16 Mar 2026 Jardine Williams · Prevention of Future Deaths report Cumbria
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Concerns raised 1
Failure to return calls from CHOC to NWAS after the third failed contact attempt 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
Jardine Williams · 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
Jardine Williams, a 29-year-old mental health nurse, died on 24 March 2025 after making a 999 call reporting worsening mental health, suicidal thoughts, a plan and an intention to carry it out. The report raised concerns about unclear and confused communication between the North West Ambulance Service and Cumbria Health on Call, including a delay in returning the call after repeated unsuccessful attempts to contact her. The report did not find a causative link between that delay and the outcome, and stated that her intent could not be determined on the balance of probabilities.
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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 return calls from CHOC to NWAS after the third failed contact attempt
Wider context from the report “As outlined above, I heard evidence that Miss Williams had made a 999 call which had been answered by the Northwest Ambulance Service (‘NWAS’) who, in turn passed the information to CHOC.
(1) I found that the flow of information and communication between NWAS and CHOC was unclear and at times appeared to be confused. The information passed to CHOC at the outset, following the 999 call, appeared to be limited and may not have provided the receiving handler with the full picture of the situation. I was concerned that full and accurate information was therefore not passing between NWAS and CHOC.
(2) Thereafter between 18.14 and 18.54 hours, 4 attempts were made by CHOC to call Miss Williams, but no successful contact was made. At 19.48 hours NWAS called CHOC for an update regarding Miss Williams. I heard evidence that as per the agreed procedure, a third and final attempt at contact would be made. By this stage however four unsuccessful attempts had already been made to contact Miss Williams, and the third attempt to contact her had been made at 18.25hours. I considered that the flow of information between CHOC and NWAS appeared to have confused on this issue.
At 20.43 hours a further call was made to CHOC from NWAS for an update on the case, and again it was confirmed that no successful contact had been made with Miss Williams. Therefore, the call was taken back by NWAS approximately 2 hours 18 minutes after the third unsuccessful attempt was made to contact Miss Williams. Thereafter, an ambulance attended Flat 2 Harraby Green Hall at 20.58 hours.
I did not find that there was a causative link between the call not being returned to NWAS after the third unsuccessful attempt to contact Miss Williams, and the eventual outcome. I was concerned that, in terms of the procedure, the call should have been returned by CHOC to NWAS after the third failed attempt to contact Miss Williams at 18.25 hours , but that the call was not returned to NWAS by CHOC until 20.43 hours .
” Source location Jardine Williams · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the incident collaboratively with CHOC’s medical and digital operations leads to identify communication and referral-process learning.
Verbatim wording from the response “Since this inquest, NWAS’ Mental Health Liaison Lead contacted CHOC to review the incident collectively. This review was undertaken with CHOC’s Medical Director and Digital Operations/Programme Manager. CHOC have acknowledged the evidence already provided by NWAS that the incident should not have been transferred to CHOC due to the identified risk of suicide and that the information provided on this occasion ought to have contained more context. It was also acknowledged by CHOC that, as the incident was categorised as a Category 3 response, it should have been returned by CHOC following the third unsuccessful attempt to make contact, which did not occur.” Source location Response from Northwest Ambulance Service
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24 Sep 2025 Steven HART · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 1
Failure to escalate risk after incidents requiring review of observations or ligature controls 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
Steven HART · 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
Steven Hart was remanded to HMP Bedford in November 2022 and, after episodes of self-harm and deterioration in his mental health, was found unresponsive in his cell on 25 March 2023 after using a ligature attached to a faulty observation panel. He was taken to hospital and died on 29 March 2023 from asphyxiation due to hanging. The principal concerns were failures in cell safety, communication and handovers, mental health assessment, and the carrying out and escalation of observations after self-harm incidents.
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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 escalate risk after incidents requiring review of observations or ligature controls
Wider context from the report “1. Failure to Adequately Monitor and Audit Cells for Ligature Points
Mr Hart was placed in a “safer cell” designed to have no ligature points. However, the observation panel ████████ was broken, ████████ which he was able to thread a ligature and hang himself.
Staff and witnesses confirmed that the damage to the cell door was known, and that maintenance was generally responsive, but the cell was not taken out of use despite the increased risk.
The prison’s own post-inquest review acknowledged that the design of the observation panels allowed prisoners to open them from inside, creating an opportunity for self-harm. Interim and permanent solutions were only implemented after the Inquest had commenced nearly two and a half years after Steven's death indicating a likely failure to tackle safety concerns promptly or appropriately.
