30 Oct 2017 Michael Edward Giles · Prevention of Future Deaths report Worcestershire
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Concerns raised 1
Absence of senior review of patients over weekends 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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Michael Edward Giles · Prevention of Future Deaths report
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Report summary
Michael Edward Giles became unwell, was admitted to hospital, underwent a diagnostic surgical procedure, then deteriorated and died. The report identified concerns about inconsistent shift handovers, lack of senior review at weekends, inadequate clinical and nursing leadership during a crisis, and inadequate case notes and 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 Absence of senior review of patients over weekends
Wider context from the report “(2) The absence of a senior review of patients over the weekend was a factor in the suboptimal care given to this patient.
” Source location Michael Edward Giles · Prevention of Future Deaths report
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How this respondent action was interpreted
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PFD Monitor interpretation Reorganize consultant working practices to increase the proportion of patients receiving review at least every 24 hours.
Verbatim wording from the response “There is already an expectation that all patients need to be reviewed 7 days per week. For those patients with high dependency needs the expectation is that they are seen and reviewed by a consultant twice daily (including acutely ill patients directly transferred and other who deteriorate). An audit of our practice from March 2017 shows that we were able to meet this requirement 93% of occasions. The overall proportion of patients who required a daily consultant review and were reviewed by a consultant was 68%. In order to improve this further working practice by consultants has been reorganised to facilitate a higher proportion of patients being seen at least once every 24 hours.
In order to keep the risks to a minimum for patients undergoing invasive procedures we are already reviewing where these can be done, i.e.” Source location 2017-0309-Response
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5 Jul 2017 Patricia Norfolk · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Lack of daily senior clinician reviews for patients View source
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Patricia Norfolk · Prevention of Future Deaths report
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Report summary
Patricia Norfolk was admitted to Royal Oldham Hospital after discovery of a fractured neck of femur, following earlier unwitnessed falls and an attendance at the hospital where no X-ray investigation was undertaken. She developed an infection following surgery, deteriorated despite medical intervention, and died from bronchopneumonia after discharge to Braeside Care Home. The principal concern was that patients were not receiving a daily senior clinician review, including during the interim period before recruitment and appointment of appropriate staff.
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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 daily senior clinician reviews for patients
Wider context from the report “That patients, such as the deceased, were not being receiving a daily senior clinician review. I have been appraised of the developments that the Trust is aspiring to in relation to senior daily reviews and decision making and recognise the steps the Trust is taking to recruit appropriate staff to undertake such reviews. However, I remain concerned regarding what happens to patients in the interim period pending recruitment and appointment.
” Source location Patricia Norfolk · Prevention of Future Deaths report
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How this respondent action was interpreted
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PFD Monitor interpretation Prepare a medical staffing paper to improve seven-day standards for daily senior clinical review.
Verbatim wording from the response “Whilst not considered as contributory to Patricia Norfolk’s death, the necessity for daily senior clinical review did form part of the recommended actions to be taken by the Trust following its Root Cause Analysis (RCA). As outlined in the directive of Professor Makin (dated 15 March 2017), a paper on medical staffing in general and acute medicine within the Trust was prepared with a view to improving seven day standards for daily senior clinical review. This directive was provided to you under cover of a letter dated 15 March 2017.” Source location 2017-0438
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How this respondent action was interpreted
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PFD Monitor interpretation Recruit four substantive consultant posts to increase capacity for seven-day clinical review.
Verbatim wording from the response “Ultimately improved medical staffing will achieve seven day clinical review albeit the numbers required currently will be lessened with improvement in patient flow. Recruitment into posts is on-going and a Diabetologist, a Chest Consultant and a Geriatrician will start this year, with further interviews planned. £10 million of funding for new consultant posts has been agreed by our Salford Group colleagues.” Source location 2017-0438
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How this respondent action was interpreted
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PFD Monitor interpretation Implement improved medical staffing to support seven-day clinical review.
