Concerns raised 3
Failure of drivers with dementia to self-report medical conditions to the DVLA View source Failure to report multiple medical conditions requiring DVLA monitoring View source Under-recording of dementia in collision statistics View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sheila Margaret Edwards · 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 Margaret Edwards was a front-seat passenger in a car whose driver became unresponsive, leading to a head-on collision on 8 January 2023. The report identified concerns that drivers with dementia and other conditions may not recognise or report them to the DVLA, creating risks to other road users, and that such conditions may be under-recorded in collision data.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of drivers with dementia to self-report medical conditions to the DVLA
Wider context from the report “1. Dementia affects approximately half a million sufferers in the United Kingdom of which the DVLA has only been notified of approximately 30,000 drivers. It would appear that there is significant underreporting of drivers who may suffer from dementia
2. The current system for vehicle licensing relies upon the self-awareness of a driver and their ability to self-report medical conditions to the DVLA . A system that relies upon the self-awareness of a person applying for a driving licence to self-report a medical condition of dementia where the condition itself is characterised by a lack of self-awareness is inherently unsafe and exposes other road users to the risk of death or serious injury
” Source location Sheila Margaret Edwards · Prevention of Future Deaths report
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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 report multiple medical conditions requiring DVLA monitoring
Wider context from the report “5. In this case, the driver suffered from focal epilepsy, which was the primary cause of the collision resulting Sheila Edwards' death. However, the memory deficit caused by dementia resulted in a lack of awareness of an underlying neurological condition. In such cases there is a substantial risk that neither of the conditions will be reported to the DVLA for monitoring . The result is that a driver with two conditions that should be monitored by the DVLA who is both unaware of their illnesses and the need to report themselves to the DVLA . This creates a substantial risk to other road users.
” Source location Sheila Margaret Edwards · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Under-recording of dementia in collision statistics
Wider context from the report “4. As a result of the way in which collision data is collected using Stats 19, there is a significant likelihood that dementia is under recorded in collision statistics . The nation this point regarding collision data regarding the visual aspect of collisions, the PFD report into the deaths of Mary Cunningham, Grace Foulds, Anne Ferguson and Peter Westwell should be consulted.
” Source location Sheila Margaret Edwards · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider research and evidence, including any additional research needed, to inform potential future changes to the driver licensing system.
Verbatim wording from the response “Officials are considering the research and evidence provided and what additional research may be needed to inform potential future changes. These considerations include the system of self-declaration and the potential for the introduction of age-based testing. Consideration is also being given to policy options as part of the Government’s Road Safety Strategy, which is being developed and the details of which will be provided in due course.” Source location Response from Department for Transport
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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 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.
Verbatim wording from the response “My Department will continue to work with healthcare professionals, driving organisations and regulatory bodies to enhance the safety of our roads and ensure that those who pose a risk to road safety due to lack of awareness of their medical condition are appropriately identified and assessed.” Source location Response from Department for Transport
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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 Continue engaging healthcare professionals and regulatory bodies to identify and address obstacles to reporting conditions when patients lack insight or capacity.
Verbatim wording from the response “Although the process for establishing that a driver meets the medical standards for driving is based on self-declaration, I recognise that this may be difficult for those drivers with conditions that may impair their insight into their health status. My department will continue to engage with healthcare professionals and their regulatory bodies to identify and address any obstacles that may hinder the reporting process, particularly where their patient lacks the insight or capacity to inform the DVLA of their condition themselves.” Source location Response from Department for Transport
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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 STATS19 cannot capture all medical contributory factors because detailed identification would impose practical burdens on police officers.
Verbatim wording from the response “I note that you have raised concerns about the STATS19 system used in GB for collecting and reporting road traffic collision data. The Department acknowledges that STATS19 has limitations in identifying the causes of collisions in detail, particularly regarding the recording of medical conditions such as dementia or cognitive impairment as a contributory factor. These limitations are set out in the guidance provided (for example, the guidance on contributory factors). Contributory factors are based on the judgement of police officers at the scene of an accident or shortly afterwards. As a result, conditions such as those affecting cognitive function may go unrecorded, especially if the impairment is not immediately apparent or if the officer is unaware of the driver’s medical history.” Source location Response from Department for Transport
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4 Apr 2025 Mr Alexi Susiluoto · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2
Failure to include homelessness-related care issues in the review of treatment for patients with dual diagnoses View source Fragmented provision of substance misuse and mental health treatment across different organisations View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mr Alexi Susiluoto · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Alexi Susiluoto, who had a history of mental health disorders, substance misuse and epilepsy, was found deceased in a hotel room on 22 May 2024. His death was attributed to alcohol misuse disorder resulting in acute ethanol toxicity, with epilepsy and prescribed medication as contributing factors. The report raised concerns about fragmented care for people with dual diagnoses who are homeless, including confusion over which services and local authority were responsible for care and funding.
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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 include homelessness-related care issues in the review of treatment for patients with dual diagnoses
Wider context from the report “1. I heard evidence that the Office for Health Improvement and Disparities is currently undertaking a review of how patients with dual diagnoses (substance misuse and mental health disorders) are treated. I was concerned by two related issues:
a. That substance misuse and mental health treatment is routinely provided by different organisations, despite close interplay between these conditions and that this can result in significant complexities for agencies caring for the same patient. I understand that this aspect is part of the current review;
b. However, I also heard that the review is not taking into consideration the additional issues that arise when a patient with dual diagnoses is also homeless . Evidence presented at the inquest set out that this already complex situation is often compounded by homelessness, since individuals are often moved between temporary accommodation and therefore between different mental health trust and substance misuse providers. In Mr Susiluoto’s case, this resulted in significant confusion as to who was providing his care and which local authority would fund potential substance misuse treatment.
