4 Jul 2019 Miriam Tighe · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure of information sharing between GPs and psychiatrists about sedative and antipsychotic medication decisions View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Miriam Tighe · 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
Miriam Tighe became a resident of Edge Hill Residential Home in August 2016 and later received hospital and residential nursing care before passing away on 28 February 2017. The report identified concerns that promazine and other sedative or antipsychotic medication continued to be prescribed and administered despite advice to stop promazine, and that communication between GPs and a psychiatrist was insufficient, leading to unsafe prescribing. The investigation recorded that her death followed naturally occurring disease, with high levels of sedation and immobility in the preceding months worsening her frailty.
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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 information sharing between GPs and psychiatrists about sedative and antipsychotic medication decisions
Wider context from the report “Promazine was sought by the home manager at Edge Hill Residential Home and prescribed by the GPs at Royton & Crompton family practice after ████████ (Psychiatrist working in the Memory Clinic (part of Pennine Care NHS Foundation Trust)) had advised that such medication be stopped on the 16th November 2016 and, again on the 16th December 2016. On both occasions, promazine continued to be prescribed by the GP and continued to be administered under the control of the manager at Edge Hill Residential Home. In the event, I found that Miriam Tighe had been over-sedated during her time as a resident at Edge Hill Residential Home. The psychiatrist had recommended alternative sedative and antipsychotic medication, which was also administered to Miriam Tighe. It was clear that the GPs and the Psychiatrist were not aware of decisions being made by each other in October to December 2016 , which led to unsafe prescribing of sedatives and antipsychotic medication .
” Source location Miriam Tighe · Prevention of Future Deaths report
Open source report
24 Jun 2019 Lewis James Doyle · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 1
Failure to send discharge letters to all current medical attendants View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS England
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AI-generated summary
Lewis James Doyle · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lewis James Doyle, who had multiple medical conditions including coronary artery disease and recurrent depressive illness, died on 8 January 2019 after developing worsening respiratory illness and pulmonary oedema following traumatic injuries sustained when he fell in front of a train. The principal concern was that discharge letters, including information about suspended or stopped medication, should be sent to all current medical attendants across primary, secondary and tertiary care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to send discharge letters to all current medical attendants
Wider context from the report “When Mr Doyle was discharged from the Liverpool Heart and Chest Hospital the GP discharge letter was sent to his GP. Mr GP Doyle was receiving treatment for Acute Coronary Syndrome but also mental health care for a Recurrent Depressive Illness (without Psychosis). Lithium had to be stopped not only because it was at a toxic level but also because of the effect of this and alternate medications on cardiac health. It occurred during the inquest that in similar scenarios better patient care could be delivered, if discharge letters were sent to all current medical attendants, whether in primary, secondary or tertiary care. Information with regarded to suspended or stopped medication was needed by the original prescribers.
” Source location Lewis James Doyle · 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 Individual trusts remain responsible for discharge summaries and transferring medication information after discharge.
Verbatim wording from the response “Whilst discharge summaries remain the responsibility of individual trusts, the NHS standard contract expects the transfer of information within 24 hours of discharge usually from provider to GP. The discharge information should contain a full and accurate summary record of medications (both prescribed and non-prescribed) including any that were discontinued and any reasons for this – in line with recommendations from the Academy of Medical Royal Colleges (AoMRC) and the Professional Record Standards Body (PRSB).¹” Source location 2019-0214-Response-from-NHS-England-and-NHS-Improvement
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing legal and professional duties provide a sufficient framework for information sharing, so further data-sharing requirements are unnecessary.
Verbatim wording from the response “I am advised that these legal and professional duties provide a clear framework for the effective sharing of information to support the care and treatment of patients, enabling medical professionals to make decisions on a case by case basis about the information that should be shared.” Source location 2019-0214-Response-by-Department-of-Health-and-Social-care
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19 Jun 2019 Mason Logue · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure of health and social care services to provide integrated care and share health information View source
This report raised 6 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
Mason Logue · 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
Mason Logue, who had been born prematurely and had a complex medical history, was found unresponsive in his mother’s bed at home on 28 October 2017. The post-mortem examination did not identify a clear cause of death, and the medical cause was recorded as unascertained. Concerns included limited integration and information sharing between services, the absence of an overarching supportive care plan and a single professional coordinating his care, and difficulties arising from differing protocols and the lack of a single IT system across NHS trusts.