Verbatim wording from the response “Having considered the content of the letter and its enclosures, including the directive of Professor Makin, you subsequently highlighted that no corresponding timescale was attached to the stated aspiration of the Trust to deliver daily senior clinical decision making and sought further information. This information was provided within an email dated 26 May which provided you with a timescale for the implementation of improved daily senior clinical decision making, namely following the completion of the recruitment process of two new substantive consultant posts, estimated at that time to be September 2017. The precursor to these posts was Trust Board agreement to the paper prepared by Professor Makin and provision of funding for the two new substantive posts.” Source location 2017-0438
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a full learning cycle on the deteriorating-patient change package.
Verbatim wording from the response “The deteriorating patient collaborative will ensure that seven day clinical review will be available to those patients medically requiring of it. Mirroring the approach adopted by our Salford Group colleagues during their successful improvement collaborative in 2008, a full cycle of learning as regard to the methodology of the change package will be completed in November 2017 following which a cohort of Innovation Wards will be selected to represent a range of divisions and specialities across the organisation. These Innovation Wards will become the early adopters of the change package and will inform as to its spread and sustainability which will in turn inform the Trust-wide roll out of the successful interventions.” Source location 2017-0438
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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 Select Innovation Wards to adopt the deteriorating-patient change package.
Verbatim wording from the response “The deteriorating patient collaborative will ensure that seven day clinical review will be available to those patients medically requiring of it. Mirroring the approach adopted by our Salford Group colleagues during their successful improvement collaborative in 2008, a full cycle of learning as regard to the methodology of the change package will be completed in November 2017 following which a cohort of Innovation Wards will be selected to represent a range of divisions and specialities across the organisation. These Innovation Wards will become the early adopters of the change package and will inform as to its spread and sustainability which will in turn inform the Trust-wide roll out of the successful interventions.” Source location 2017-0438
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How this respondent position was interpreted
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PFD Monitor interpretation The Trust could not realistically provide daily senior clinical review to all patients because medical staffing constraints were outside its control.
Verbatim wording from the response “The Trust acknowledges that the action as per the RCA report for ‘all patients to receive a daily senior clinician review’ was, with hindsight, more aspirational than realistically achievable due to circumstances outside its control, as detailed above. This has been fed back to those responsible for the action plan, for reflection when considering future actions.” Source location 2017-0438
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How this respondent position was interpreted
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PFD Monitor interpretation The Trust considered the actions within its power to improve daily senior clinical review already taken and communicated, requiring no additional response work.
Verbatim wording from the response “The use of your PFD Report has not had any meaningful practical effect on the improvement of public safety given the actions within the Trust’s power to take have already been taken and communicated to you in advance of you issuing your PFD Report. Furthermore, the PFD Report’s practical effect is questionable given the date for the Trust’s response loosely coincides with the date originally envisaged for the implementation of improved medical staffing.” Source location 2017-0438
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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 Further action on daily senior clinical review without recruitment should be addressed to the Secretary of State for Health as a national issue.
Verbatim wording from the response “Whilst the Trust has taken steps to address this within its locality, as previously indicated, this is a national issue and consequently any steps to address your concern as to daily senior clinical review in the absence of recruitment such as that undertaken by the Trust would more appropriately addressed to The Rt Hon Jeremy Hunt MP, Secretary of State for Health.” Source location 2017-0438
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3 Jul 2017 Sheila Mary Hynes · Prevention of Future Deaths report Newcastle upon Tyne
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Concerns raised 1
Failure to involve and record discussions with the primary surgeon before remounting the valve View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Sheila Mary Hynes · 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
Sheila Mary Hynes died after an aortic and mitral valve replacement procedure in which a mechanical aortic valve was remounted in an inverted position and re-implanted. The resulting acute heart damage led to her death. Concerns included remounting the valve contrary to the manufacturer’s instructions, inadequate awareness of the associated risks, and directing a scrub nurse without relevant training or experience to remount it.
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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 involve and record discussions with the primary surgeon before remounting the valve
Wider context from the report “(1) During Mrs Hynes operation a direction was given to remount the Sorin Carbomedics 23mm mechanical aortic valve on its holder whilst preparations to implant the valve were undertaken. Remounting the valve on its holder is contrary to the manufacturer’s instructions for use.