” Source location Mr Alexi Susiluoto · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Fragmented provision of substance misuse and mental health treatment across different organisations
Wider context from the report “1. I heard evidence that the Office for Health Improvement and Disparities is currently undertaking a review of how patients with dual diagnoses (substance misuse and mental health disorders) are treated. I was concerned by two related issues:
a. That substance misuse and mental health treatment is routinely provided by different organisations , despite close interplay between these conditions and that this can result in significant complexities for agencies caring for the same patient . I understand that this aspect is part of the current review;
b. However, I also heard that the review is not taking into consideration the additional issues that arise when a patient with dual diagnoses is also homeless. Evidence presented at the inquest set out that this already complex situation is often compounded by homelessness, since individuals are often moved between temporary accommodation and therefore between different mental health trust and substance misuse providers. In Mr Susiluoto’s case, this resulted in significant confusion as to who was providing his care and which local authority would fund potential substance misuse treatment.
” Source location Mr Alexi Susiluoto · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a comprehensive action plan to improve provision for people with co-occurring substance-use and mental-health needs.
Verbatim wording from the response “Your report mentions a review my department is taking into treatment for people with substance use and mental health conditions, and you raise concerns that the review is not considering the additional complexities and issues that occur when someone is also experiencing, or at risk of, homelessness. My department recognises the vital importance of high-quality integrated care for those with co-occurring conditions and who sleep rough, or who are at risk of sleeping rough. To clarify, we have not undertaken a formal review but, following recommendation from Dame Carol Black’s independent review of drugs, have been developing a comprehensive action plan to set out a path to improving service provision for those with co-occurring substance use and mental health needs.” Source location Response from DHSC
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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 Continue working with NHS England to improve integrated care for people with substance-use and mental-health needs.
Verbatim wording from the response “Thank you for bringing these concerns to my attention. I want to assure you my department and NHSE recognise these issues and are continuing to work closely together to improve integrated care for those with substance use issues. I hope this response is helpful.” Source location Response from DHSC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish UK clinical guidelines on alcohol treatment, including recommendations for co-occurring conditions, multidisciplinary assessment, care planning and care coordination.
Verbatim wording from the response “- DHSC will soon publish the UK clinical guidelines on alcohol treatment to support and improve the quality of treatment for people with alcohol dependence. The guidelines include chapters on working with people with co-occurring alcohol dependence and mental health and/or physical health conditions. They also include recommendations on multi-disciplinary assessment, care planning and care co-ordination.” Source location Response from DHSC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the Department of Health and Social Care to improve access to mental health services and coordination across health services for people experiencing homelessness.
Verbatim wording from the response “I am leading cross-government efforts to deliver the long-term solutions we need to get us back on track to ending all forms of homelessness. This includes chairing a dedicated Inter-Ministerial Group (IMG), bringing together Ministers from across Government to develop a long-term strategy. DHSC Ministers attend the IMG, and we are working closely with the DHSC to address the health needs of people experiencing homelessness and rough sleeping. This includes improving access to mental health services and improving join-up between all services across the health system to ensure people experiencing homelessness are supported with all their health needs. We expect to publish our Homelessness Strategy following the conclusion of Phase 2 of the Spending Review.” Source location Response from MHCLG
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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 The Department of Health and Social Care will respond separately on matters relevant to its department, including the needs review.
Verbatim wording from the response “I understand the Parliamentary Under-Secretary of State for Public Health and Prevention in the DHSC will be responding separately on matters relevant to their department that your report raises,” Source location Response from MHCLG
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing actions and the cross-government homelessness strategy are considered sufficient, so no further Ministry action is proposed.
Verbatim wording from the response “Given the actions and relevant cross-government strategy being already undertaken and led by my department, I am proposing that no further action is taken by the Ministry of Housing, Communities and Local Government in relation to this case.” Source location Response from MHCLG
Open published response
31 Dec 2024 David Joseph Crompton · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 5
Failure to obtain and supply prescribed anti-epileptic medication promptly View source Lack of clear designated systems for dealing with medication supply shortages View source Failure to provide leaflets explaining roles during medication supply shortages View source
Failure to learn lessons from potentially dangerous medication supply intervals View source Failure of pharmacies to search for supplies when prescribed medication is unavailable View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
David Joseph Crompton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Joseph Crompton, who had epilepsy, was left without his prescribed Tegretol for approximately 10 days in April 2024 and again in December 2024. His falls in both periods occurred when he was without the medication, and the inquest recorded a fall downstairs on 13 December 2024, with causes of death including hypoxic ischaemic encephalopathy, out-of-hospital cardiac arrest and cervical spine injury. The principal concerns were delays in supplying essential anti-epileptic medication, reliance on family members to seek alternative supplies, and the absence of clear systems for managing medication shortages.
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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 obtain and supply prescribed anti-epileptic medication promptly
Wider context from the report “(1) It is important that when anti-epileptic medication is prescribed by a GP that this is obtained and supplied promptly by the dispensing pharmacy . It is a matter of concern that for relatively lengthy periods on two occasions Mr Crompton was left without this important medication .
” Source location David Joseph Crompton · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clear designated systems for dealing with medication supply shortages
Wider context from the report “(4) Comment was made at the inquest to the effect that the pharmaceutical profession should have clear designated systems to deal with any shortages of supply encountered ; for example, reference to hospital departments to ensure patients are not left without important medications . Leaflets explaining the role of those concerned in this situation were not provided.
” Source location David Joseph Crompton · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide leaflets explaining roles during medication supply shortages
Wider context from the report “(4) Comment was made at the inquest to the effect that the pharmaceutical profession should have clear designated systems to deal with any shortages of supply encountered; for example, reference to hospital departments to ensure patients are not left without important medications. Leaflets explaining the role of those concerned in this situation were not provided .
” Source location David Joseph Crompton · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to learn lessons from potentially dangerous medication supply intervals
Wider context from the report “(3) The inquest was informed that following the April 2024 episode, hospital specialists commented that the absence of Tegretol for around 10 days “will likely have contributed to your seizure activity”. It is questionable whether lessons were learnt from this potentially dangerous interval .
” Source location David Joseph Crompton · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of pharmacies to search for supplies when prescribed medication is unavailable
Wider context from the report “(2) The evidence given by family members at the inquest was that when the pharmacy was unable to supply the prescribed Tegretol medication, it was left to them to contact other pharmacies to see if they could obtain it, rather than for the pharmacy to search for supplies .
” Source location David Joseph Crompton · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Inspect the pharmacy’s systems for managing out-of-stock medicines and supply issues.