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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 Failure of health and social care services to provide integrated care and share health information
Wider context from the report “The inquest heard that Mason was discharged directly from the tertiary centre into the community after a prolonged period of care in NICU. His mother had previously been known to Family Services. There was limited evidence available of an integrated approach to care from the Local Authority, Tertiary Centre, Local Hospital and Community Health Professionals. As a result, information about his health was not shared between all health professionals . There was no overarching supportive care plan in place on discharge.
” Source location Mason Logue · Prevention of Future Deaths report
Open source report
17 Jun 2019 Oliver Hall · Prevention of Future Deaths report Suffolk
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Concerns raised 1
Failure to transfer the NHS 111 Service’s original disposition information to ambulance crews and treating clinicians 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
Oliver Hall · 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
Oliver Hall, a six-year-old boy, became acutely unwell on 23 October 2017 and died in the early hours of 24 October 2017 after developing meningococcal septicaemia. The report identified concerns about NHS 111 disposition information not being transferred to ambulance and treating clinicians, delays in ambulance availability information, and conflicting guidance about the significance of his heart rate.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to transfer the NHS 111 Service’s original disposition information to ambulance crews and treating clinicians
Wider context from the report “1. It is apparent that there is a failure in the process of the transfer information regarding a patient's original disposition by the NHS 111 Service to the ambulance service and the treating clinicians on the ground .
In Oliver’s case a non-clinician NHS Pathway Advisor using the NHS Pathway algorithms identified a ‘severe illness and a rash suggestive of septicaemia’ following a 5-minute phone call with his mother. As identified at inquest meningococcal septicaemia was Oliver’s actual cause of death and the NHS 111 Service identified this as a possible risk at 13.00, some 5 hours 45 minutes before it was diagnosed by a medical clinician.
In response to their algorithms the NHS 111 Service implemented a disposition of ‘emergency ambulance response for septicaemia’ and an automatic referral was made to the 999 service. This disposition and a ‘severe illness and a rash suggestive of septicaemia’ were included in the information transferred to the East of England Ambulance Service.
However, it was then identified that the current East of England Ambulance Service system does not provide the ambulance crew (and therefore in this case subsequently the GP’s) with that information .
The message made available to the crew simply read ‘headache/abdo-pain/fever- no access issues, patient not alone 38.8’.
Both the ambulance crew and GP’s stated in their evidence that had they known the original disposition from the NHS 111 Service had been suggestive of septicaemia it would have informed their decision-making processes and may have changed their clinical management of Oliver.
” Source location Oliver Hall · 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 Consult other ambulance trusts to share best practices and solutions for recording and transmitting patient disposition information.
Verbatim wording from the response “The Trust is currently in consultation with our colleagues in other UK Ambulance Trusts who use the same Computer Aided Dispatch system, some of which also use the same triage system (Pathways) as UK 111 providers.” Source location 2019-0198-Response-by-East-of-England-Ambulance-Service-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Draft and issue dispatch instructions specifying pertinent information, including NHS 111 disposition descriptions, for transmission to attending resources.
Verbatim wording from the response “Whilst this work is ongoing the Trust is drafting an instruction, which will be issued to all Dispatch staff, outlining the pertinent information that needs to be passed to attending resources. This will include for 111 calls the disposition description as determined by Pathways.” Source location 2019-0198-Response-by-East-of-England-Ambulance-Service-NHS-Trust
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 organisation is not constituted to mandate or instruct individual ambulance services on local information-sharing processes.
Verbatim wording from the response “To clarify, AACE is a private company owned by the English Ambulance NHS Trusts. It exists to provide ambulance services with a central organisation that supports, coordinates and implements nationally agreed policy. Our primary focus is the ongoing development of the English ambulance services and the improvement of patient care. We are a company owned by NHS organisations and possess the intellectual property rights of the JRCALC UK ambulance service clinical practice guidelines. AACE is not constituted to mandate or instruct ambulance service wherever we do have national influence via the regular meetings of ambulance Chief Executives and Trust Chairs along with a network of national specialist sub-groups.” Source location 2019-0198-response-by-Association-of-Ambulance-Chief-Executives
Open published response
10 Jun 2019 Beverley Shaw · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Failure to respond to and action clinical information requests from the substance misuse service View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Hopwood House Medical Practice NHS Greater Manchester Integrated Care Board Turning Point
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
NHS Greater Manchester Integrated Care Board
Promote wider uptake of Focussed Care across Oldham practices to support substance-use-related care.
View source
Turning Point
Complete a wide-ranging review of GP communication across all community substance misuse services.
