Epilepsy, 19 Sep 2013 – 19 Jun 2026
Epilepsy-related Prevention of Future Deaths reports
All dates19 Sep 2013 – 7 Sep 2026
Select SUDEP or Non-SUDEP to filter concerns and reports. 3 reports could not be assigned and remain in All only. Counts are PFD reports, not deaths.
About this dataset
We searched all 6,433 reports in the published corpus using a fixed text-search method, then assessed 317 candidates against source-based inclusion criteria. Ninety reports were included. Epilepsy had to be materially relevant to the death or a substantive coroner’s concern; incidental mentions were excluded.
Eligibility and SUDEP assignment were assessed with GPT-5.6 Sol and checked for valid source quotations. Assignment uses a balance-of-probabilities threshold: SUDEP or non-SUDEP must be more likely than not on the report’s evidence. The exact term SUDEP need not appear. Genuinely unclear eligible reports remain in All only. These are model-assisted documentary assessments, not independently validated clinical diagnoses.
The search can miss reports with sparse terminology or incomplete source text. This dataset does not represent all epilepsy deaths. Recurring concerns and responses are taken from the existing published evidence. Published corpus snapshot: 7 September 2026. Cohort selection updated 5 November 2026. The title shows the first and last included reports’ publication dates.
Reports over time
Matching reports published each year within the selected date range.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Matching reports sent to each recipient.
Most commonly raised concerns
All classifications 90 reports 19 Sep 2013 – 7 Sep 2026
- Unreliable seizure care and managementControls dedicated to recognising, assessing, monitoring, responding to and managing seizures are not reliably provided.9 reportsSelected
- Incomplete, inaccurate or unavailable clinical and care recordsClinical and care records are incomplete, inaccurate, inconsistent, unavailable or otherwise unreliable for safe care.7 reportsSelected
- Unsafe medication administrationA recurring failure of the medication-administration system to ensure that medicines are administered safely, accurately, promptly and as prescribed.6 reportsSelected
- Failure to ensure clinical investigation results are reliably available, interpreted and acted uponRecurring deficiency in the end-to-end management of clinical investigation results, including their availability, transmission, checking, review, interpretation, follow-up and escalation when needed.4 reportsSelected
- Inadequate driver licensing controls for road safetyDriver licensing systems do not reliably identify, record, review or restrict drivers whose inexperience, health or vehicle-related risk requires additional safeguards.4 reportsSelected
- Inadequate staff competence to provide first aidReports identify an unsafe first-aid capability condition across healthcare, care, custody and other staff. The recurring concern is the unreliability of staff competence to recognise emergencies and provide appropriate first aid, rather than any single training, refresher, assessment or practical-performance failure.4 reportsSelected
- Unreliable hospital discharge processesHospital discharge does not reliably bring together planning, clinical readiness, relevant organisations, safe execution and required follow-up.4 reportsSelected
- Failure to communicate clinically important information reliably between care servicesRecurring concern that clinically important guidance, decisions and patient information are not kept accurate, current and available to the clinicians and emergency services who need them.3 reportsSelected
- Failure to provide required medication promptly when clinically neededThe anchor identifies delayed prescribing of a patient's usual medication after an unexpected admission, while another report identifies delayed prescribing and non-provision of urgent therapeutic medication. These support a recurring concern about timely provision of clinically required medication rather than only the anchor's admission or prescribing-step failure.3 reportsSelected
- Failure to provide timely clinical follow-up after medication prescribingPrescribed medication is not reliably followed up for effectiveness, safety, collection, adherence and patient response.3 reportsSelected
- Failure to seek medical attention when a person's condition warrants itReports identify an unreliable escalation control in which care staff or other responders do not promptly seek medical or paramedic assistance when a person's injury, pain, fall or deterioration warrants clinical attention.3 reportsSelected
- Insufficient police training for safe recognition and response to mental-health and behaviour-related medical crisesReports identify insufficient police training to recognise and respond safely to mental-health crises and behaviour-related medical emergencies.3 reportsSelected
- Insufficient qualified healthcare staffing capacityHealthcare services lack enough appropriately qualified staff to provide the required clinical coverage and patient care safely for the workload, acuity and specialist needs.3 reportsSelected