Verbatim wording from the response “The particular pharmacy has been inspected by our Inspection Team, who looked for evidence that the pharmacy was meeting our Standards for Registered Pharmacies. The purpose of these standards is to create and maintain the right environment in pharmacies to protect and improve people’s health and wellbeing. The inspection included looking for evidence about the systems in place to manage medicines which were out of stock at the pharmacy and where there were supply issues at the wholesalers. This was to ensure practices in the pharmacy relating to stock management were appropriate.” Source location Response from General Pharmaceutical Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish guidance explaining how pharmacies should respond when prescribed medicines are unavailable.
Verbatim wording from the response “In November 2024 we published an article about medicines shortage, https://www.pharmacyregulation.org/about-us/news-and-updates/regulate/struggle-around-medicines-shortages The article states that if the pharmacy is unable to supply a particular medicine stated on prescription then they should talk to the patient to discuss their options. The article outlines examples of steps that pharmacy should take.” Source location Response from General Pharmaceutical Council
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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 The pharmacy’s staged process sought medication supplies, and referral to other pharmacies followed unsuccessful attempts to obtain the prescribed brand.
Verbatim wording from the response “(2) The evidence given by family members at the inquest was that when the pharmacy was unable to supply the prescribed Tegretol medication, it was left to them to contact other pharmacies to see if they could obtain it, rather than for the pharmacy to search for supplies.” Source location Response from Midway Pharmacy
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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 National medication shortages prevented the pharmacy from obtaining the prescribed Tegretol medication and require a national resolution.
Verbatim wording from the response “The process of managing owings is staged to ensure we obtain patients’ medications in a prompt and timely manner. On this occasion, only a single supplier (AAH Pharmaceuticals) had the medication in stock, and other Midway pharmacies could not obtain supplies. There was a clinical risk of changing the brand of medication supplied due to the condition being treated, and Mr Crompton was referred to other pharmacies that may have had the medication in stock.” Source location Response from Midway Pharmacy
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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 Manufacturing medicines and wider supply and shortage issues fall outside the regulator’s direct role.
Verbatim wording from the response “We are aware of supply issues with some Tegretol products. While we do not have a direct role in the manufacturing of medicines or wider issues such as supply and shortages, we understand that medicines shortages can cause problems for patients and carers. We know that pharmacy professionals are also concerned and have to use their professional judgement and make decisions in challenging situations, balancing a range of factors such as individual patient needs and available supplies of medicines. Our standards require pharmacy professionals to deliver patient-centred care, which includes making the care of the patient their first concern and using their judgement to make professional decisions. This may include making decisions about providing medication in an emergency.” Source location Response from General Pharmaceutical Council
Open published response
Concerns raised 7
Failure of referral communication channels to provide reliable access and confirmation View source Delays in triaging and progressing referrals for mental health care View source Failure to communicate clinically relevant information between services about epilepsy and psychosis View source
Failure to send discharge summaries to the General Practitioner View source Failure to identify urgency in referrals involving paranoia, delusions and suicidal ideation View source Failure to carry out consultant review of antipsychotic medication alongside epilepsy medication View source Inappropriate rejection of referrals despite evidence of psychosis View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Bryan Andrews and Mary Andrews · 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
Bryan and Mary Andrews died at their home on 27 November 2022 from multiple stab wounds inflicted by their adult son. The principal concern was a lack of communication between services about the relationship between his epilepsy and psychotic symptoms, resulting in treatment delays, rejected referrals and failures to share important information.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of referral communication channels to provide reliable access and confirmation
Wider context from the report “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths.
This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation.
He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
” Source location Bryan Andrews and Mary Andrews · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in triaging and progressing referrals for mental health care
Wider context from the report “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths.
This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation.
He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
” Source location Bryan Andrews and Mary Andrews · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate clinically relevant information between services about epilepsy and psychosis
Wider context from the report “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths.
This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation.
He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
” Source location Bryan Andrews and Mary Andrews · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to send discharge summaries to the General Practitioner
Wider context from the report “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths.
This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation.
He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
” Source location Bryan Andrews and Mary Andrews · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to identify urgency in referrals involving paranoia, delusions and suicidal ideation
Wider context from the report “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths.
This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation.
He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
” Source location Bryan Andrews and Mary Andrews · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to carry out consultant review of antipsychotic medication alongside epilepsy medication
Wider context from the report “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths.
This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation.
He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
” Source location Bryan Andrews and Mary Andrews · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inappropriate rejection of referrals despite evidence of psychosis
Wider context from the report “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths.
This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation.
He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
” Source location Bryan Andrews and Mary Andrews · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Neurology Department with electronic crisis assessments and outcome plans for service users receiving neurological treatment.
Verbatim wording from the response “The Single Point of Access Service within SHSC is no longer in operation, following a transformation programme of our Urgent and Crisis Services. We have, therefore, not set out any actions in this response relating to how this service deals with referrals, given that referrals now go into each individual service. We are committed to taking the following actions:” Source location Response from Sheffield Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include discharge summaries in annual service record-keeping audits to verify timely transmission to GPs and required quality standards.
Verbatim wording from the response “2. Discharge summaries are electronically sent to GPs through our electronic patient record system. In this case, although the discharge summary was created on 9 May 2022, the day of discharge, it was further edited on 13 May 2022. It appears that because the discharge” Source location Response from Sheffield Health and Social Care
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No further action is proposed for Single Point of Access referrals because that service no longer operates and referrals now enter individual services.
Verbatim wording from the response “The Single Point of Access Service within SHSC is no longer in operation, following a transformation programme of our Urgent and Crisis Services. We have, therefore, not set out any actions in this response relating to how this service deals with referrals, given that referrals now go into each individual service. We are committed to taking the following actions:” Source location Response from Sheffield Health and Social Care
Open published response
26 Jan 2024 Michael Leslie PEGG · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 3
Crowded and noisy treatment areas ill-suited to proper patient treatment View source Insufficient clinician awareness and ability to apply NICE guidelines for adrenal insufficiency View source Failure to apply NICE steroid-treatment guidelines for adrenal insufficiency during intercurrent illness View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Michael Leslie PEGG · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Leslie Pegg, who lived with congenital adrenal insufficiency and epilepsy, was admitted to Worcestershire Royal Hospital after two significant seizures and died there on 15 January 2023 following deterioration and pneumonia. The report raised concerns that steroid treatment fell far short of relevant NICE guidelines, that staff awareness and application of the guidelines were insufficient, and that crowded treatment areas created difficulties in providing appropriate care.