View source
Turning Point
Improve recording of GP communications in the electronic client records system.
View source
Turning Point
Review and improve follow-up systems for requests to GPs for information.
View source See 1 more action
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AI-generated summary
Beverley Shaw · 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
Beverley Shaw was found deceased in her bed at home in Oldham in the early hours of 11 December 2018. The inquest heard that she had multiple prescribed medicines, was receiving methadone, and was using cocaine and butane gas. Concerns included inadequate communication between the substance misuse service and GP practice about her butane gas use, lack of a full medication review, and incomplete transfer of 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 respond to and action clinical information requests from the substance misuse service
Wider context from the report “○ There is no record of a response from the GP practice to Turning Point following their letter dated the 15th May 2018. This had a number of requests for actions by the GP including the sharing of any blood results (LFT, FC and U&E), together with information confirming whether there was any blood disorders of drugs which may interact with methadone. There was no evidence that this information was shared or actioned.
” Source location Beverley Shaw · 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 Promote wider uptake of Focussed Care across Oldham practices to support substance-use-related care.
Verbatim wording from the response “The events surrounding Ms Shaw’s death highlight the requirement for effective and up to date ‘Did Not Attend’ policies to be followed in Primary Care and to initiate discussion in practice meetings to ensure holistic information is shared and reviewed by the team in a manner which supports clinicians to make decisions based on the full facts and influencing factors. Such discussions can trigger communication back to secondary providers such as Turning Point to clarify and/or share information. The presence of Focussed Care within a number of Oldham practices has been seen to support such instances where substance use influences existing co-morbidities and as a CCG we are promoting wider uptake of this across the Oldham footprint.” Source location 2019-0191-Response-by-Oldham-NHS-CCG
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a wide-ranging review of GP communication across all community substance misuse services.
Verbatim wording from the response “Whilst we recognise that the clinician had written to the GP, we accept that there is more that we could do to improve this communication, not only in this tragic case but also more broadly across our substance misuse services. Therefore, we have undertaken a wide ranging review of GP communication across all our community substance misuse services, not just in Rochdale and Oldham. That review has been led by our Senior Management Team, including our senior clinical team, and our Risk and Assurance department.” Source location 2019-0191-Response-by-Turning-Point
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve recording of GP communications in the electronic client records system.
Verbatim wording from the response “This review has highlighted the key processes that we needed to change in order to improve effective communication and reduce the risk of future recurrence. Those processes are the template used by prescribers to review clients, the frequency of communication with GPs, the way that communication is recorded on our electronic client records system and the processes for audit of the frequency of that communication.” Source location 2019-0191-Response-by-Turning-Point
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and improve follow-up systems for requests to GPs for information.
Verbatim wording from the response “We also reviewed our systems for following up requests to GPs for information and the way in which we transfer client data at the beginning and at the end of contracts.” Source location 2019-0191-Response-by-Turning-Point
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 A joint learning meeting with Turning Point would occur only if Oldham CCG supported it.
Verbatim wording from the response “The practice would also, if supported through Oldham CCG have a meeting with Turning Point separately as a learning event to see what further changes we can both make to make sure miscommunications are avoided in the future” Source location 2019-0191-Response-by-Hopwood-House-Medical-Practice
Open published response
29 Jan 2019 Sophie Holman · Prevention of Future Deaths report London (East)
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Concerns raised 1
Failure to communicate changed asthma medication to primary care View source
This report raised 23 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Sophie Holman · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sophie Holman, a 10-year-old girl with chronic asthma, died on 13 December 2017 after collapsing during a severe asthma attack while being taken to hospital. The report identifies concerns about inadequate long-term management, fragmented records, failure to recognise the cumulative severity and risks of her asthma, lack of a coordinated asthma action plan and safety-netting, and missed opportunities for specialist referral.
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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 Failure to communicate changed asthma medication to primary care
Wider context from the report “In the secondary care there was:
a) Failure to recognise and act upon the underlying chronic condition punctuated by a number of severe attacks with life threatening features one of which was a near-fatal attack where Sophie was ‘blue and unresponsive’ with an oxygen saturation of 86% (2.7.2012)
b) Failure to recognise the need for and initiate referral of this child to a specialist respiratory service as recommended in the NRAD recommendations
c) Failure to take appropriate action when it was known that the family had a home nebuliser
d) Failure to implement the recommendations in the NICE Quality Statement 25, and BTS/SIGN guideline to ensure a pre-discharge review of the child’s asthma by an appropriately trained individual
e) Failure to effectively communicate changed medication in 2013 of the child to the general practitioner
f) Implementation of a hospital policy whereby this child was discharged from secondary care three times because of failure of the parents to bring the child to planned outpatient appointments
g) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-evidence based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication
” Source location Sophie Holman · Prevention of Future Deaths report
Open source report
18 Dec 2018 Natalie Zara HUNTER · Prevention of Future Deaths report Isle of Wight
View report summary
Concerns raised 1
Failure to provide timely Discharge Summaries to GPs View source
This report raised 1 other concern. 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. 6
Isle of Wight NHS Trust
Establish a Medical Director-led workstream to improve the quality and timeliness of discharge summaries.