- Unreliable DVLA medical fitness notification arrangementsThe anchor identifies limited professional awareness and uncertain effectiveness of guidance for notifying the DVLA about medically relevant driving risks. A different report identifies clinicians failing to advise patients with cough syncope to stop driving and notify the DVLA, while another identifies failure to notify the DVLA of relevant medical conditions. These support the named DVLA medical-fitness notification process rather than guidance awareness alone.3 reportsSelected
- Unreliable communication of patient-care information between clinical staffClinical staff responsible for the same patient's care do not reliably exchange relevant information about care, treatment and risk.3 reportsSelected
- Unreliable healthcare patient transfer processesHealthcare transfers do not reliably provide the procedures, responsibility, documentation and clinical information needed for safe movement and continuity of care.3 reportsSelected
- Unreliable mental health referral pathwaysReports identify different failures within the mental health referral process, including referrals not being made when indicated, received referrals not being actioned, and frontline practitioners lacking clarity about when and where to refer. These support a recurring concern with the reliability of mental health referral pathways rather than any single referral or awareness failure.3 reportsSelected
- Unreliable patient observation arrangementsPatient observation systems do not reliably set, support and deliver the observation level required by assessed safety risk.3 reportsSelected
- Unsafe interoperability between prison custody and healthcare proceduresReports identify failures in the bounded interface between prison custody, contracted custody providers and healthcare services, where procedures, responsibilities and safety-relevant information do not operate together reliably.3 reportsSelected
- Electronic patient records failing to make relevant clinical information available and actionableRecurring concern that electronic patient-record systems do not reliably present, preserve, share or prompt action on clinically relevant information across the patient’s care.2 reportsSelected
- Failure to communicate safety-critical care information effectively between care providers and familiesReports identify unsafe communication between care providers and families, including failures to convey risks, care instructions, concerns or other information needed to support safe care and decision-making.2 reportsSelected
- Failure to conduct required welfare checks on people in distressThe anchor identifies a risk that care home staff will not check a resident in distress, while a different canonical report identifies failure to conduct a later welfare check on a person left in potential medical distress. Together these support a recurring concern about welfare checks not being completed when a person may require assistance.2 reportsSelected
- Failure to ensure safe prisoner transfersRecurring concern that the end-to-end prisoner transfer process is unreliable, leaving transferred prisoners exposed to unmanaged risks or interruptions in essential support.2 reportsSelected
- Failure to identify and address recurring safety issues through organisational learningDifferent reports identify failures of reporting, review and learning arrangements to retain, recognise and address substantive or recurring patient-safety issues, rather than merely failures to complete one specific corrective action.2 reportsSelected
- Failure to reliably document the rationale for consequential decisionsDifferent reports identify missing or inadequate records explaining the rationale and evidential basis for consequential decisions, including the anchor’s crucial decisions and comparable mental-capacity, NRPF and transfer decisions. The shared concern is unreliable rationale documentation for decisions that affect safety, accountability and continuity of care, rather than any one decision type or record system.2 reportsSelected
- Failure to reliably learn from medication incidents and implement safeguardsThe medication incident learning process is unreliable: incidents are not consistently followed up or reviewed to identify, communicate and implement safeguards that protect patients from recurrence.2 reportsSelected
- Failure to reliably recognise and respond to acute clinical deteriorationClinical deterioration is not reliably recognised, monitored, escalated and acted upon with the urgency it requires.2 reportsSelected
- Failure to reliably refer patients to required specialist servicesThe anchor identifies a required physiotherapy referral that was not completed. A different report identifies delayed referrals to physiotherapy, occupational therapy, dietetics and Parkinson’s specialist services. Together these support an end-to-end concern with required specialist referrals not being made promptly and reliably, rather than a concern limited to one physiotherapy referral.2 reportsSelected
- Failure to secure and control medicationReports identify medication as remaining accessible, unsecured or inadequately controlled, creating risks of misuse, overdose, theft or access by people other than the intended patient.2 reportsSelected