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 Crowded and noisy treatment areas ill-suited to proper patient treatment
Wider context from the report “3) For a substantial part of his time at Worcestershire Royal Hospital, Mr. Pegg was being treated in a bed in a corridor in the Emergency Department, and then in the Majors Overflow area, both busy, crowded and noisy areas ill-suited to the proper treatment of patients . In his evidence to the inquest about trying to ensure that the Trust’s staff are aware of these Guidelines, Dr Raven told the inquest:
“As long as we still have crowded settings, it is difficult to provide assurances that these guidelines will be followed , for example because we have a high turnover of locum clinicians and agency nursing staff.”
It is particularly concerning to hear that patients’ wellbeing may be put at risk because a hospital Trust may not be able properly to ensure that the staff it employs are aware of, and able to apply NICE Guidelines.
It is perhaps unfair to put responsibility for rectifying this situation solely at the door of the Worcestershire Acute Hospitals NHS Trust, which is why this report is also being sent to NHS England and Health Education England.
” Source location Michael Leslie PEGG · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient clinician awareness and ability to apply NICE guidelines for adrenal insufficiency
Wider context from the report “2) Although in this case, I was unable to conclude that the above omissions in steroid treatment probably caused or contributed to Mr. Pegg’s death, it was nonetheless concerning to hear that none of those treating him had sufficient awareness of the NICE Guidelines as to be able to apply them properly in his case . Unless action is taken to ensure clinicians employed by the Trust are aware of, and able to apply these Guidelines , there remains a risk that another patient with adrenal insufficiency may die in similar circumstances ;
” Source location Michael Leslie PEGG · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to apply NICE steroid-treatment guidelines for adrenal insufficiency during intercurrent illness
Wider context from the report “1) Over the two days that Mr. Pegg was at Worcestershire Royal Hospital, those treating him failed to apply the NICE guidelines which relate to the treatment of those with adrenal insufficiency conditions who are being treated for intercurrent illness . ████████, who conducted the Trust’s serious incident investigation into these events, told the inquest:
“There was a policy in place for administering steroids, as per the 2020 NICE guidelines – this advises:
(a) double dosing of oral steroids in cases of intercurrent illness until 48 hours after recovery (also known as Sick Day rule 1);
(b) if [the patient has ] significant trauma, prolonged vomiting or diarrhoea, then 100mg IV hydrocortisone [ should be administered ];
(c) if suspected adrenal crisis, 100mg IV hydrocortisone immediately.”
In fact, the steroid treatment provided to Mr. Pegg during this admission fell far short of those Guidelines , in that:
(a) He only received one double dose of his oral hydrocortisone medication , which he was usually required to take twice a day;
(b) He received no doses at all ( double or standard ) of his oral prednisolone medication , which he was usually required to take once a day;
(c) Although he did eventually receive a 100mg dose of IV hydrocortisone on 14.1.23, this should have been given much earlier that day when his condition seriously deteriorated .
” Source location Michael Leslie PEGG · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Close and discontinue use of the Emergency Department overflow area.
Verbatim wording from the response “• The “overflow area” of the ED is no longer being used, having closed in October 2023.” Source location Response from Worcestershire Acute Hospitals NHS Trust
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Highlight steroid replacement in Emergency Department handovers and repeat the messaging to maintain medical staff awareness.
Verbatim wording from the response “• Steroid replacement (and other time critical meds) has been highlighted in effective handover in ED in 2023 and will be repeated (appendix 4) to raise and maintain awareness for all medical staff working in the ED.” Source location Response from Worcestershire Acute Hospitals NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prioritise adrenal insufficiency and steroid replacement for Medical Examiner review, triggering further case review when concerns are identified.
Verbatim wording from the response “• The Medical Examiners, at the request of the Trust, are working with Adrenal Insufficiency/Steroid Replacement as one of their high priority conditions which means that any concerns identified with steroid replacement will trigger further case review. The focus therefore remains on this area and will continue to be so until we are fully assured that our processes for identifying and managing this condition are effective.” Source location Response from Worcestershire Acute Hospitals NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the updated Emergency Department adult patient document, which automatically includes highlighted steroid replacement as a time-critical medication for all adults.
Verbatim wording from the response “several occasions since Mr Pegg’s sad death. Discussions included the importance of the adult patient document in the Emergency Department which was updated in June 2023. This now includes a time critical medications (highlighted steroid replacement) (please see appendix 1 attached). This is automatically included for all adults presenting to the Emergency Department.” Source location Response from Worcestershire Acute Hospitals NHS Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate steroid replacement safety materials to Emergency and Medical staff and display them in the Emergency Department handover area.
Verbatim wording from the response “• A “detect and reflect” document and “time critical medication safety flash” have been circulated to all Emergency and Medical staff to raise awareness of the need for steroid replacement therapy (appendix 2, 3). These are displayed in the Emergency Department handover area.” Source location Response from Worcestershire Acute Hospitals NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Have the Acting Chief Medical Officer highlight steroid replacement during induction for new doctors rotating into the hospitals.
Verbatim wording from the response “• The Acting Chief Medical Officer will be attending the Induction for new doctors in August in order to highlight this area of focus for the Trust for all junior doctors rotating into our hospitals.” Source location Response from Worcestershire Acute Hospitals NHS Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incorporate steroids and other time-critical medications into the Emergency Department electronic patient record.
Verbatim wording from the response “• The Trust is due to move to an electronic patient record in the Emergency Department in Autumn 2024 – time critical medications including steroids are due to be incorporated into this.” Source location Response from Worcestershire Acute Hospitals NHS Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate in the Royal College of Emergency Medicine audit of prescribing and administration of time-critical medicines, including steroids.