Concerns arising are:
a) The rational for departing from the manufacturer's instructions for use was neither discussed nor recorded.
b) The primary surgeon and operating team were unaware of the risks of departing from the manufacturer's instructions for use namely potential inverted remount.
c) A scrub nurse with neither training nor experience was instructed to remount the valve contrary to the manufacturer's instructions for use. The rational for this direction was neither discussed nor recorded.
d) The primary surgeon with overall responsibility for the procedure did not instruct remounting of the valve; There are no recorded discussions with the primary surgeon on this issue.
” Source location Sheila Mary Hynes · Prevention of Future Deaths report
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25 Apr 2017 Linsay Bushell · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 1
Lack of senior clinical challenge and guidance in ward management View source
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Linsay Bushell · 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
Linsay Bushell, aged 37, died on 13 October 2014 after being found having self-ligatured under her bed while detained in a psychiatric ward; the medical cause was asphyxia due to compression of the neck due to ligature strangulation. The report identified concerns including inadequate access to psychological therapies, limited understanding and documentation of self-harm, poor handover and observation records, fragmented care, delays in finding suitable placement, and insufficient staff training and support.
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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 senior clinical challenge and guidance in ward management
Wider context from the report “The Court heard evidence that 40% to 50% of mentally disordered female patients suffered from EUPD rather than mental illness and yet there was no provision or priority for therapeutic psychological services to be commissioned in the NHS England Area.
The Jury found:
Para 3
1. Linsay Bushell was certified as having died on the evening of 13th October, 2014. at the Royal Liverpool University Hospital.
2. Linsay Bushell came by the fatal event that caused her death at 20.20 at room 2 on the Brunswick Ward at the Broad Oak Unit on 13th October 2014.
3. The medical cause of Linsay's death was Asphyxia due to Compression of the Neck due to Ligature Strangulation.
4. Linsay put herself in the position in which she was found however her intention was unclear.
5. At the time of her death and for most of her adult life, Linsay had suffered from a form of mental disorder namely an unstable borderline personality disorder.
6. The real and imminent risk of self-harm or suicide was recognised during Linsay's care at the Broad Oak Unit in the time leading up to her death.
7. The risk was managed adequately and effectively during Linsay's period as an in-patient.
8. The jury accept the admissions of Mersey Care NHS Foundation Trust and adopt the findings that the Trust has made.
a. In the Trust Position Statement
Mersey Care considers the death of any service user with the utmost seriousness and care. As an organisation it is committed to providing a high standard of care to service users generally. If, in connection with any patient under its care, mistakes have been made whether in the form of individual errors or as a result of system or structural defects, then the Mersey Care Trust Board is committed to uncovering those errors, correcting them and learning lessons from them.
2. Following the death of Linsay Bushell on 13th October 2014, Mersey Care instigated an investigation into her death, including the wider circumstances of her death, to find out whether there were shortcomings in the care provided to Linsay and, if so, devise ways of improving practice. That investigation was an internal review and root cause analysis by a multi-disciplinary panel which included an external medical reviewer. Its Terms of Reference were agreed by the Trust Board and were deliberately wide so as to pick up deficits in care or indeed examples of good practice throughout Linsay's involvement with the Trust and so enable as deep a learning exercise as possible in what was acknowledged to be a complex clinical picture. The review panel considered relevant documents and interviewed members of staff and the investigator's report was provided to Mersey Care Trust Board in December 2015.
3. Following the internal investigation, the Trust Board instructed ████████ the Chief Operating Officer of the Local Services Division to consider the report of the internal investigation and undertake her own review and appraisal of the circumstances of the death. She was also instructed to devise a workable and practical strategy to address the issues which were raised by the internal review and her own consideration of the material.
4. The Trust is committed to transparency and accountability. The purpose of this Position Statement is to advise the Court and Linsay's family of the Trust's response to the work which has been undertaken internally by the Trust and of the approach which will be taken to the forthcoming inquest into Linsay's death. It is hoped that, by doing so, the Court's case management task in respect of the forthcoming inquest will be facilitated; also importantly that Linsay's family will be reassured by their understanding that an approach which is consistent with the conclusions of the internal review of the death is to be adopted at the inquest.