- Inadequate control of illicit substance use and supply in secure institutionsThe anchor identifies an ongoing failure to mitigate illicit substance entry, distribution and use in a secure hospital, while assertions from different reports identify continuing illicit-drug influx, widespread access and weak supply-reduction controls in prisons. These distinct manifestations support a bounded concern about controlling illicit substances in secure institutional settings, rather than only room searches, drug testing or a prison-specific strategy.2 reportsSelected
- Inadequate controls on contraband mobile phones in prisonsDifferent reports identify failures in the prison control system for preventing and mitigating access to contraband mobile phones, including their easy availability to prisoners and their use to facilitate drug dealing and other prison-security risks.2 reportsSelected
- Inadequate recording of medication prescribing decisionsReports identify unreliable medication prescribing records that can obscure prescribing status, rationale, changes or safety-critical decisions and thereby allow unsafe medication to be prescribed or administered.2 reportsSelected
- Incomplete clinical history-takingReports identify an unsafe clinical assessment condition in which relevant patient history is not obtained sufficiently to support recognition of symptoms, risks and appropriate care.2 reportsSelected
- Unreliable Care Programme Approach care coordinationReports identify different failures within the named Care Programme Approach, including the absence of a structured medication review and failures to allocate coordinators, complete required reviews, maintain care plans and follow up patients. Together these support a recurring concern with the reliable operation of CPA care coordination rather than medication review alone.2 reportsSelected
- Unreliable RIO clinical-record functionsThe anchor identifies an unclear timeliness standard for RIO entries, while different reports identify failures of RIO to support complete information capture, cross-team access and usable observation records. Together these support a recurring concern with the reliability of the named RIO clinical-record system rather than only one entry-timing or documentation manifestation.2 reportsSelected
- Unreliable access to emergency communicationReports identify failures in dedicated emergency communication arrangements that can delay summoning or contacting emergency help.2 reportsSelected
- Unreliable communication of critical medication information to GPsRecurring deficiency in the medication-information exchange process between services and GPs, including information needed to maintain supplies, assess prescribing safety and support continuity of treatment.2 reportsSelected
- Unreliable escalation by care staff for required medical attentionCare staff do not reliably recognise and escalate deterioration, pain or other safety concerns to obtain timely medical assessment or advice.2 reportsSelected
- Unreliable implementation of medication changesReports identify different failures in the medication-change process, including failure to act on a prescribed reduction, failure to ensure carers acknowledge changes, and difficulty implementing specialist-directed changes accurately. Together these support the wider unsafe condition that medication changes are not reliably implemented across prescribing, communication and follow-up controls.2 reportsSelected
- Unreliable inter-agency information sharing for coordinated careThe anchor identifies absent agreed communication means and inaccessible shared patient information between mental health agencies. Other canonical reports identify relevant risk information not being shared between agencies and poor inter-agency information sharing preventing coordinated care, supporting a recurring concern with the reliability of inter-agency care information sharing rather than only the anchor's repository or communication-channel failure.2 reportsSelected
- Unreliable management of medication doses not takenThe anchor identifies missing guidance for monitoring prescribed medication that self-administering patients do not take when dispensed. A different report identifies inconsistent procedures for responding when service users refuse or do not take medication. Together these support a recurring concern with the reliability of detecting, monitoring and escalating omitted or refused medication doses, rather than a concern limited to one guidance document or one home's procedure.2 reportsSelected
- Unreliable medication dosage verification and communicationReports identify unsafe failures to ensure that medication dosages are accurately verified, clarified and communicated across prescribing, dispensing and administration activities.2 reportsSelected
- Unreliable observation of people in custodyThe anchor report identifies failure to transfer and replicate medically required observation levels when a detained person moves into GEO AMEY custody, while a different report identifies uncertainty about whether the correct observation level, including constant watch, was provided to a person in prison custody. Together these support a recurring concern about the reliability of the custody observation process rather than only one handover or level-setting failure.2 reportsSelected