Verbatim wording from the response “• The Emergency Departments on both sites are participating in a Royal College of Emergency Medicine audit looking at the prescribing and administration of time critical medicines, including steroids. This audit will provide a “benchmark” for the Trust and also highlight areas where further improvement is required. The audit is still in data collection phase but results will be available later in the year.” Source location Response from Worcestershire Acute Hospitals NHS Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish guidance for preventing and managing adrenal insufficiency emergencies in adults.
Verbatim wording from the response “NHS England has also worked closely with the Society for Endocrinology and the Royal College of Physicians on the issue of under-recognition and treatment of adrenal insufficiency or crisis. This culminated in the publication of ‘Guidance for the prevention and emergency management of adult patients with adrenal insufficiency’ in July 2020, which outlines the causes of adrenal insufficiency, groups at risk of an adrenal crisis, emergency management and management for surgical procedures. As a result of work in this area, a new NHS Steroid Emergency Card was developed, to be carried by patients at risk of adrenal crisis and ensure the prompt delivery of steroids to those patients presenting within an emergency or acute medicine setting.” Source location Response from NHS England
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop the NHS Steroid Emergency Card for patients at risk of adrenal crisis.
Verbatim wording from the response “NHS England has also worked closely with the Society for Endocrinology and the Royal College of Physicians on the issue of under-recognition and treatment of adrenal insufficiency or crisis. This culminated in the publication of ‘Guidance for the prevention and emergency management of adult patients with adrenal insufficiency’ in July 2020, which outlines the causes of adrenal insufficiency, groups at risk of an adrenal crisis, emergency management and management for surgical procedures. As a result of work in this area, a new NHS Steroid Emergency Card was developed, to be carried by patients at risk of adrenal crisis and ensure the prompt delivery of steroids to those patients presenting within an emergency or acute medicine setting.” Source location Response from NHS England
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust is responsible for addressing local emergency department crowding, staffing, overflow-area and acuity concerns.
Verbatim wording from the response “NHS England would refer you to the Trust on what actions are being taken locally to address your concerns. We have been sighted on their Serious Investigation Report and Action Plan and note that they have taken learnings around Emergency Department crowding and improving end-of-life care for patients and are reviewing staffing levels in the Overflow Area and Acuity.” Source location Response from NHS England
Open published response
7 May 2024 Peter Jason FANNING · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2
Insufficient availability of feeding-tube replacement services for patients with complex needs View source Failure to maintain nutrition after feeding-tube dislodgement View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Peter Jason FANNING · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter Jason FANNING, who had cerebral palsy, severe physical impairment, epilepsy and relied on a gastrostomy feeding tube, experienced repeated tube dislodgements and admissions for replacement. He developed pneumonia and died on 19 December 2023; concerns related to limited availability for complex feeding-tube replacements and maintaining nutrition after dislodgement.
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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 Insufficient availability of feeding-tube replacement services for patients with complex needs
Wider context from the report “1. The inquest heard evidence that there is only one radiology list per week to accommodate replacement of feeding tubes in patients with complex needs . In Peter’s case this meant he had to wait a week for the tube to be replaced meaning he had suboptimal nutrition during this period. Consideration should be given to whether additional services are required for replacement of feeding tubes in patients with complex needs.
” Source location Peter Jason FANNING · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain nutrition after feeding-tube dislodgement
Wider context from the report “2. The inquest heard evidence that Peter’s nutritional status was suboptimal due to repeated tube dislodgments and waiting for radiology or theatre slots to be available. Consideration needs to be given as to how best to maintain patients’ nutrition after tube dislodgments when they rely on feeding tubes .
” Source location Peter Jason FANNING · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase interventional radiology capacity to four weekly lists across three sites and provide three consultants for x-ray-guided feeding-tube insertion.
Verbatim wording from the response “X-ray guided tube insertion
The Interventional Radiology department has increased capacity from one to four intervention radiology (IR) lists per week across our Heartland’s, Good Hope and Solihull Hospital sites (HGS), which can accommodate x-ray guided feeding tube insertions. We also now have three IR consultants who are able to provide this service (increased from one previously) and these changes have been in place since April 2024.” Source location Response from University Hospitals Birmingham
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide a temporary additional interventional radiology theatre at Heartlands for two days per week using additional funding.
Verbatim wording from the response “Also, temporary funding has been made available to increase IR capacity on the Heartlands site and we have an additional IR theatre running in the Heartlands Treatment Centre for two days per week. A business case is currently being considered to support this becoming a full-time provision.” Source location Response from University Hospitals Birmingham
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider a business case to make the additional Heartlands interventional radiology theatre provision full time.
Verbatim wording from the response “Also, temporary funding has been made available to increase IR capacity on the Heartlands site and we have an additional IR theatre running in the Heartlands Treatment Centre for two days per week. A business case is currently being considered to support this becoming a full-time provision.” Source location Response from University Hospitals Birmingham
Open published response
28 Feb 2024 Chloe Anne Tapp · Prevention of Future Deaths report Essex
View report summary
Concerns raised 15
Failure to implement identified actions addressing unsafe neurology practice View source Delays and unsafe processes in investigation reporting and results access View source Provision of medication tapering instructions based on incorrect doses View source
Chronic staffing shortages across neurology doctors, nurses and administrative staff View source Failure to establish medication doses and apply appropriate conversion factors View source Unsafe backlogs for neurology first and follow-up appointments View source Failure to deliver medication tapering information through a valid and timely communication channel View source Failure to make timely referrals to adult neurology services View source Worsening unsafe condition of the neurology department View source Failure to provide visual assessment when clinically required View source Failure to respond to patient communications requiring medication clarification View source Insufficient national neurologist capacity relative to demand View source Failure to answer patient and carer communications in a timely manner View source Failure to record medication tapering regimes in clinical notes View source Unsafe practice in the neurology department View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Chloe Anne Tapp · 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
Chloe Anne Tapp, a 20-year-old with epilepsy and other medical conditions, suffered seizures and respiratory and cardiac arrest on 7 October 2021 and died in hospital on 8 October 2021. The principal concerns included delays transferring her to adult neurology, a telephone consultation despite her being non-verbal, an incorrect and inadequately documented medication tapering regime, and unanswered attempts to obtain clarification. Broader concerns were raised about staffing shortages, unsafe backlogs and difficulties responding to patients and carers within the neurology department.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to implement identified actions addressing unsafe neurology practice
Wider context from the report “Notwithstanding Chloe’s death in 2021, the letter in July 2023 and follow-up in January 2024, many of the more significant actions identified remained as part of an Action Plan . Business cases were being drawn up for a number of areas (but not additional consultants) and these had not yet been approved, nor was it guaranteed that they would be .