5. The conclusions of the internal review include some examples of good or notable practice and many areas where the service or care provided to Linsay fell short of the desired standards. Following concerns raised by a member of staff, the Review Team considered the contents, including the conclusions, of the internal review undertaken. Having done so, the Review Team adheres to the conclusions which were expressed in the report. The Trust Board fully acknowledges that mistakes had been made in Linsay's care when she was a resident on Broad Oak Unit and that these mistakes afforded Linsay the opportunity to ligature on 13th October 2014. The Trust accepts responsibility for Linsay's death. Whilst understanding that no apology will fully assuage the feelings of Linsay's family and those who were close to her, the Trust nonetheless offers that apology. It is made with sincerity.
6. The review panel considered that Linsay's psychiatric condition was complex. Her condition fluctuated in response to stressors such as bereavement and illicit drug use. However, a main theme to emerge from the internal review panel report was the failure of the Trust to provide Linsay with a service that was psychologically driven at all levels of care. The Trust accepts this criticism.
It is accepted that psychology interventions were not available on a consistent basis throughout Linsay's residence on the Unit and that ward staff were inadequately supported in their provision of such care and treatment.
a. Whilst an attempt to understand the motivation for self-harming behaviour is apparent from the Acute Care Plans (which were not available to the panel) the Trust accepts that this was inadequate. The Trust also accepts that the record keeping and standard of documentation was inadequate so that a more detailed picture of Linsay's self-harming behaviour and its triggers was not available. As a result, staff were hampered in considering the best ways of limiting and controlling Linsay's self-harming behaviour.
b. Whilst understanding that patients suffering from Personality Disorders may present a complex management problem, a focused and co-ordinated approach to finding the most appropriate establishment to meet Linsay's needs was not adopted. It was recognised that Brunswick Ward did not meet Linsay's short or long-term needs. Although efforts were made by the Care Co-ordinator to locate the most appropriate placement for Linsay, funding was not immediately available. This had the effect of causing Linsay distress and disappointment. The Trust accepts this criticism.
c. Staff were not sufficiently trained and supported in their understanding of Emotionally Unstable Personality Disorders and the high suicide rate associated with this condition particularly during long term hospital stays. Again, the Trust accepts this criticism.
7. Further themes to emerge from the internal review included: the lack of implementing a co-ordinated approach to checking patients after handover; that handover documentation was scant; that documentation of observation levels was insufficiently clear; that there were limited interventions regarding substance misuse and its effect on Linsay's self-harming behaviour and that ward management needed greater support. All of these observations and criticisms are accepted by the Trust.
8. ████████ has been tasked with reviewing Linsay's care during her residence on Brunswick Ward and reviewing the conclusions of the internal report. She is involved in the wider Trust initiatives which include reducing the risk of suicide by patients and enhancing the understanding and treatment of those patients who suffer from Personality Disorders. She has set out the steps which have been taken in her statement. The key points are as follows:
a. Given the wide understanding that those suffering from Personality Disorders are best managed in the community, a Personality Disorder Hub has been established in the community. This is now led by ████████ a Consultant Psychiatrist in Psychotherapy, and is intended to co-ordinate and manage the care of patients with Personality Disorders within the community. The objective is that, where possible, admissions to hospital are kept short, or avoided altogether. This involves close and collaborative working by all of those involved in the patient's care. This is facilitated by the PD Hub.
b. Case managers have been recruited and assigned to service users who attend the emergency services regularly (as a consequence of self-harming behaviour). These case managers work closely with the PD Hub and focus care on the individual. The care given is psychologically based. It is targeted at helping the patient to devise strategies to limit self-harming behaviour.
c. Borderline Personality Disorder Guidelines have been devised which stipulate that meetings of professionals should take place in complex cases and a specific Extended Care Plan should anticipate and considers care both in the community and in inpatient units. The objective is to provide a coherent and co-ordinated plan of care which is tailored to the particular needs and challenges posed by the particular patient.
d. Nursing staff have received training in Personality Disorders. Complex Case discussions take place on all wards. This is intended to enable multi-disciplinary team discussion between professionals in particularly challenging cases.
e. A daily Bed Management system has been introduced which, amongst other objectives, is intended to ensure that patients with Personality Disorders are discharged back into the community with minimum delay and with an appropriate support package.