2. Failure to Effectively Communicate Risk and Incidents
There was a general failure to distribute and communicate relevant observations and concerns regarding Mr Hart’s mental state. Staff often did not have time to receive handovers or read current and previous ACCT (Assessment, Care in Custody and Teamwork) documents during their shift. After a serious self-harm incident with Steven involving ████████ the officer involved failed to report the incident to OSCAR 1 (the officer in charge), as required by protocol. He simply removed the ████████ and did not conduct any further assessment or review of Steven. This failure prevented a multi-disciplinary review and possible escalation of risk management. The night shift handover on 25 March 2023 was insufficient, with lack of vital information provided to the receiving officer, leading to inadequate understanding of Mr Hart’s risk.
3. Failure to Carry Out Appropriate Observations
Observations of Mr Hart were reduced from constant supervision to four irregular checks per hour, despite ongoing risk factors and recent self-harm attempts. CCTV evidence suggested that required observations were not always carried out to the proper standard, and some checks may not have been performed at all. The officer insisted they were carried out, although CCTV evidence strongly suggested that was improbable. The jury found that the failure to call OSCAR 1 after the telephone cord incident directly impacted Mr Hart, as it possibly prevented a further ACCT review and escalation of observations or removal of ligature materials .
The death of Steven Hart was contributed to by systemic failings in cell safety, communication, and observation practices. There were, paradoxically, along-side poor practice and care, examples of exceptionally good practice by a group of officers of which several have left the prison service. There was generally a failure to implement robust systems for cell safety audits, enforce effective communication and handover protocols, and ensure strict compliance with observation requirements for vulnerable prisoners.
” Source location Steven HART · 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 Remind staff and provide additional training and support on escalating incidents and conducting ACCT reviews when risk increases.
Verbatim wording from the response “Staff have been reminded, and received additional training and support where necessary, on the importance of escalating incidents and ensuring that ACCT reviews take place when risk increases.” Source location Response from HM Prison & Probation Service
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16 Jun 2025 Mrs Norma Faye Campbell · Prevention of Future Deaths report East London
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Concerns raised 1
Lack of an electronic observation system for automatically escalating high NEWS scores in A&E View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Barts Health NHS Trust
Implement electronic observations and Early Warning Score visibility across Emergency Department clinical areas using the upgraded patient record and observation machines.
View source
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Mrs Norma Faye Campbell · 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
Mrs Norma Faye Campbell attended Whipps Cross Hospital emergency department on 13 January 2024 with clear signs of sepsis and died there in the early hours of 14 January 2024 after suffering a cardiac arrest. The report identifies delays and omissions in sepsis treatment, monitoring, fluid resuscitation and escalation of care. It also raises concerns about overcrowding, inadequate staffing and facilities, insufficient resuscitation beds, lack of electronic observations and the absence of Critical Care Outreach Team support in the emergency department.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of an electronic observation system for automatically escalating high NEWS scores in A&E
Wider context from the report “4. There is no electronic observation system in place within the A&E department of Whipps Cross Hospital (such as Live Note). Patients presenting with high NEWS scores are not therefore automatically brought to the attention of clinical supervisors .
” Source location Mrs Norma Faye Campbell · 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 Implement electronic observations and Early Warning Score visibility across Emergency Department clinical areas using the upgraded patient record and observation machines.
Verbatim wording from the response “In 2024 the Trust upgraded the electronic patient record in the Emergency Department to the “Launchpoint” system provided by Oracle and purchased in May 2024 an additional 49 observations machines that directly relay clinical observations to the electronic patient record.” Source location Response from Barts Health NHS Foundation Trust
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11 Mar 2025 Mr Allan Taylor · Prevention of Future Deaths report Sunderland
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Concerns raised 1
Failure to escalate non-compliance with Level 2 EICO observation requirements 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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Mr Allan Taylor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Allan Taylor was admitted to Sunderland Royal Hospital after an unwitnessed fall at home and later suffered a further unwitnessed fall in hospital, fracturing his right neck of femur. He died in theatre on 1 June 2024 after becoming hypotensive and suffering cardiac arrest during surgery. The report identified that required Level 2 observations were not provided because the side room was not within sight or sound of the nursing station, and the issue was not escalated; it noted that closer observation might have enabled assistance and possibly prevented the fall.