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays and unsafe processes in investigation reporting and results access
Wider context from the report “The consultant in question gave evidence of a very bleak picture of ongoing practice in the neurology department; a letter from all four consultants in that department had been sent to the Trust in July 2023, where patient care was described as ‘sub-optimal’, and numerous concerns were set out including:
o Chronic staff shortages in respect of doctors, nurses and administrative staff within the neurology department
o Substantial and unsafe backlogs for first and follow up appointments
o Inability to answer, in a timely manner, the volume of phone calls, phone messages and emails from patients/carers raising queries.
o The delays / ways in which investigations are carried out and reported , and the way in which clinical staff can access results .
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Provision of medication tapering instructions based on incorrect doses
Wider context from the report “A handwritten note of a tapering regime based on incorrect doses was sent to Chloe.
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Chronic staffing shortages across neurology doctors, nurses and administrative staff
Wider context from the report “The consultant in question gave evidence of a very bleak picture of ongoing practice in the neurology department; a letter from all four consultants in that department had been sent to the Trust in July 2023, where patient care was described as ‘sub-optimal’, and numerous concerns were set out including:
o Chronic staff shortages in respect of doctors, nurses and administrative staff within the neurology department
o Substantial and unsafe backlogs for first and follow up appointments
o Inability to answer, in a timely manner, the volume of phone calls, phone messages and emails from patients/carers raising queries.
o The delays / ways in which investigations are carried out and reported, and the way in which clinical staff can access results.
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to establish medication doses and apply appropriate conversion factors
Wider context from the report “An overworked consultant under considerable pressure, did not have time before or during the consultation to establish the dose that Chloe was taking and/or apply the appropriate conversion factor , for medications that can interact negatively at higher doses .
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unsafe backlogs for neurology first and follow-up appointments
Wider context from the report “The consultant in question gave evidence of a very bleak picture of ongoing practice in the neurology department; a letter from all four consultants in that department had been sent to the Trust in July 2023, where patient care was described as ‘sub-optimal’, and numerous concerns were set out including:
o Chronic staff shortages in respect of doctors, nurses and administrative staff within the neurology department
o Substantial and unsafe backlogs for first and follow up appointments
o Inability to answer, in a timely manner, the volume of phone calls, phone messages and emails from patients/carers raising queries.
o The delays / ways in which investigations are carried out and reported, and the way in which clinical staff can access results.
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to deliver medication tapering information through a valid and timely communication channel
Wider context from the report “The same regime was repeated in a letter to the Epilepsy Nurses, but this letter was not received until October 2021 (in paper form) as the initial email was sent to an address that no longer existed .
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to make timely referrals to adult neurology services
Wider context from the report “Neurology departments are so overwhelmed and/or understaffed that a vulnerable young girl (particularly so during the Covid-19 pandemic), was not referred in a timely manner to adult neurology services and in fact, it transpired a referral had not been made at all . This appears to have been done for the first time in August 2021.
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Worsening unsafe condition of the neurology department
Wider context from the report “The state of the department , compared to when Chloe died was described as ‘worse’ .
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide visual assessment when clinically required
Wider context from the report “An initial consultation with a complex non-verbal patient was arranged over the telephone , notwithstanding the concerns about a tremor which would have required visual assessment .
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to respond to patient communications requiring medication clarification
Wider context from the report “Phone calls and messages left with the neurology department went unanswered , at a time when clarity over the tapering regime was needed .
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient national neurologist capacity relative to demand
Wider context from the report “The independent consultant neurologist in giving evidence expressed that this was not an unfamiliar picture across a number of different Trusts and that there was a recognised shortage of neurologists and increase in demand for that speciality nationally .
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to answer patient and carer communications in a timely manner
Wider context from the report “The consultant in question gave evidence of a very bleak picture of ongoing practice in the neurology department; a letter from all four consultants in that department had been sent to the Trust in July 2023, where patient care was described as ‘sub-optimal’, and numerous concerns were set out including:
o Chronic staff shortages in respect of doctors, nurses and administrative staff within the neurology department
o Substantial and unsafe backlogs for first and follow up appointments
o Inability to answer, in a timely manner, the volume of phone calls, phone messages and emails from patients/carers raising queries.
o The delays / ways in which investigations are carried out and reported, and the way in which clinical staff can access results.
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to record medication tapering regimes in clinical notes
Wider context from the report “No note was made of the tapering regime for the medication change in Chloe’s notes.
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unsafe practice in the neurology department
Wider context from the report “A further letter was sent by Chloe’s consultant in January 2024 in lieu of her attending a meeting where progress was to be discussed. That letter highlighted that, not only did the concerns remain live , she believed that the department had now reached levels of ‘unsafe practice’ .
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue implementing and monitoring actions from the Serious Incident investigation and neurology improvement action plan.
Verbatim wording from the response “The matters raised in the Consultant’s letter in July 2023 were of great concern. I am aware my colleague Dr David Walker, Chief Medical Officer, wrote to you at the time to confirm the work we were taking to ensure the service was safe, a copy of his letter is attached. Our Serious Incident investigation went on to investigate these concerns, and those findings have informed the detailed action plan attached.” Source location Response from Mid and South Essex NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a GIRFT review visit to Mid and South Essex NHS Foundation Trust’s neurology department.
Verbatim wording from the response “Having considered your Report and the concerns raised, a GIRFT visit to Mid and South Essex NHS Foundation Trust has been arranged to review the specific situation within their Neurology department.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Appoint two nursing posts within the neurology team.