View source
Isle of Wight NHS Trust
Conduct an in-depth review of discharge summaries and communications to GPs following relevant mental health contacts.
View source
Isle of Wight NHS Trust
Map communication processes with staff groups and develop a standard operating procedure or flowchart.
View source
Isle of Wight NHS Trust
Audit discharge-summary quality, including admission reasons, care received, and medication reviews or changes.
View source
Isle of Wight NHS Trust
Use formal teaching sessions with junior doctors to embed learning from the discharge-summary audit.
View source
Isle of Wight NHS Trust
Present discharge-summary audit outcomes at Trust quality forums to share learning.
View source See 3 more actions
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AI-generated summary
Natalie Zara HUNTER · 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
Natalie Zara HUNTER, who had a history of mental health and alcohol-related problems and 18 previous serious suicide attempts, was found deceased in her apartment on 16 March 2018 after suspending herself by a ligature. The report raised concerns about delayed or missing discharge summaries from the Isle of Wight NHS Trust, affecting continuity of GP and mental health care, and about insufficient out-of-hours mental health and crisis staffing on the Isle of Wight.
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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 timely Discharge Summaries to GPs
Wider context from the report “1. Natalie HUNTER’s GP, ████████ gave live evidence about Miss HUNTER’s 18 previous serious attempts to take her life. During the course of his evidence he referred to the lack of Discharge Summaries from the Isle of Wight NHS Trust . He said it is not uncommon for a Discharge Summary not to be sent to a GP’s practice by the IOW NHS Trust, or if it is sent, for it to be sent very late after the patient has been discharged from the Trust .
2. ████████ raised concerns about this as the Discharge Summary should contain details of why the patient was admitted; what care they received during their time at the IOW NHS Trust; what medication they were prescribed, and whether such medication was intended to be continued; and whether there were going to require ongoing care/treatment as a result of this admission/treatment.
3. If no Discharge Summary is received , it has a big impact on the care that GPs are able to offer to their patients and the continuity of care which is needed, particularly in relation to mental health input.
4. On several occasions, ████████ had been unaware of the nature of the admissions (which were almost all linked to her serious suicidal attempts) – and significantly the ongoing risk of further attempts on Miss HUNTER’s life as he had either not received a Discharge Summary or had received it too late for it to have any meaningful input into Miss HUNTER’s care .
” Source location Natalie Zara HUNTER · 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 Establish a Medical Director-led workstream to improve the quality and timeliness of discharge summaries.
Verbatim wording from the response “The Trust fully accepts that there have been issues with discharge summaries across the organisation, and confirms that a work stream lead by the Medical Director is in place to improve the quality and timeliness of the discharge summary.” Source location 2018-0392-Isle-of-Wight-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct an in-depth review of discharge summaries and communications to GPs following relevant mental health contacts.
Verbatim wording from the response “The action plan sets out the expectation that Mental Health Services will conduct an in depth review of the current situation and include the quality of other communication that is sent to GPs to inform them of patients contact with the services.” Source location 2018-0392-Isle-of-Wight-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Map communication processes with staff groups and develop a standard operating procedure or flowchart.
Verbatim wording from the response “• The backdrop – process mapping with all staff groups and from this a Standard Operating Procedure (SOP)/flowchart will be developed.” Source location 2018-0392-Isle-of-Wight-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit discharge-summary quality, including admission reasons, care received, and medication reviews or changes.
Verbatim wording from the response “• An audit into quality of discharge summaries to ensure they contain the reason for admission, care and treatment received during the episode of care and detail of any medication review or changes.” Source location 2018-0392-Isle-of-Wight-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use formal teaching sessions with junior doctors to embed learning from the discharge-summary audit.
Verbatim wording from the response “• The audit will be led by a Consultant Psychiatrist and will engage Junior Doctors at formal teaching sessions to ensure that learning outcomes are embedded.” Source location 2018-0392-Isle-of-Wight-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Present discharge-summary audit outcomes at Trust quality forums to share learning.