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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 escalate non-compliance with Level 2 EICO observation requirements
Wider context from the report “1. The evidence confirmed that the guidelines for Level 2 EICO observations, which required a nurse to be within sight or sound of Allan, were not complied with as Allan was in a Side Room 1, which was not within sight or sound of the nursing station. It has been explained that the geography of that ward is such that this is the furthest side room away from the nursing station, and a vestibule is before it.
2. The evidence was that this was not escalated to the Matron or Site Manager , which may have resulted in the movement of an additional member of staff to ensure compliance with the EICO Level 2 observations.
3. The evidence was that had Allan been within sight or sound for observations, it was likely that upon Allan attempting to get out of bed, assistance could have been provided to him, which in turn may have prevented the fall.
” Source location Mr Allan Taylor · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and amend the observation guideline, renaming it Enhanced Therapeutic Observation and Care and strengthening observation, assessment, escalation, family involvement and documentation requirements.
Verbatim wording from the response “Our internal investigation identified omissions in care regarding the level of observation in place for Mr Taylor and the lack of escalation of concerns. Actions were undertaken to address this issue; an urgent review of the existing Enhanced Interactive Care and Observation (EICO) guideline took place which has now been amended and renamed Enhanced Therapeutic Observation and Care (ETOC) for patients in line with recent national changes in guidance as recommended by NHS England. In addition to exploring best practice nationally, the review of the guideline also took into consideration how other local Trusts manage safe observation and care of patients.” Source location Response from South Tyneside and Sunderland NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the amended Enhanced Therapeutic Observation and Care guideline across the organisation.
Verbatim wording from the response “This amended guideline (please see attached draft) has increased the levels of observation from 3 to 4 levels, it includes clarity around the assessment of ETOC against these levels, better family involvement and the importance of escalation and requirement for accurate documentation where there are any concerns regarding patient safety including rationale for any actions taken. This guideline will be implemented across the organisation during May 2025 with a plan to evaluate the impact of this guideline after six months.” Source location Response from South Tyneside and Sunderland 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 Evaluate the impact of the Enhanced Therapeutic Observation and Care guideline six months after implementation.
Verbatim wording from the response “This amended guideline (please see attached draft) has increased the levels of observation from 3 to 4 levels, it includes clarity around the assessment of ETOC against these levels, better family involvement and the importance of escalation and requirement for accurate documentation where there are any concerns regarding patient safety including rationale for any actions taken. This guideline will be implemented across the organisation during May 2025 with a plan to evaluate the impact of this guideline after six months.” Source location Response from South Tyneside and Sunderland NHS Foundation Trust
Open published response
Concerns raised 1
Failure to contact a police supervisor to discuss options when conveyance may affect local officer availability View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Lachlan Charles Campbell · 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
Lachlan Charles Campbell died on 1 November 2022 after being found outside a railway station in a distressed and possibly drug-affected state, where he remained for several hours in heavy rain and cold conditions. The report identifies concerns about delays in ambulance attendance, incomplete information sharing between ambulance and police services, and police officers not providing shelter, warmth, or timely medical attention. The inquest concluded that these failures contributed to his death.
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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 contact a police supervisor to discuss options when conveyance may affect local officer availability
Wider context from the report “2) Information sharing between SWAST and D&CP.
A number of issues were revealed during the course of the evidence.
a) A concern for welfare call was received by police at circa 00:15. Officers attended on scene at circa 01:00 and chased an ambulance at 01:42 only to find one had not been previously called resulting in an initial delay of nearly 1.5 hours.
b) The initial caller had been a bus driver. His mobile details were not taken and so SWAST was unable to call him back for further information they required. When police officers were asked for their numbers, they provided their shoulder numbers, not their mobile numbers. SWAST thus had incomplete information when considering what disposition was appropriate.
c) Police Officers were advised the call had resulted in a Category 2 disposition but were not provided with an ETA. The target time was 18 minutes but an ambulance did not arrive until 06:15, some 4.5 hours later. Had Officers been aware of the likely delays, their evidence was that they would have considered other options (such as conveying Lachlan to hospital in their car.)
d) In reaching a Category 2 disposition, SWAST understood the Officers were remaining with Lachlan. In the event, they left him to deal with an unresolved domestic violence incident. At inquest, evidence was given that, had this been known to SWAST, a Category 1/2 disposition may have been reached.
e) In the event Officers had concluded there was a need to convey Lachlan to hospital, it would have meant there were no available Officers in the Penzance area. While this is a matter for police to reflect upon, it was notable the Officers’ supervisor was not contacted to discuss options .
f) The inquest heard that in other countries (USA) there are arrangements in place for police to drop victims in need of urgent treatment at hospital (eg stabbings) without being detained for extended periods (current handover for ambulance crews in excess of 2 hours.) If ambulance delays are set to continue and police may need increasingly to convey patients to hospital, is there value in considering whether arrangements of this nature would be beneficial?