Verbatim wording from the response “We now have two nursing posts within the team, both roles have recently been appointed to. Our overall administrative support has also increased and additional funding for administrative staff has been obtained for our Multiple Sclerosis service that sits under the Neurology umbrella.” Source location Response from Mid and South Essex NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase neurology administrative support and obtain additional funding for administrative staff in the Multiple Sclerosis service.
Verbatim wording from the response “We now have two nursing posts within the team, both roles have recently been appointed to. Our overall administrative support has also increased and additional funding for administrative staff has been obtained for our Multiple Sclerosis service that sits under the Neurology umbrella.” Source location Response from Mid and South Essex NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish neurology medical staffing with four consultants and three specialty doctors, with annual staffing-needs review.
Verbatim wording from the response “In addition to this, we have invested in staffing within the neurology service. Our medical staffing is now fully established which includes four consultants and three specialty doctors. Our medical staffing is reviewed annually to check the needs of the service are properly met.” Source location Response from Mid and South Essex NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the Long Term Workforce Plan, expanding domestic education, training and recruitment while improving culture, leadership and staff wellbeing.
Verbatim wording from the response “NHS England is also working at a national level to deliver the Long Term Workforce Plan which was published in June 2023. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit neurology clinic records for record-keeping compliance and conduct quarterly reviews for divisional governance assurance.
Verbatim wording from the response “To ensure adherence to the expected standards we have completed an audit of neurology clinic records during February and March 2024.The results of this audit showed overall good compliance with dictation, headers, footers, and onward referrals. Small deviations that were picked up were fed back to the team and actioned. Audit reviews will continue quarterly to provide assurance to the divisional governance meeting. These are in addition to the Trust wide record keeping audits.” Source location Response from Mid and South Essex NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop national neurology guidance and specifications supporting integrated care, including epilepsy services.
Verbatim wording from the response “NHS England’s Neurology Programme is in the process of developing guidance and specifications to support Systems and NHS Trusts to develop integrated care for neurology services, including epilepsy. However, this cannot directly impact issues arising from funding shortfalls in individual services or challenges with recruitment and retention of appropriately qualified medical and nursing staff in some parts of the country, as raised in your Report.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish and disseminate a national bundle of care for children and young people with epilepsy, including transition recommendations.
Verbatim wording from the response “Transition pathways from paediatric to adult services are a particular point of risk with variable processes across the country, with both paediatric and adult neurology services stretched. This is particularly a recognised issue for epilepsy. NHS England’s Paediatrics Programme recently published the national bundle of care for children and young people with epilepsy. Published in October 2023, and builds on existing guidance from the National Institute for Health and Care Excellence (NICE), it is aimed at clinicians by outlining specific recommendations for integrated care systems on the provision of care for children and young people with epilepsy particularly around transition.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate specialist neurology consultations in person rather than routinely by telephone for clinically vulnerable, complex patients.
Verbatim wording from the response “We agree that a telephone appointment was not appropriate to fully assess Chloe’s clinical presentation on this occasion. However, at that time we were operating clinics differently to manage the significant risks presented by the COVID-19 pandemic.” Source location Response from Mid and South Essex NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate and reinforce the requirement that medication tapering regimes are recorded in notes and scanned into electronic patient records.
Verbatim wording from the response “It is our usual practice to record tapering regimes in patient notes, and this is the expected standard as set out in our clinical record keeping standards policy. The regime was recorded in the letter to Chloe’s GP dated 8 September 2021, however the related table drawn up by the Consultant should have been included in Chloe’s notes.” Source location Response from Mid and South Essex NHS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Many concerns about Chloe’s care fall within the NHS Foundation Trust’s remit rather than NHS England’s national programme or policy remit.
Verbatim wording from the response “In your Report you raise concerns over pressures being placed on neurology departments and that there was a recognised shortage of neurologists amid an increase in demand. This response focuses on the concerns raised relevant to NHS England national programme or policy. Many of your concerns around the quality of care delivered to Chloe sit within the remit of Mid and South Essex NHS Foundation Trust, and I note that you have also addressed your Report to them.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The consultant had time to establish Chloe’s dose because it was documented and clinic capacity was available before the appointment.
Verbatim wording from the response “Chloe’s then current dose was readily available to the Consultant prior to her appointment, it was listed on the second page of the GP letter 10 August 2021. We have reviewed the clinic that took place on 3 September 2021 and can confirm that prior to Chloe’s appointment there was one unfilled clinical slot. This is a slot we plan to keep free for urgent/ unexpected cases; and there was one further patient who did not attend. We therefore consider the consultant had time to establish Chloe’s current dose prior to the consultation.” Source location Response from Mid and South Essex NHS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National guidance cannot directly address funding shortfalls or recruitment and retention challenges in individual neurology services.
Verbatim wording from the response “NHS England’s Neurology Programme is in the process of developing guidance and specifications to support Systems and NHS Trusts to develop integrated care for neurology services, including epilepsy. However, this cannot directly impact issues arising from funding shortfalls in individual services or challenges with recruitment and retention of appropriately qualified medical and nursing staff in some parts of the country, as raised in your Report.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trusts are responsible for ensuring safe staffing levels during the day-to-day operation of their hospitals.
Verbatim wording from the response “These actions will aim to close anticipated staffing shortfalls in the NHS in the long term, however Trusts have a responsibility to ensure safe staffing levels in the current day to day operation of their hospitals. This is in line with Care Quality Commission (CQC) Regulation 18 which states that providers must deploy enough suitably qualified, competent, and experienced staff to enable them to meet all other regulatory requirements.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust considers its neurology staffing establishment appropriate to meet service needs after staffing increases and annual review arrangements.
Verbatim wording from the response “In addition to this, we have invested in staffing within the neurology service. Our medical staffing is now fully established which includes four consultants and three specialty doctors. Our medical staffing is reviewed annually to check the needs of the service are properly met.” Source location Response from Mid and South Essex NHS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consultants already had 24/7 pharmacy support and online resources for dosage-conversion queries, although the available support was not accessed.
Verbatim wording from the response “Our consultants are also supported by the pharmacy team who are available 24/7 to assist with dosage conversion queries and ad hoc queries. They also have access to online support and resources. Unfortunately, the consultant did not access this support.” Source location Response from Mid and South Essex NHS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The delay in referral was not attributable to the Trust, which disputes responsibility for the alleged failure to refer Chloe to adult neurology.