- Unreliable recording of required observations in care and custodyDifferent reports identify inaccurate, delayed, anticipatory or falsified records of required observations, including 15-minute observations in prison custody and patient-care settings. The shared unsafe condition is that observation records do not reliably reflect when and how observations were actually conducted, rather than any one observation frequency, recording location or electronic system.2 reportsSelected
- Unreliable review and action on clinically significant incoming correspondenceReports identify failures across the incoming clinical-correspondence process, including failure to identify GP medication-review requests, failure to bring action-requiring correspondence to medical staff, and correspondence being filed without GP review or action. The shared unsafe condition is that clinically significant correspondence may not reliably reach the responsible clinician or trigger the required clinical response.2 reportsSelected
- Unreliable safety CCTV monitoring systemsDifferent reports identify failures in the operation of CCTV used as a safety control, including absent staff access arrangements, inadequate coverage, non-working cameras, insufficient monitoring and unclear staff instructions. Together these support the reliability of safety CCTV monitoring as the parent concern rather than any single access, coverage, equipment or training failure.2 reportsSelected
- Unreliable urgent mental health referral and assessment pathwaysUrgent mental-health referral pathways do not reliably secure timely access, coordination and specialist assessment.2 reportsSelected
- Unreliable welfare-check processes for people whose health is of concernThe anchor identifies unclear purpose and use of the welfare sheet for monitoring prisoners whose health is of concern. A separate report identifies inconsistent criteria for what constitutes a welfare check and when it is recorded. Together these support a recurring concern with the reliability of the bounded welfare-check process, rather than only the sheet or recording component.2 reportsSelected
- Unsafe cell-sharing decisions for prisonersRecurring deficiencies in the prison cell-sharing risk system can leave prisoners exposed to unsafe pairings or prevent them from understanding changes affecting their cell-sharing status.2 reportsSelected
- Unsafe medication prescribingReports identify unsafe prescribing decisions in which the medication, indication, dose or relevant clinical circumstances are not adequately evaluated before prescribing.2 reportsSelected
All reports in this date range
19 Sep 2013 – 7 Sep 2026 · 90 reports
Showing all concerns and their linked actions and positions from reports in this date range. Select a recurring concern above to narrow the evidence.
Actions and positions describe what recipients stated in published responses. Select a statement to read its source wording.
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Concerns raised3
Failure to secure patients' own medication
Lack of clinical handover to receiving wards
Failure to pass on doctors' instructions for cardiac monitoring
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
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Action
Share the updated Self-Harm Policy and patient-search procedure with Emergency Care staff and support acknowledgement of understanding.
Stated by James Paget University Hospitals NHS Foundation Trust -
Action
Add a patient-search procedure to the Self-Harm Policy covering searches for medication and other items that could enable overdose or self-harm.
Stated by James Paget University Hospitals NHS Foundation Trust -
Action
Disseminate the updated Self Harm Policy and patient-search procedure to Emergency Care staff and promote its requirements through written and face-to-face communication.
Stated by James Paget University Hospitals NHS Foundation Trust
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Action
Add a patient-search procedure to the Self Harm Policy, covering removal and safe storage of medications and other harmful items in Emergency Department patients at risk.
Stated by James Paget University Hospitals NHS Foundation Trust -
Action
Develop and implement a standard ED-to-EADU handover process and form that includes specialist requirements such as cardiac monitoring.
Stated by James Paget University Hospitals NHS Foundation Trust -
Action
Audit the implemented ED Patient Handover Form monthly from September until consistent compliance is demonstrated.
Stated by James Paget University Hospitals NHS Foundation Trust -
Action
Audit compliance with the ED patient handover form monthly after the scheduled September audit until consistent compliance is demonstrated.
Stated by James Paget University Hospitals NHS Foundation Trust -
Action
Introduce the ED patient handover process and form for transfers, including communication of cardiac monitoring and other specialist requirements.