” Source location Lachlan Charles Campbell · 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 Reiterate to frontline personnel the expectation that officers communicate concerns about redeployment and resource availability to supervising officers.
Verbatim wording from the response “It is Devon & Cornwall Police’s expectation that our officers communicate any concerns of this type to their supervising officer (a sergeant, in the present case) at the time. Sergeants are able to make a decision to redeploy other police resources, including in liaison with an inspector and / or the Force Incident Manager (the officer in the control room who is responsible for overseeing the initial force response to incidents) as appropriate. In extreme circumstances, a more senior officer can be contacted by the control room for assistance and support in respect of redeployment. The Assistant Chief Constable with responsibility for local policing in Devon & Cornwall Police has reiterated this expectation in recent messaging to frontline personnel.” Source location Response from Devon and Cornwall Police
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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 Whether police should convey patients to hospital is a matter for Devon and Cornwall Police to consider.
Verbatim wording from the response “In the event Officers had concluded there was a need to convey Lachlan to hospital, it would have meant there were no available Officers in the Penzance area. While this is a matter for police to reflect upon, it was notable the Officers’ supervisor was not contacted to discuss options.” Source location Response from South Western Ambulance Service NHS Foundation Trust
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23 Dec 2024 David Christopher Peter Lodge · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 1
Failure to appropriately escalate NEWS2 scores above seven for specialist advice 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 NHS Humber Health Partnership
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
NHS Humber Health Partnership
Update and seek approval for the deteriorating-adult policy and NEWS2 escalation ladder, including family and carer concerns and defined response times.
View source
NHS Humber Health Partnership
Deliver Trust-wide simulation training on recognising deterioration, assessing patients and escalating concerns, including learning-disability scenarios.
View source
NHS Humber Health Partnership
Provide designated rapid-assessment capacity, escalation clinicians, safety nurses, sepsis champions and streaming-desk nursing cover for deteriorating patients.
View source
NHS England
Publish and provide the NEWS2 resource pack to support implementation of standardized assessment and escalation for acute illness.
View source See 1 more action
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AI-generated summary
David Christopher Peter Lodge · 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
David Christopher Peter Lodge, who had a learning disability, was found unwell beside his deceased father after lying for up to four days and died at Hull Royal Infirmary on 13 January 2022 from bilateral pneumonia. Concerns included inadequate pain assessment, no chest examination, failure to appropriately escalate high NEWS2 scores or transfer him to intensive care, and missed opportunities to learn from the death through a serious incident investigation.
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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 appropriately escalate NEWS2 scores above seven for specialist advice
Wider context from the report “(3) NEWS2 scores above seven are not appropriately escalated for specialist advice. Clinical recommendations for 30 minute observations were not being followed. An independent expert, a Consultant in Intensive Care, gave evidence to the court that Mr Lodge should have been admitted to the Intensive Care Unit at Hull Royal Infirmary at which Mr Lodge would have undergone closer examinations on a lower patient to nurse ratio.
” Source location David Christopher Peter Lodge · 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 seek approval for the deteriorating-adult policy and NEWS2 escalation ladder, including family and carer concerns and defined response times.
Verbatim wording from the response “39. The Emergency Department follows the CP326: Recognition of the Deteriorating Adult Patient Policy. This is a Trust wide policy and is therefore also used outside of the Emergency Department.” Source location Response from Humber Health
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver Trust-wide simulation training on recognising deterioration, assessing patients and escalating concerns, including learning-disability scenarios.
Verbatim wording from the response “48. In addition to the monthly training outlined above the Nurses Training in Simulation and Sepsis team (NUT-S), have been running training sessions since 2022. The NUTS-S team was created off the back of the incident involving Mr Lodge which prompted the development of learning and the NUTS-S team have used Mr Lodge’s case as a simulated example within the training sessions. The training was developed by the Trust’s Deputy Director, Hull Institute of Learning and Simulation which began as a Pilot training session and was first delivered to the Nurses in the Acute Medicine Department and was later rolled out to include the Nursing Team within the Emergency Department and it is now Trust wide. The training covers different scenarios, however the structure and focus is always the same and includes a patient who shows signs of deterioration.” Source location Response from Humber Health
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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 Provide designated rapid-assessment capacity, escalation clinicians, safety nurses, sepsis champions and streaming-desk nursing cover for deteriorating patients.