9. Although ████████ describes in her statement the various responses which have been made by the Trust to improve the management of patients with Personality Disorders, the individual elements are intended to work as only part of an integrated model. The strength of the structure lies in its overarching objective of transforming the approach generally to meeting the needs of those with Personality Disorders, recognised as presenting a particular set of challenges to any healthcare organisation.
10. ████████ also addressed in her statement the further steps which have been taken to support staff in complying with Trust policies, including the Care Programme Approach, observation levels, suicide prevention and training, record keeping and shift handover documentation. Regular audits for compliance and ongoing support is undertaken. There has been a review of leadership roles within the Unit generally including Brunswick Ward and support and guidance for those occupying a leadership role is regularly provided.
11. As ████████ has stated, although much has changed since Linsay's death, there is no room for complacency. She and others within the Trust will continue their work and undertake a regular evaluation of service levels.
12. It is hoped that Linsay's family are encouraged in their understanding that the Trust have taken Linsay's death very seriously indeed. Lessons have been learned. Her death has been a catalyst for change for the better.
b. In the implementation of Lessons learnt the Trust further accepts
1. The review team identified this as "a very complex case" and noted that "it is unclear whether or not LB harmed herself with a view to achieving death or in an effort to gain help from staff which had happened on many occasions before during her in-patient stay".
a. The review team reached a number of critical conclusions relating to the care which Linsay received during the course of her involvement with the Trust. The principal conclusions were as follows:-
b. Limited understanding and analysis of self-harming behaviour. The review team noted that Linsay was described as undertaking self-harming behaviour on many occasions and that her 'ligaturing' was used in the notes in a generic sense with no specific details given on many occasions. The review team concluded that despite repeated attempts at self-harm with the same behaviour, insufficient effort was made to look at this particular risk. They also concluded that the notes did not pick up exploration of the reasons behind many self-harm attempts. Instead, they thought it was generally assumed that Linsay's self-harming behaviour was as a result of either drugs or some form of stress or 'loss' and that a more detailed exploration of her episodes of self-harm might have proved useful in terms of developing preventative strategies. Linsay did not have a "safety plan" as this was not Trust policy at the time. However, she did have a Care Plan.
c. Failure to implement a co-ordinated approach towards checking the safety of patients following handover. Staff told the reviewers there was no co-ordinated approach to allocating tasks on the night in question. On that night there was no formal "walk around" undertaken by a qualified member of staff as required by policy. The review team concluded that it was essential that generic safety systems such as the handover check are implemented very robustly as they are the alternative to individual observations being used which in this case were thought to have a negative effect on Linsay.
d. Poor quality of handover information. The handover notes were frequently scant in content. There was no standard template as to what should be included in handover. The review team was unclear how the nursing handover was quality controlled. On just one occasion it was mentioned in handover that Linsay had ligatured during the day but despite the frequency of this behaviour the handover notes did not capture this at all.
e. Confusion about observation levels. There were occasions when it was unclear what level of observation Linsay was on. On the day of the incident staff told the reviewers they were informed that Linsay had been on leave with a member of staff and that it had gone very well, that she was settled and had just had a take-away meal. There was no discussion as regards any risk that Linsay may have been at, taking into account previous behaviour after leave. Recording of changes in observation levels were frequently unclear.
f. No process to monitor the completion of CPA documentation. The review team could not identify the processes that were in place to ensure that all patients had an up to date risk management plan and care plan hence they found that the plans in place for Linsay were not current although Linsay did in fact have a current care plan.
g. Limited content and poor quality of documentation. Documentation of observation levels was not as clear as it should have been and given her very high risk it was important to document any observation changes and the reasoning behind this. This might help build up a picture of the best way of mitigating any potential risk from any form of self-harm, particularly with that associated with ligaturing. It would also help staff adopt a more 'psychological' approach to care rather than using physical intervention like high observation levels or PRN medication if 'agitated', the latter of which was similar in a way to her 'substance misuse. The review team noted that staff did spend a lot of time talking to Linsay but the notes did not capture any questioning as to why she had tried to self-harm at a particular time.