Stated by James Paget University Hospitals NHS Foundation Trust
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Concerns raised2
Failure to enquire about additional resources when the local crisis team has no capacity
Insufficient mental health crisis team staff capacity for same-day assessment when clinically required
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure of governance and safety-review processes to identify, investigate, reflect upon, and remediate sub-optimal practice
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Contact families during PSIRM reviews so their concerns inform the review and decision on the level of investigation required.
Stated by Barts Health NHS Trust -
Action
Report each new inquest in Datix, present it at PSIRM, and expedite any outstanding M&M review to inform the required learning response.
Stated by Barts Health NHS Trust -
Action
Complete a specialist review of governance processes relating to this case, engage the Foster family, and share the outcome with HM Coroner.
Stated by Barts Health NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Trusts are responsible for documenting patient safety incident response decisions and explaining when no specific learning response is undertaken.
Stated by Department of Health and Social Care
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Position
Under PSIRF, not all deaths require investigation; Trusts must document and explain decisions under the existing patient safety incident response governance process.
Stated by Department of Health and Social Care
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Concerns raised3
Failure of drivers with dementia to self-report medical conditions to the DVLA
Failure to report multiple medical conditions requiring DVLA monitoring
Under-recording of dementia in collision statistics
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Consider research and evidence, including any additional research needed, to inform potential future changes to the driver licensing system.
Stated by Department for Transport -
Action
Continue working with healthcare professionals, driving organisations and regulatory bodies to identify and assess people who pose road-safety risks because of unrecognised medical conditions.
Stated by Department for Transport -
Action
Continue engaging healthcare professionals and regulatory bodies to identify and address obstacles to reporting conditions when patients lack insight or capacity.
Stated by Department for Transport
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
STATS19 cannot capture all medical contributory factors because detailed identification would impose practical burdens on police officers.
Stated by Department for Transport
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Concerns raised2
Failure to include homelessness-related care issues in the review of treatment for patients with dual diagnoses
Fragmented provision of substance misuse and mental health treatment across different organisations
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Action
Develop a comprehensive action plan to improve provision for people with co-occurring substance-use and mental-health needs.
Stated by Department of Health and Social Care -
Action
Continue working with NHS England to improve integrated care for people with substance-use and mental-health needs.
Stated by Department of Health and Social Care -
Action
Publish UK clinical guidelines on alcohol treatment, including recommendations for co-occurring conditions, multidisciplinary assessment, care planning and care coordination.
Stated by Department of Health and Social Care
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Action
Work with the Department of Health and Social Care to improve access to mental health services and coordination across health services for people experiencing homelessness.
Stated by Ministry of Housing, Communities and Local Government
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The Department of Health and Social Care will respond separately on matters relevant to its department, including the needs review.
Stated by Ministry of Housing, Communities and Local Government
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Position
Existing actions and the cross-government homelessness strategy are considered sufficient, so no further Ministry action is proposed.
Stated by Ministry of Housing, Communities and Local Government
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Concerns raised6
Failure to maintain medical oversight of medication-dependent patients until appropriately medicated
Failure to recognise and communicate medication-related crisis vulnerability in medical records
Failure to provide appropriately urgent clinical support and safety-netting for medication-related crisis risk
Failure to ensure medication-dependent patients understand medication-related death risks and plan emergency action
Failure to account for unreliable local pharmacy availability of urgently needed medication
Provision of generic safety-netting advice to patients at risk of sudden medication-related crisis
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Commission and launch the Pharmacy First service to support timely access to urgently required medicines.
Stated by NHS England -
Action
Investigate technology to track medication stocks across community pharmacies and improve management of high-impact national shortages.
Stated by NHS England -
Action
Deliver the Medicines Safety Improvement Programme to improve access to time-critical medicines for people with cliff-edge conditions, including epilepsy, and incorporate learning from Charlie’s death.
Stated by NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
It is not safely possible to differentiate medication urgency because of variable uses, brand names and alternative condition descriptions.
Stated by NHS England
-
Position
Current technology cannot track medication stocks across community pharmacies, limiting the ability to implement such tracking nationally.