Verbatim wording from the response “52. Over the last 18-24 months many changes have been implemented in the Emergency Department for incoming patients who need prompt treatment. The Emergency Department at present have 2 out of 8 bays within the initial assessment area which are earmarked for quick assessment and treatment. These are used, when capacity allows, for patients who are clinically unwell and may have a high NEWS. This allows for closer supervision and quick assessment of these patients.” Source location Response from Humber Health
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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 Publish and provide the NEWS2 resource pack to support implementation of standardized assessment and escalation for acute illness.
Verbatim wording from the response “NEWS is based on a simple aggregate scoring system in which a score is allocated to physiological measurements, already recorded in routine practice, when patients present to, or are being monitored in hospital. An aggregated score of above 7 is considered high clinical risk and should trigger an urgent or emergency response by a clinician or team with competence in the assessment and treatment of acutely ill patients, including recognising when the escalation of care to a critical care team is appropriate. The response team must also include staff with critical care skills, including airway management.” Source location Response from NHS England
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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 Without direct clinical involvement or access to Trust records, NHS England cannot comment directly on David’s care.
Verbatim wording from the response “In response to the specific questions of the Coroner, NHS England was not involved directly in providing clinical care to David and therefore does not have access to the clinical records of the Trust where he was admitted. On account of this, NHS England cannot comment directly on the care he received. I note that your Report was also sent to Hull University Teaching Hospitals NHS Trust, and it appropriate that they respond to the Coroner’s concerns specifically relating to David’s care and treatment. Humber and North Yorkshire Integrated Care Board (ICB), the responsible commissioner for the Trust, is engaging with the Trust on their response and will share” Source location Response from NHS England
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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 Hull University Teaching Hospitals NHS Trust should respond to concerns about David’s care and treatment.
Verbatim wording from the response “In response to the specific questions of the Coroner, NHS England was not involved directly in providing clinical care to David and therefore does not have access to the clinical records of the Trust where he was admitted. On account of this, NHS England cannot comment directly on the care he received. I note that your Report was also sent to Hull University Teaching Hospitals NHS Trust, and it appropriate that they respond to the Coroner’s concerns specifically relating to David’s care and treatment. Humber and North Yorkshire Integrated Care Board (ICB), the responsible commissioner for the Trust, is engaging with the Trust on their response and will share” Source location Response from NHS England
Open published response
Concerns raised 1
Failure to escalate increased abdominal pain to a senior doctor within 2 hours 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
Susan EVANS · 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
Susan Evans underwent elective gastric bypass surgery on 11 July 2023, developed abdominal pain, was discharged without review by the specialist bariatric team or a senior doctor, and was later readmitted with abdominal sepsis from an anastomotic leak. She died at Queen Alexandra Hospital on 12 August 2023. The principal concern was that the hospital’s written and informal policies for specialist review and escalation of pain were not followed, which the inquest found contributed more than minimally to her death.
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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 escalate increased abdominal pain to a senior doctor within 2 hours
Wider context from the report “Queen Alexandra’s written post operative care pathway for patients who have undergone a gastric bypass operation states that:
- There is to be a daily review by a bariatric specialist nurse, consultant or registrar.
- A senior doctor is to review within 2 hours if there is increased abdominal pain in order to rule out anastomotic leak or bleed.
In addition to this, the inquest heard evidence that patients should be seen by a member of the specialist bariatric team prior to discharge. This is not included in the written policy.
Neither the written nor informal policy set out above were followed in Ms Evans’ case. She was not reviewed by a member of the specialist bariatric team at any point on day 2 after surgery and the pain she experienced from the early hours of 13 July 2023 was not escalated to a senior doctor at all.
The inquest heard evidence that medical staff who were not part of the specialist bariatric team were unlikely to appreciate the significance of pain.
The failure to follow policy contributed more than minimally to Ms Evans death and is therefore a matter of concern.
” Source location Susan EVANS · 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 Implement a Bariatric Discharge Protocol in the pathway booklet requiring pre-discharge specialist review, pain-control assessment, discharge criteria and consultant discussion when criteria are unmet.