h. Limited interventions regarding substance misuse as an inpatient. Linsay's highest risk of suicide seemed to be in the aftermath of substance misuse. Whilst this was commented on, specialist measures to try and mitigate it were not put in place. The addiction case worker did not attend multi-disciplinary team meetings whilst on the ward, though they did see Linsay whilst she was an inpatient in Childwall Brook Nursing Home. The reviewers noted that the care appeared to be fragmented in that different parts of the services did not plan or deliver the care that was needed together.
i. Poor coordination of referral to a specialist provider. The team pursued a variety of specialist placements in an attempt to meet Linsay's care needs going forwards. One of them, Cambrian Care, undertook an assessment and accepted Linsay as they felt that they had the ability to provide her with the appropriate care required. When the funding was requested it was rejected by the Clinical Commissioning Group (CCG). It was at this time that the funding of Out of Area Placements was being changed with the Trust being given the delegated responsibility for allocating resources on behalf of the CCG. Consequently Linsay's future needs were re-assessed and internal placements were considered in the Trust's own services. The review was completed a short time before Linsay's death, and recommended that an Out of Area specialist placement should be supported. The review team felt that the whole process of having Linsay assessed externally and then the process being stopped would have raised her expectations inappropriately. The significant delay in undertaking a review process was felt by the review team to have kept Linsay in an area that was recognised as not being able to meet all her short and long term needs.
j. Ward Management. Brunswick ward was a very busy admission ward. The Ward Manager did not have a background in leading such a ward nor did the Modern Matron who came from a community background. This meant that senior challenge and specific clinical guidance for staff was not available . During interviews it was suggested that there had been some friction between nurse management on the ward that may have contributed to a background of poor team working. The review team advised that it was important staff were led by experienced managers who understand both the management processes and the clinical area they are responsible for.
k. Transfer of Patients from one organisation to another. The review team identified and amongst staff that patients could not be transferred from one organisation to another until they were "stable". This was impracticable for cases like Linsay's as she was rarely, if ever, stable. She lived in an area inaccessible to her treating psychiatry service when she lived in Kensington whilst remaining under 5 Boroughs Partnership NHS Foundation Trust's care. The review team concluded that regular engagement with local Mersey Care services might have avoided Linsay's final admission.
l. Lack of implementing a clear care pathway. Linsay had a diagnosis of Emotional Unstable Personality Disorder which is associated with a high suicide rate long-term. This is particularly increased during extended in-patient stays. Staff stated during interview that they had not had training related to self-harming behaviour or in the care of people with an Emotionally Unstable Personality Disorder. The reviewers could not identify a clear pathway that was being followed to care for Linsay which took into account her complex needs. Whilst staff appeared to have worked hard at building a relationship up with Linsay the review team concluded that it was generally at a superficial level. The review team noted that the Trust had a Borderline Personality Disorder strategy and guidance but could not find that it was implemented or understood by staff. The review team recognised the national view is that admissions for people with a Borderline Personality Disorder are often counterproductive to improving the mental state of a patient and at worst contribute to difficulties and worsening of the condition. How and when clinicians feel able to take managed and considered “positive” risks is important. How these issues are factored into an extended care plan and the support that clinicians can receive on these cases needs to be clear and thought through by the Trust. The review team are aware that this work was on going within the organisation.
m. Lack of specialist psychological work/guidance to staff. The review team found that specialist interventions were not available on a consistent basis. The review team found that there was inconsistent availability of psychology on the ward environment during the last period of Linsay's admission. The review team were told that Linsay was not amenable to psychological interventions and had tried different modalities in the past. It was a concern that whilst Linsay may not have wanted or been able to avail herself of therapy the overall strategy of care should have been directed and guided from a more psycho-therapeutic perspective.
2. The review team could not identify one specific root cause but felt that the contributory factors interacted together to create a situation whereby Linsay remained distressed on the ward, with limited up take of psychological therapy to help reduce the distress seemingly enhanced by her recent losses. The staff clearly tried hard to work with her but with limited knowledge. There was a sense of fragmented care in that specialist services such as those offered by the addiction team were not engaged in the ward discussions despite Linsay engaging with them during her short stay at Childwall Brook Nursing Home. The period to identify a suitable placement for Linsay seemed overly protracted and seemed to focus thoughts on an external answer to the escalating situation.