Verbatim wording from the response “• The outcome of the audit will be presented at quality forums across the Trust to share the learning from this evidence” Source location 2018-0392-Isle-of-Wight-NHS-Trust
Open published response
22 Nov 2018 Matthew Gerard Craven · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure to share admission and encounter information with wider mental health services 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
Matthew Gerard Craven · 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 Gerard Craven was found dead at home on 19 April 2018 after consuming pregabalin in excess of his prescribed amount; toxicology showed a fatal dose of pregabalin. Concerns included repeated rejected referrals for psychiatric assessment, the absence of a challenge or escalation process, no agreed timescales for routine appointments, limited documentation of referral decisions, and inadequate sharing and review of mental health information.
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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 admission and encounter information with wider mental health services
Wider context from the report “On one admission to the acute hospital following an overdose, he was seen by an alcohol worker from the Mental Health Trust. There was no evidence that that worker had checked to see or understand any previous engagements with Mental Health Services. Information about that admission and encounter was not shared with wider mental health services even though they were part of the same trust.
” Source location Matthew Gerard Craven · 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 Move alcohol liaison practitioners to Stepping Hill Hospital and integrate them into the all-age liaison mental health team.
Verbatim wording from the response “Pennine Care’s alcohol liaison practitioners are moving to be based at Stepping Hill Hospital with the all age liaison mental health service and will form part of the same team which will significantly reduce the likelihood of any such concern arising again. The new model will be in place by the end of February 2019.” Source location 2018-0365-Response-by-Pennine-Care-NHS-Trust
Open published response
18 Oct 2018 Joseph James GRANTHAM · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure to provide timely and accurately directed discharge information identifying the responsible paediatrician View source
This report raised 6 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
Joseph James GRANTHAM · 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
Joseph James Grantham was born with a neural tube defect and later developed laryngomalacia. He became unresponsive at church on 9 July 2017, and resuscitation efforts were unsuccessful; the post-mortem found no cause of death and the death was attributed to natural causes. Concerns included delays and gaps in sharing clinical information, unclear responsibility for his care, unavailable records, and insufficient communication about monitoring requirements between healthcare services.
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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 Failure to provide timely and accurately directed discharge information identifying the responsible paediatrician
Wider context from the report “1. After his birth Joseph was transferred to the neonatal unit at St Mary's due to the complexities of his health. Following his discharge, it took 6 weeks for the trust to send the discharge paperwork to the GP and the District General Hospital (DGH) to whom they were transferring his paediatric care. As a result, there was no clear understanding amongst health professionals as to the paediatrician with responsibility for his care . Letters were therefore copied into a mixture of paediatricians. The discharge letter to the DGH was addressed to a consultant who was in fact a registrar at the trust.
” Source location Joseph James GRANTHAM · Prevention of Future Deaths report
Open source report
18 Sep 2018 Paul Price · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Delays in transferring critical mental health information between mental health services and GPs View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Birmingham and Solihull Mental Health NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Birmingham and Solihull Mental Health NHS Foundation Trust
Establish Trustwide timescales and targets for completing GP letters.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust
Invest in electronic recording, listening devices, and hybrid mail to support timely GP correspondence.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust
Participate in developing and implementing Docman electronic mail links with local GP surgeries.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust
Implement electronic GP correspondence through the Trust-wide Hybrid Mail rollout and Docman, supported by GP-practice IT infrastructure.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust
Implement monthly monitoring to ensure GP letters are issued within the nationally required two-week timescale.
View source See 2 more actions
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AI-generated summary
Paul Price · 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
Paul Price had a history of depression and anxiety, and was found outside his room on 04/06/18 after falling from a window; he was pronounced deceased at hospital, with the medical cause of death recorded as multiple injuries. Concerns included delays in communicating mental-health assessment information to his GP, incompatible IT systems, and a failure to return a call about concerns for his wellbeing.
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 Delays in transferring critical mental health information between mental health services and GPs
Wider context from the report “1. Paul was seen for a full assessment on 04/05/18. The summary of that attendance in a letter was not received by the GP until 29/05/18 . In the meantime Paul had attended his GP with ongoing concerns about his mental health and requesting further medication. The delay in receiving critical information about vulnerable patients could put them a risk and result in over prescribing medication . In addition I was told that the IT systems for Birmingham and Solihull Mental Health Trust and the GPs are incompatible meaning that letters have to be faxed or posted causing further delay .