Verbatim wording from the response “In response to the concerns set out above, there is already a policy in place which covers points 1 and 2. Unfortunately, on this occasion, it was sadly not followed. At least in part, because it was not clearly visible in the patient’s ward notes to act as a prompt. To counter this, the Bariatric lead surgeon has written a Bariatric Discharge Protocol (the new protocol) which has been incorporated into the bariatric pathway booklet which is completed for each patient undergoing bariatric surgery and kept in their medical notes for use by treating clinicians (doctors and nurses). This protocol requires a member of the bariatric team or suitable clinician to review the patient prior to discharge and ensure the patient’s pain is settling and controlled with suitable analgesia prior to discharge.” Source location Response from Portsmouth Hospital NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the Bariatric Discharge Protocol through surgical governance and team meetings and email it to surgical staff with bariatric out-of-hours or emergency responsibility.
Verbatim wording from the response “The new protocol, (which includes safety netting advice, advising patients how to make contact if they become unwell following discharge) has been shared at the Surgical Clinical Governance meeting which is attended by surgical resident doctors and consultants. The protocol was also discussed in the Bariatric Team meeting and is going to be discussed again at the Biannual AGM on 7/3/2025.” Source location Response from Portsmouth Hospital NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Further disseminate the Bariatric Discharge Protocol at the Biannual AGM, nursing surgical study day and surgical ward-level safety huddles.
Verbatim wording from the response “The new protocol, (which includes safety netting advice, advising patients how to make contact if they become unwell following discharge) has been shared at the Surgical Clinical Governance meeting which is attended by surgical resident doctors and consultants. The protocol was also discussed in the Bariatric Team meeting and is going to be discussed again at the Biannual AGM on 7/3/2025.” Source location Response from Portsmouth Hospital NHS Trust
Open published response
27 Sep 2024 Maria Patricia Kelly · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to escalate unsuccessful contact attempts for a welfare check View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
GRAY’S INN MEDICAL GROUP North London 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
North London NHS Foundation Trust
Contact unallocated service users through a welfare-call system and escalate concerns under new guidance.
View source
North London NHS Foundation Trust
Train staff and implement the MaST tool for real-time caseload tracking and prioritisation of high-risk service users.
View source
North London NHS Foundation Trust
Use RAG case tracking, weekly allocation meetings and interim manual audits to prioritise and follow up high-risk cases.
View source
North London NHS Foundation Trust
Provide staff guidance on RCRP protocols, including escalation within the police system when welfare-check requests are declined.
View source
GRAY’S INN MEDICAL GROUP
Clarify whether reported welfare-check arrangements have been completed in future cases.
View source
GRAY’S INN MEDICAL GROUP
Discuss welfare-check clarification arrangements with practice management and the clinical lead.
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AI-generated summary
Maria Patricia Kelly · 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
Maria Patricia Kelly, who lived alone and was in poor health, was found deceased at home by police on 15 May 2024 after concerns were raised by neighbours and a housing officer. The report identifies prolonged lack of contact with primary care and mental health services, numerous failed encounters, and no welfare check until the neighbours’ concerns were raised; the inquest determined natural causes.
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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 escalate unsuccessful contact attempts for a welfare check
Wider context from the report “Ms Kelly’s medical records show that she suffered from a large number of medical conditions including steatosis of the liver, hydronephrosis, left anterior fascicular block, chronic kidney disease, iron deficiency anaemia, gastro-oesophageal reflux, hyperlipidaemia, simple schizophrenia, borderline personality disorder, recurrent depressive disorder and anorexia nervosa (possibly in remission). She had been also diagnosed with Non-Hodgkins Lymphoma in the past.
She was prescribed repeat medications of Atorvastatin and Lansoprazole for her physical health problems, and Flupentixol (as directed by her consultant) and Mirtazapine for her mental health. A prescription appears to have been last issued by her GP on 1 August 2024.
From 23 August 2023 until the practice was notified of her death, her GP summary showed 31 failed encounters for mental health reviews, as well as failed encounters for blood tests and bowel screening.
Her last medical (mental health) review with South Camden Rehabilitation of Recovery Team (SCRRT) was on 7 March 2023. Ms Kelly’s care coordinator went on leave in September 2021. Ms Kelly was placed onto the waiting list for allocation of a new care coordinator on 29 December 2023 after a review of the team’s patient list found that there had been no contact with her since 11 August 2023. It was recorded that were “many attempts” (not quantified) to contact her. After a review on 29 December 2023 there were then 12 unsuccessful home visits and 6 failed telephone attempts.
Despite this, no welfare check was undertaken, nor any request for a welfare made to her housing officer or police, until neighbours raised concerns on 14 May 2024.
” Source location Maria Patricia Kelly · 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 Contact unallocated service users through a welfare-call system and escalate concerns under new guidance.