Discontinuity of Care/Management of Care
3. The Trust has done a lot of work looking at how to develop the service it offers to service users with a diagnosis of personality disorder. It has developed Guidelines for the management of these individuals and established a Personality Disorder Hub (PD Hub) headed by ████████ a Consultant Psychologist, in November 2014. These Guidelines are produced at pages 311 - 355 of the Inquest Bundle B.
4. The Trust's Borderline Personality Disorder Guidelines advise that in complex cases there should be a meeting of professionals followed by the development of a specific Extended Care Plan (ECP). The ECP starts with a formulation/summary of the history and care provided, and then describes the type of care that should be provided in different settings including inpatient units.
5. Evidence suggests that prolonged or repeated hospital admissions are not helpful for service users with a diagnosis of personality disorder. The PD Hub aims to keep admissions to hospital as short as possible and to avoid them altogether where appropriate. The Trust has recruited individual psychologists and nurses trained and qualified in managing patients with a personality disorder diagnosis to work as case managers for this group of service users. They are responsible for managing the care of the most complex service users regardless of where the service user goes and thus are able to provide continuity of care and work with other care teams to provide consistency of approach.
6. The team initially identified 40 service users who attended A&E on a regular basis and allocated these to the 4 case managers then in post so that each case manager was responsible for 10 service users. Given the success of this work more case managers have been recruited so that the most complex service users who have increased need now have a specialist case manager.
7. The case managers are focussed care for the individual. The approach to care is psychologically based and will include the case manager working with the service user to look at their risk taking and what triggers it. They will then work with the service user to develop strategies to enable the service user to cope with these triggers. Triggers may include memories of past abuse.
8. The Trust is working towards extending the recently introduced day service available for people with personality disorder as part of our evidenced based PD pathway.
9. The aim is to help the service user to manage their condition differently and thus avoid hospital admission if possible.
Risk Assessment/Care Planning
10. Linsay's mental state, level of distress, reported symptomology and self-harming or suicidal behaviour fluctuated quite markedly during her admission. I accept that there was an unstructured approach to reviewing and planning interventions with Linsay which meant there was no collaboratively developed understanding of her risk.
11. Staff are expected to reassess the risks following each ligature incident and episode of self-harm and document the fact that an assessment had taken place and the conclusions reached. Such reviews ought to have included a detailed exploration of Linsay's mental state, her thoughts and feelings and the level of observation she required.
” Source location Linsay Bushell · Prevention of Future Deaths report
Open source report
16 Mar 2017 James Charles MALLETT · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Delays and failures in escalating serious patient deterioration to senior medical staff View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
James Charles MALLETT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Charles Mallett, aged 93, was admitted to hospital after a fall at home and later sustained a fatal head injury in a further inpatient fall. Concerns included delayed medical attendance, unclear and untimely neurological observations, inadequate contemporaneous records, insufficient falls prevention, and nursing staff training and experience that were considered inadequate.
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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 and failures in escalating serious patient deterioration to senior medical staff
Wider context from the report “(2) There was no apparent urgency to secure the prompt attendance of a doctor to assess the patient . The nursing staff, who were described by Sr Snowden as a "junior workforce" did not seem to understand the seriousness of the injury and did not seek senior help from the night team . The nursing staff did not carry out regular and/or timely neurological observations.
” Source location James Charles MALLETT · Prevention of Future Deaths report
Open source report
28 Oct 2016 Leslie Isaac LERNER · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 1
Failure of senior clinicians to examine patients and specify required treatment View source
This report raised 17 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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
Leslie Isaac LERNER · 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
Leslie Isaac Lerner died on 3 June 2016 after treatment for a fractured shoulder, including application of an incorrect sling that caused a deep pressure sore and additional pain. The report identified concerns about inadequate senior review, analgesia, communication, handover, continuity of care, recognition of pneumonia and deterioration, and delay in initiating end-of-life care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of senior clinicians to examine patients and specify required treatment
Wider context from the report “13th May 2016
(1) Junior Doctor applied wrong sling with wrong knot for Mr Lerner after she had learned that he had had a fractured shoulder which was to be treated conservatively.
I heard that a Nurse should have applied the sling because the chances are that he or she would have known which sling to use and how to apply it.
