAM and will consider these carefully.” Source location Response from NHS England
Open published response
Concerns raised 1
Lack of integrated electronic access to medical and treatment records between treating teams View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Samuel Alexander Morgan · 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
Samuel Alexander Morgan, who was suffering from alcohol addiction and had diagnoses of ADHD and social anxiety, was found deceased at his parents’ house on 9 May 2019 after tying a ligature around his neck. The principal concern was that addiction and mental health services could not electronically access each other’s records, meaning important information about suicide risk and patient safety might be lost or insufficiently understood between treating teams.
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 integrated electronic access to medical and treatment records between treating teams
Wider context from the report “I am concerned that in cases where an individual is receiving treatment from alcohol and drug addiction services and treatment from the primary community mental health team that neither team is able to access the other teams records electronically . The lack of integrated electronic records between treating team means that important information regarding patient safety is not easily accessible between treating teams . Treating teams are reliant on referral letters which are necessarily limited and not always sufficient to capture all the detailed information available to a referring team. This is particularly concerning where there is dual diagnosis - such as substance misuse and mental health - given these are often complex cases. This is particularly the case where complex cases have not been referred into secondary mental health services and so do not have access to a care-coordinator who can oversee and understand the views of the various professionals treating and assisting an individual.
I am concerned that the lack of such an integrated electronic system of medical and treatment records inhibits the effective sharing of information regarding patient safety and so increases the risk that information of significance regarding a risk to life will be lost between agencies and not sufficiently understood between all those managing risk.
” Source location Samuel Alexander Morgan · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enable two-way WCCIS information sharing between Swansea community mental health and drug and alcohol teams.
Verbatim wording from the response “1. For Swansea based teams there is opportunity to share information between community mental health teams and drug and alcohol services via WCCIS which will allow 2 way sharing of all information in the WCCIS system relating to episodes of care both within community mental health services and drug and alcohol services. The technical changes to enable this will be completed within 10 working days and it is intended that this will be implemented week commencing 7th August 2023.” Source location Response from Swansea Bay University Health Board
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Further WCCIS rollout is on hold pending Welsh Government approval of National Programme Team recommendations.
Verbatim wording from the response “The solution to this is intended to be the implementation of the Welsh Community Care Information System, (WCCIS) which is a national IT programme aimed at enabling the safe sharing of information between health and social care. This has been partially rolled out within the Health Board as part of the implementation of the solution within Swansea Local Authority. Further roll out within the Health Board is currently on hold pending the approval by Welsh Government of recommendations made within a Ministerial Advice Paper presented by the National Programme Team. The situation is complicated by the fact that only one of our Local Authority partners has chosen to implement WCCIS. The current deployment of the solution within SB UHB is managed by Swansea Local Authority who” Source location Response from Swansea Bay University Health Board
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Local Authority must request and implement any amendments to WCCIS system functionality.
Verbatim wording from the response “The solution to this is intended to be the implementation of the Welsh Community Care Information System, (WCCIS) which is a national IT programme aimed at enabling the safe sharing of information between health and social care. This has been partially rolled out within the Health Board as part of the implementation of the solution within Swansea Local Authority. Further roll out within the Health Board is currently on hold pending the approval by Welsh Government of recommendations made within a Ministerial Advice Paper presented by the National Programme Team. The situation is complicated by the fact that only one of our Local Authority partners has chosen to implement WCCIS. The current deployment of the solution within SB UHB is managed by Swansea Local Authority who” Source location Response from Swansea Bay University Health Board
Open published response
Concerns raised 1
Incomplete information sharing between healthcare and prison security staff View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
HM Prison and Probation Service
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AI-generated summary
Thomas Victor HUNTLEY · 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
Thomas Victor Huntley died in HMP Winchester after he was found unresponsive in his cell on 28 May 2020, following a planned act intended to end his life. The inquest identified concerns about missing and inadequately recorded risk information, failures in ACCT documentation and risk assessment, inadequate observations, information sharing between prison and healthcare staff, and ligature risks in cells.
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 Incomplete information sharing between healthcare and prison security staff
Wider context from the report “Information sharing.
In evidence it was clear that the ACCT document was the only written document used for sharing information between the healthcare staff employed by the NHS trust and the prison security staff. Healthcare staff record and share their information within SystemOne which the prison security staff do not have access to. Prison security staff record information within NOMIS which healthcare staff do not have access to.
Evidence from witnesses revealed that these information systems are not necessarily fully reviewed for relevant information prior to attending ACCT meetings .
In addition a decision relating to Mr Huntley’s care (i.e. the move to a different cell) was taken by healthcare staff at their own meeting when they did not have the benefit of information available to prison staff.
████████ of HMP Winchester informed me that a Safety Intervention Meeting was now carried out weekly, chaired by a Senior Governor and attended by representatives of the prison, physical and mental health care providers and the probation service. This meeting covers each person subject to an ACCT and any relevant information is share via the ACCT case manager, NOMIS and the multi disciplinary team. ████████ could not assist me with whether this was a HMP Winchester initiative or had a wide application across the prison estate.
My concern is therefore that the current procedures and policies for sharing information are incomplete or not fully complied with . This renders the information which separate teams make decisions about a prisoner incomplete and increases the risk that important factors are not considered.
” Source location Thomas Victor HUNTLEY · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operational staff cannot access healthcare records because medical confidentiality prevents direct access to SystmOne.
Verbatim wording from the response “While SystmOne, the electronic system used by healthcare staff to record medical information cannot be accessed by operational staff for reasons of medical confidentiality, the appropriate sharing of information is encouraged through a range of methods, for example the morning operational meeting is multi-disciplinary and allows all those working with individuals to provide updates and ensure necessary information is shared. The Daily Briefing sheet and wing observation books are also vital tools to ensure all staff are aware of concerns regarding a prisoner.” Source location Response from HM Prison and Probation Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing multidisciplinary meetings, briefing sheets and observation books are considered sufficient to share necessary prisoner safety information.
Verbatim wording from the response “While SystmOne, the electronic system used by healthcare staff to record medical information cannot be accessed by operational staff for reasons of medical confidentiality, the appropriate sharing of information is encouraged through a range of methods, for example the morning operational meeting is multi-disciplinary and allows all those working with individuals to provide updates and ensure necessary information is shared. The Daily Briefing sheet and wing observation books are also vital tools to ensure all staff are aware of concerns regarding a prisoner.” Source location Response from HM Prison and Probation Service
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.