Verbatim wording from the response “For service users who are still unallocated, we have implemented a welfare call system. These patients are regularly contacted to check in on their well-being. New guidance has also been put in place to ensure effective management of these patients, including clear instructions on when to escalate concerns. This initiative forms part of an ongoing Quality Improvement (QI) project aimed at improving care continuity and safety.” Source location Response from North London NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train staff and implement the MaST tool for real-time caseload tracking and prioritisation of high-risk service users.
Verbatim wording from the response “The MaST tool will play a key role in improving caseload management and prioritisation. Staff training is currently underway, with sessions delivered throughout October to enable the implementation of MaST. A MaST Champion has been appointed to guide the team through the implementation process. Training will be completed by November 2024, after which MaST will enable real-time tracking and prioritisation of high-risk service users. This will ensure close monitoring of service users on the waiting list, and timely follow-up.” Source location Response from North London NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use RAG case tracking, weekly allocation meetings and interim manual audits to prioritise and follow up high-risk cases.
Verbatim wording from the response “We have reinforced our case tracking procedures using the RAG-rating system which identifies levels of risk (Red, Amber, Green). Weekly allocation meetings are held to ensure that high-risk cases are prioritised for follow-up. While we await MaST full implementation,” Source location Response from North London NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide staff guidance on RCRP protocols, including escalation within the police system when welfare-check requests are declined.
Verbatim wording from the response “6. Right Care Right Person (RCRP) Guidance
We have provided guidance to staff on the use of the Right Care Right Person (RCRP) protocols to ensure effective escalation to external agencies (specifically the Police) to support the management of welfare checks and missing persons. This includes escalating within the Police system when requests for support with welfare checks are declined by Police.” Source location Response from North London NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clarify whether reported welfare-check arrangements have been completed in future cases.
Verbatim wording from the response “However, we will of course endeavour to clarify if things have been sorted in future, and if not, possibly call Adult Social Care (we have recently been told by police about other cases that they do not do welfare checks anymore). We have discussed this with practice management here and the clinical lead - myself.” Source location Response from Gray's Inn Medical Group
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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 Discuss welfare-check clarification arrangements with practice management and the clinical lead.
Verbatim wording from the response “However, we will of course endeavour to clarify if things have been sorted in future, and if not, possibly call Adult Social Care (we have recently been told by police about other cases that they do not do welfare checks anymore). We have discussed this with practice management here and the clinical lead - myself.” Source location Response from Gray's Inn Medical Group
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Concerns raised 1
Failure to seek urgent clinical assistance for significant per rectum bleeding View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
East Lancashire Hospitals NHS 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. 4
East Lancashire Hospitals NHS Trust
Remove doctors’ task books and route non-urgent requests through Cerner, with urgent concerns verbally escalated to medical staff or the Acute Care Team.
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East Lancashire Hospitals NHS Trust
Display the ward escalation plan with staged escalation requirements, observation frequencies and staff responsibilities, supported by staff awareness and training.
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East Lancashire Hospitals NHS Trust
Enable nursing staff to accompany doctors on ward rounds and use the daily multidisciplinary meeting to escalate concerns and immediate actions.
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East Lancashire Hospitals NHS Trust
Arrange simulation-based deterioration training for community-ward staff, including assessment, escalation, handover, documentation and gastrointestinal-bleeding scenarios.
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AI-generated summary
Margaret Clement · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Margaret Clement, aged 92, died at Royal Blackburn Hospital on 15 June 2022 after developing significant rectal bleeding, vomiting blood and an upper gastrointestinal bleed following hospital admission after a fall. Concerns included inadequate nursing records and handovers, ineffective prioritisation of urgent tasks, failure to seek urgent clinical assistance for significant rectal bleeding, and inadequate assessment of compliance with procedural changes.
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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 seek urgent clinical assistance for significant per rectum bleeding
Wider context from the report “(5) Nursing staff failed to seek urgent clinical assistance when presented with a significant per rectum bleed
” Source location Margaret Clement · 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 Remove doctors’ task books and route non-urgent requests through Cerner, with urgent concerns verbally escalated to medical staff or the Acute Care Team.
Verbatim wording from the response “Firstly, since 21 June 2024, the doctors’ tasks book on Reedyford has been removed. I can confirm that now all doctors’ tasks (non-urgent) are requested via the Whiteboard on Cerner (the Trust’s Clinical Electronic Record system) during core hours. Urgent actions are communicated verbally and escalated directly to medical staff during core hours and to the Acute Care Team out of hours.” Source location Response from East Lancashire Hospitals
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Display the ward escalation plan with staged escalation requirements, observation frequencies and staff responsibilities, supported by staff awareness and training.