(2) Although the Junior Doctor discussed Mr Lerner with her Senior, the Senior did not actually see him nor specifically state which type of sling (should have been a collar and cuff) should be applied .
I was told that the Senior should always see the Patient .
” Source location Leslie Isaac LERNER · Prevention of Future Deaths report
Open source report
11 Oct 2016 Barry THOMPSON · Prevention of Future Deaths report Blackpool and the Fylde
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Concerns raised 1
Failure to act on elevated National Early Warning Scores View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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
Barry THOMPSON · 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
Barry Thompson, an insulin-dependent diabetic, died on 27 February 2016 while a patient on the Acute Medical Unit, after being admitted with sepsis from diabetic foot ulcers and hyperglycaemia. The report identified concerns about failure to provide insulin, fluids, adequate monitoring, antibiotics and medical review, as well as inaccurate and incomplete records and ineffective information sharing during transfer between departments.
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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 act on elevated National Early Warning Scores
Wider context from the report “(1) Non-compliance with National and Local protocols:
Mr Thompson was triaged as a high priority on admission to the Emergency department at 12.37 am on 26th February 2016. It is recorded that he not had his morning insulin. He was not seen by a doctor nor given antibiotics within an hour according to the National Standard and the (Hospital’s) Sepsis Pathway. He was seen by a doctor at 16.52 (although his case was drawn to the attention of a doctor earlier by a nurse and instructions given for care). Further a NEWS score of 7 (National Early Warning Score) was not actioned according to policy which would have resulted in Mr Thompson being reviewed by at least middle grade doctor immediately .
” Source location Barry THOMPSON · Prevention of Future Deaths report
Open source report
16 May 2016 Jonathan Lewis Fry · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Lack of senior Consultant review View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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
Jonathan Lewis Fry · 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
Jonathan Lewis Fry was admitted after an unwitnessed fall and was diagnosed with an L1 compression fracture. He later became increasingly unwell and was found unresponsive on 20 April 2015; the post-mortem cause of death was recorded as pulmonary embolism due to deep venous thrombosis. The principal concerns were the absence of senior Consultant review, inadequate follow-up of tests and results, and inconsistent or incomplete medical records.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of senior Consultant review
Wider context from the report “1) There was no Senior review by a Consultant from admission to the time of his death and was no locum cover
” Source location Jonathan Lewis Fry · Prevention of Future Deaths report
Open source report
17 Feb 2016 Matthew Crowley · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Delays in senior doctor review of PAR 5 patients View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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
Matthew Crowley · 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 Crowley, aged 39, presented to Maidstone Hospital acutely unwell with sepsis and multiple organ failure, and died at Pembury Hospital at 06.47 on 10 June 2015 after transfer. The report identified concerns including delays in triage, senior medical review, treatment escalation, decision-making and transfer, as well as inadequate communication with the receiving ITU.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in senior doctor review of PAR 5 patients
Wider context from the report “(2) The patient was not seen by a doctor for 2 hours 20 minutes despite being PAR 5 and requiring therefore an immediate review by a senior doctor
” Source location Matthew Crowley · Prevention of Future Deaths report
Open source report
21 Oct 2015 Samantha Beach · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 1
Failure to escalate clinical care to more senior colleagues in the obstetric department View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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
Samantha Beach · 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
Samantha Beach developed severe chest pain and intermittent tachycardia shortly after giving birth to her third child, but her symptoms were not appropriately investigated or escalated. She later suffered cardiac arrests and died after surgery for bleeding from a ruptured splenic artery aneurysm. Concerns included inadequate escalation of care, poor sharing of information between community and hospital services, and failure to involve the obstetric department when she attended the Emergency Department.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to escalate clinical care to more senior colleagues in the obstetric department
Wider context from the report “(1) The clinical care provided to Sam in the obstetric department was not escalated appropriately to more senior colleagues ,
” Source location Samantha Beach · Prevention of Future Deaths report
Open source report
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Includes failures of senior clinical oversight of patient care, including absent or delayed senior input at presentation, early or daily senior review, review of patients referred for advice, and ongoing senior clinical direction or challenge where senior involvement is required for safe care.