” Source location Paul Price · 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 Establish Trustwide timescales and targets for completing GP letters.
Verbatim wording from the response “1. In relation to the delay in Paul’s GP receiving critical information this has highlighted a potential systemic issue that is not localised to one service. We have established Trustwide timescales and targets for the completion of GP letters but have found, on investigation, that across the Trust different Consultants and teams have different local arrangements and that with staff leave and absence, there are variations in capacity to complete these within defined timescales. The Trust has invested heavily in electronic recording and listening devices and the use of hybrid mail and along with a management focus on dealing with team and capacity variations should give us confidence that we have addressed these issues. I would ask if I may, that I write to you in three months to update you on the outcome and progress made to address the concern.” Source location Paul-Price-Response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest in electronic recording, listening devices, and hybrid mail to support timely GP correspondence.
Verbatim wording from the response “1. In relation to the delay in Paul’s GP receiving critical information this has highlighted a potential systemic issue that is not localised to one service. We have established Trustwide timescales and targets for the completion of GP letters but have found, on investigation, that across the Trust different Consultants and teams have different local arrangements and that with staff leave and absence, there are variations in capacity to complete these within defined timescales. The Trust has invested heavily in electronic recording and listening devices and the use of hybrid mail and along with a management focus on dealing with team and capacity variations should give us confidence that we have addressed these issues. I would ask if I may, that I write to you in three months to update you on the outcome and progress made to address the concern.” Source location Paul-Price-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate in developing and implementing Docman electronic mail links with local GP surgeries.
Verbatim wording from the response “We are also in the process of developing an electronic mail system linking to GP surgeries via Hybrid Mail. This system is called Docman and currently there is a project working group being led by Birmingham Women and Children’s NHS Foundation Trust which we have joined. This group is working to implement Docman across all GP surgeries locally and then to develop it as a national system.” Source location Paul-Price-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement electronic GP correspondence through the Trust-wide Hybrid Mail rollout and Docman, supported by GP-practice IT infrastructure.
Verbatim wording from the response “I am pleased to be able to advise you that since issuing this Prevention of Future Deaths report, we have implemented significant improvements in relation to both the quality and timeliness of communication with GPs. This includes the full roll out of a hybrid mail system across the Trust. On 5 March 2019, we enabled a new feature within Hybrid Mail called Docman. This feature dramatically reduces the time it takes for GPs to receive letters from the Trust. Instead of letters being posted, they are sent electronically and we have worked in partnership with our Local Clinical Commissioning Group to ensure that GP practices have the necessary IT infrastructure to receive such communication. Letters sent to GPs via Docman will normally arrive at their destination on the same working day and are released from Hybrid mail every 15 minutes.” Source location Paul-Price-Response2
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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 Implement monthly monitoring to ensure GP letters are issued within the nationally required two-week timescale.
Verbatim wording from the response “In addition to this we have implemented a monthly monitoring process to ensure that letters are provided within the nationally required 2 week timescale.” Source location Paul-Price-Response2
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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 Trustwide timescales, electronic recording, hybrid mail and management oversight are considered sufficient to address delays in completing GP letters.
Verbatim wording from the response “1. In relation to the delay in Paul’s GP receiving critical information this has highlighted a potential systemic issue that is not localised to one service. We have established Trustwide timescales and targets for the completion of GP letters but have found, on investigation, that across the Trust different Consultants and teams have different local arrangements and that with staff leave and absence, there are variations in capacity to complete these within defined timescales. The Trust has invested heavily in electronic recording and listening devices and the use of hybrid mail and along with a management focus on dealing with team and capacity variations should give us confidence that we have addressed these issues. I would ask if I may, that I write to you in three months to update you on the outcome and progress made to address the concern.” Source location Paul-Price-Response
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 Rapid information sharing across NHS providers requires a national solution beyond the Trust’s local systems and arrangements.
Verbatim wording from the response “2. With respect to the incompatibility of BSMHFT and GP systems, this is a local issue that is reflected nationally and we have previously written to you about this more general topic. We are, and continue to be of the view that there does need to be a national solution to rapid information sharing between NHS care providers. We have previously written to NHS England (NHSE) about this need, however there is no solution at present, which means that risk remains in our systems. We have worked collaboratively with our local MERIT mental health partners (Birmingham Childrens, D&W, BCP and CWP) to find a local solution to this; we do now have a single system in place that allows us to access each other’s information electronically.” Source location Paul-Price-Response
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.