Stated by NHS England
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Concerns raised5
Failure to obtain and supply prescribed anti-epileptic medication promptly
Lack of clear designated systems for dealing with medication supply shortages
Failure to provide leaflets explaining roles during medication supply shortages
Failure to learn lessons from potentially dangerous medication supply intervals
Failure of pharmacies to search for supplies when prescribed medication is unavailable
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Inspect the pharmacy’s systems for managing out-of-stock medicines and supply issues.
Stated by General Pharmaceutical Council -
Action
Publish guidance explaining how pharmacies should respond when prescribed medicines are unavailable.
Stated by General Pharmaceutical Council
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
The pharmacy’s staged process sought medication supplies, and referral to other pharmacies followed unsuccessful attempts to obtain the prescribed brand.
Stated by Midway Pharmacy
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Position
National medication shortages prevented the pharmacy from obtaining the prescribed Tegretol medication and require a national resolution.
Stated by Midway Pharmacy -
Position
Manufacturing medicines and wider supply and shortage issues fall outside the regulator’s direct role.
Stated by General Pharmaceutical Council
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Concerns raised11
Lack of specialist NHS paediatric neuro-consultant oversight
Failure to maintain comprehensive, understandable, accurate and contemporaneous medical records
Failure to undertake regular Paediatric Early Warning Score assessments
Deficiencies in ongoing staff training
Deficient clinical governance of management and investigation
Failure to conduct regular audits of clinical practice
Failure to provide sufficiently frequent direct night-time visual observations
Failure to ensure robust procedures are in place
Delays in fulfilling Duty of Candour obligations
Failure to undertake regular multidisciplinary clinical reviews
Lack of regular independent consultant oversight and coordination of investigations and multidisciplinary management
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.16
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Action
Strengthen NHS integration, referral pathways, and coordination with primary, secondary, and tertiary services for timely specialist care.
Stated by The Children's Trust -
Action
Reduce reliance on private consultants by integrating ongoing specialist care, including epilepsy management, within NHS services.
Stated by The Children's Trust -
Action
Undertake a comprehensive inspection of the service, including assessment of overnight observations, care planning, clinical monitoring and governance.
Stated by Care Quality Commission
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Action
Audit medical records regularly against NHS standards and address ongoing health-record integration issues with system partners.
Stated by The Children's Trust -
Action
Request monthly updates on monitoring-frequency and Paediatric Early Warning System audits to assess ongoing implementation and identify practice gaps.
Stated by Care Quality Commission -
Action
Maintain clear, individualised, regularly updated care plans aligned with Paediatric Early Warning Scores and audit their implementation.
Stated by The Children's Trust -
Action
Conduct overnight monitoring-practice audits and monthly quality walks to verify compliance with observation policies and care plans.
Stated by The Children's Trust -
Action
Work with Tadworth Children’s Trust and stakeholders through Rapid Quality Review meetings to review care quality, identify risks, and formulate improvement plans.
Stated by NHS England -
Action
Refine the clinical governance structure and strengthen leadership oversight of care practices, protocols, and improvement implementation.
Stated by The Children's Trust -
Action
Complete the thematic review of serious incidents and near misses and embed resulting quality-improvement workstreams in governance arrangements.
Stated by The Children's Trust -
Action
Conduct regular audits of care quality, care-plan adherence, and monitoring effectiveness under internal and external scrutiny.
Stated by The Children's Trust -
Action
Implement and embed a shift handover protocol communicating required supervision and observations and recording the preceding shift’s clinical observations.
Stated by The Children's Trust -
Action
Align frequency-of-monitoring policy and clinical guidelines with national best practice through wider consultation and critique.
Stated by The Children's Trust -
Action
Review and audit video surveillance, wearable sensors, and other monitoring tools to ensure appropriate use alongside direct checks.
Stated by The Children's Trust -
Action
Consider duty-of-candour review findings alongside manager-regulation consultation findings while developing healthcare candour policy.
Stated by Department of Health and Social Care -
Action
Review and improve the internal multidisciplinary care model across medical, nursing, care, and therapy services alongside broader NHS integration.