Verbatim wording from the response “Secondly, the SOP091 Pendle Community Hospital Ward Escalation Plan which was referred to at the inquest, includes a nurse escalation process, outlines the Early Warning Score, the frequency of observations and an escalation protocol, and has been printed/laminated and attached to the clinical observation equipment, so it is visibly available on the ward. A hard copy of the SOP is also available on the ward and all staff are aware of the escalation pathway which contains the staged process, outlining what action needs to be taken and by when. I have received assurance from the Ward Manager that all staff are now compliant with the awareness and training of the nurse escalation process on the ward.” Source location Response from East Lancashire Hospitals
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enable nursing staff to accompany doctors on ward rounds and use the daily multidisciplinary meeting to escalate concerns and immediate actions.
Verbatim wording from the response “With regards to the above concern, I am aware that nursing staff on the ward relied heavily on the doctor’s task book to escalate to actions. In addition to the removal of the task books, nursing staff now accompany the doctors on their ward rounds and make use of the daily MDT to escalate concerns and immediate actions where necessary.” Source location Response from East Lancashire Hospitals
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Arrange simulation-based deterioration training for community-ward staff, including assessment, escalation, handover, documentation and gastrointestinal-bleeding scenarios.
Verbatim wording from the response “Firstly, the Trust has arranged simulation training for all staff on the community wards. The staff are presented with a history of the patient and are asked to detail how they would assess that individual; this is repeated a number of times looking at the appropriate and most effective ways to identify any concerns or deteriorations in a patient. The staff are expected to complete full assessments of clinical observations, a physical examination of the patient, discuss handover and who they would escalate to. Detailed documentation is also discussed, including Incident reporting and the importance of accurate timely documentation.” Source location Response from East Lancashire Hospitals
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10 Apr 2024 Paul Dow · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Failure to escalate calls when repeated non-response may indicate loss of consciousness 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
Paul Dow · 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 Dow died on 3 April 2023 after taking an overdose of medication while alone in a hotel room. He had indicated that the overdose might be an attempt to take his own life, but both ambulance calls were coded as category 3, with no clinician involved at the time. There were also concerns that the lack of response to three follow-up calls, potentially indicating loss of consciousness, did not lead to escalation.
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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 escalate calls when repeated non-response may indicate loss of consciousness
Wider context from the report “1. Despite giving a clear indication that he had taken an overdose of a lot of medication with an indication that he did so to take his own life the calls at 18.35 and 19.38 were both coded as category 3.
2. There was no involvement from a clinician at the time of either call.
3. Mr Dow was on his own in the hotel room. When a clinician called on 3 separate occasions there was no response. During her evidence Ms Lee, the Service Delivery Manager of the Emergency Operations Centre accepted that this could indicate that Mr Dow had lost consciousness but the call made at 18.35 was not escalated
” Source location Paul Dow · 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 Route overdose and poisoning calls through Clinical Navigation for timely clinician review, escalation, further triage and welfare action when specialist triage is delayed.
Verbatim wording from the response “Since Mr Dow’s death, there have been various operational changes within the Trusts EOCs with regards to how emergency calls are dealt with.” Source location Response from North West Ambulance Service
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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 When patients do not answer return calls, existing arrangements provide ambulance dispatch and clinician-led judgement on whether categorisation should be upgraded.
Verbatim wording from the response “As set out above, when Mr Dow did not pick up the three calls made by the NWAS Specialist Practitioner, the decision was made by that clinician to dispatch an ambulance to him. This was, in and of itself, an escalation of the call, as it had initially been deemed appropriate for further telephone triage.” Source location Response from North West Ambulance Service
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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 Automatic upgrading of every unanswered patient call is not feasible because it would significantly burden ambulance capacity and response-time targets.
Verbatim wording from the response “It is common for return calls from the ambulance service to patients to go unanswered. In that scenario, it is not possible for this to result in an automatic upgrading of calls. Automatically upgrading the categorisation of all calls to patients that go unanswered would have a significant impact in dispatching the ambulance service is able to provide to patients who have already been triaged at a higher priority (for example category 1 and category 2 calls) and would place a significant burden on the Trust’s wider response times for all patient incidents, such that the achieving of target response times is likely to become unachievable.” Source location Response from North West Ambulance Service
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.