Stated by The Children's Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.7
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Position
NHS England had no direct or commissioning oversight of Mia’s care because it was local-authority-funded residential care, not specialised commissioning care.
Stated by NHS England
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Position
Some concerns about Mia’s care are better addressed by Tadworth Children’s Trust and the Care Quality Commission.
Stated by NHS England -
Position
Existing shared NHS neurological care, local and tertiary access, and monthly multidisciplinary case discussions were considered sufficient clinical oversight.
Stated by Care Quality Commission -
Position
The Local Authority, not NHS England, is responsible for overseeing the quality of the residential care service because it commissioned the bed.
Stated by Department of Health and Social Care -
Position
Strengthened monitoring policies, audits and governance arrangements were considered sufficient to address risks concerning night-time observations and safe care.
Stated by Care Quality Commission -
Position
The delay in executing the Duty of Candour was not considered a breach of the Health and Social Care Regulations.
Stated by Care Quality Commission -
Position
Tadworth Children’s Trust remains responsible for ensuring consistent multidisciplinary clinical support for all children in its care.
Stated by NHS England
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Concerns raised7
Failure of referral communication channels to provide reliable access and confirmation
Delays in triaging and progressing referrals for mental health care
Failure to communicate clinically relevant information between services about epilepsy and psychosis
Failure to send discharge summaries to the General Practitioner
Failure to identify urgency in referrals involving paranoia, delusions and suicidal ideation
Failure to carry out consultant review of antipsychotic medication alongside epilepsy medication
Inappropriate rejection of referrals despite evidence of psychosis
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Provide Neurology Department with electronic crisis assessments and outcome plans for service users receiving neurological treatment.
Stated by Sheffield Health Partnership University NHS Foundation Trust -
Action
Include discharge summaries in annual service record-keeping audits to verify timely transmission to GPs and required quality standards.
Stated by Sheffield Health Partnership University NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
No further action is proposed for Single Point of Access referrals because that service no longer operates and referrals now enter individual services.
Stated by Sheffield Health Partnership University NHS Foundation Trust
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Concerns raised3
Crowded and noisy treatment areas ill-suited to proper patient treatment
Insufficient clinician awareness and ability to apply NICE guidelines for adrenal insufficiency
Failure to apply NICE steroid-treatment guidelines for adrenal insufficiency during intercurrent illness
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.10
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Action
Close and discontinue use of the Emergency Department overflow area.
Stated by Worcestershire Acute Hospitals NHS Trust -
Action
Highlight steroid replacement in Emergency Department handovers and repeat the messaging to maintain medical staff awareness.
Stated by Worcestershire Acute Hospitals NHS Trust -
Action
Prioritise adrenal insufficiency and steroid replacement for Medical Examiner review, triggering further case review when concerns are identified.
Stated by Worcestershire Acute Hospitals NHS Trust
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Action
Use the updated Emergency Department adult patient document, which automatically includes highlighted steroid replacement as a time-critical medication for all adults.
Stated by Worcestershire Acute Hospitals NHS Trust -
Action
Circulate steroid replacement safety materials to Emergency and Medical staff and display them in the Emergency Department handover area.
Stated by Worcestershire Acute Hospitals NHS Trust -
Action
Have the Acting Chief Medical Officer highlight steroid replacement during induction for new doctors rotating into the hospitals.
Stated by Worcestershire Acute Hospitals NHS Trust -
Action
Incorporate steroids and other time-critical medications into the Emergency Department electronic patient record.
Stated by Worcestershire Acute Hospitals NHS Trust -
Action
Participate in the Royal College of Emergency Medicine audit of prescribing and administration of time-critical medicines, including steroids.
Stated by Worcestershire Acute Hospitals NHS Trust -
Action
Publish guidance for preventing and managing adrenal insufficiency emergencies in adults.
Stated by NHS England -
Action
Develop the NHS Steroid Emergency Card for patients at risk of adrenal crisis.
Stated by NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The Trust is responsible for addressing local emergency department crowding, staffing, overflow-area and acuity concerns.
Stated by NHS England