Verbatim wording from the response “We acknowledge your concern that there was a delay in Chloe’s referral to adult neurology services, however this delay was not attributable to Mid and South Essex Hospital NHS Foundation Trust.
Chloe was known to our paediatric services however, once she reached 16 years of age her epilepsy was managed by the Royal London Hospital in conjunction with her GP; we did not receive any communication from them relating to her transitional care.” Source location Response from Mid and South Essex NHS
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation After age 16, Chloe’s epilepsy was managed by the Royal London Hospital and her GP, who were responsible for transitional communication.
Verbatim wording from the response “We acknowledge your concern that there was a delay in Chloe’s referral to adult neurology services, however this delay was not attributable to Mid and South Essex Hospital NHS Foundation Trust.
Chloe was known to our paediatric services however, once she reached 16 years of age her epilepsy was managed by the Royal London Hospital in conjunction with her GP; we did not receive any communication from them relating to her transitional care.” Source location Response from Mid and South Essex NHS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Telephone assessment was selected as safer during the COVID-19 pandemic because Chloe was clinically vulnerable to potentially life-threatening infection.
Verbatim wording from the response “We agree that a telephone appointment was not appropriate to fully assess Chloe’s clinical presentation on this occasion. However, at that time we were operating clinics differently to manage the significant risks presented by the COVID-19 pandemic.” Source location Response from Mid and South Essex NHS
Open published response
Concerns raised 4
Failure to refer dosage-clarification correspondence to a clinician View source Failure to refer medication-change correspondence to a clinician for consideration View source Failure to give the prescribing GP express instructions to amend Brivaracetam prescriptions after dosage changes View source
Failure to maintain a reliable written basis for Brivaracetam dosage administration View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Joshua Ethan BURGESS · 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
Joshua Ethan Burgess, who had epilepsy and Lennox-Gastaut syndrome, died at home on 19 November 2022 after vomiting and aspirating during an epileptic seizure. The report identifies concerns about communication and prescribing processes for Brivaracetam, including failures to update the prescription, medication being withheld for several days, and a subsequent increase to 10ml twice daily despite information that 4ml twice daily was appropriate.
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 refer dosage-clarification correspondence to a clinician
Wider context from the report “1. The Neurology department of the Royal Stoke University Hospital operated a system whereby it did not instruct the prescribing GP to amend the prescription of Brivaracetam when changes to dosage had been agreed with Mr Burgess’ mother. The evidence from the Consultant Neurologist was that an assumption was made that when changes to medication had been discussed and agreed that Mr Burgess’ mother would attend the GP surgery to discuss the changes in medication. The same witness gave evidence that it was assumed a pharmacist within the GP surgery would read the correspondence from the neurology department and make the necessary changes to prescriptions without express instructions to do so.
2. The “workflow” within the Brook Medical Centre was such that letters sent from the Neurology department discussing changes in medication (albeit not containing a request to amend the prescription) were processed by support staff and not referred to a clinician to consider and so no changes were made to the prescription.
3. The letter of 27 July 2022 from the Neurology department to Brook Medical Centre seeking clarification as to the correct dosage of Brivaracetam was processed by support staff and a summary medications sent without referral to a clinician .
4. Godfrey Care were informed by Mr Burgess’ mother and the Neurology department of Royal Stoke University that the appropriate dose of Brivaracetam was 4ml twice daily. Medication was withheld between 22-26 July 2022 due to the information not being in writing from the prescriber, however the evidence at inquest was that 10ml twice daily was commenced on 26 July 2022 following a call to the 111 service.
” Source location Joshua Ethan BURGESS · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to refer medication-change correspondence to a clinician for consideration
Wider context from the report “1. The Neurology department of the Royal Stoke University Hospital operated a system whereby it did not instruct the prescribing GP to amend the prescription of Brivaracetam when changes to dosage had been agreed with Mr Burgess’ mother. The evidence from the Consultant Neurologist was that an assumption was made that when changes to medication had been discussed and agreed that Mr Burgess’ mother would attend the GP surgery to discuss the changes in medication. The same witness gave evidence that it was assumed a pharmacist within the GP surgery would read the correspondence from the neurology department and make the necessary changes to prescriptions without express instructions to do so.
2. The “workflow” within the Brook Medical Centre was such that letters sent from the Neurology department discussing changes in medication (albeit not containing a request to amend the prescription) were processed by support staff and not referred to a clinician to consider and so no changes were made to the prescription .
3. The letter of 27 July 2022 from the Neurology department to Brook Medical Centre seeking clarification as to the correct dosage of Brivaracetam was processed by support staff and a summary medications sent without referral to a clinician.
4. Godfrey Care were informed by Mr Burgess’ mother and the Neurology department of Royal Stoke University that the appropriate dose of Brivaracetam was 4ml twice daily. Medication was withheld between 22-26 July 2022 due to the information not being in writing from the prescriber, however the evidence at inquest was that 10ml twice daily was commenced on 26 July 2022 following a call to the 111 service.
” Source location Joshua Ethan BURGESS · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to give the prescribing GP express instructions to amend Brivaracetam prescriptions after dosage changes
Wider context from the report “1. The Neurology department of the Royal Stoke University Hospital operated a system whereby it did not instruct the prescribing GP to amend the prescription of Brivaracetam when changes to dosage had been agreed with Mr Burgess’ mother . The evidence from the Consultant Neurologist was that an assumption was made that when changes to medication had been discussed and agreed that Mr Burgess’ mother would attend the GP surgery to discuss the changes in medication. The same witness gave evidence that it was assumed a pharmacist within the GP surgery would read the correspondence from the neurology department and make the necessary changes to prescriptions without express instructions to do so .
2. The “workflow” within the Brook Medical Centre was such that letters sent from the Neurology department discussing changes in medication (albeit not containing a request to amend the prescription) were processed by support staff and not referred to a clinician to consider and so no changes were made to the prescription.
3. The letter of 27 July 2022 from the Neurology department to Brook Medical Centre seeking clarification as to the correct dosage of Brivaracetam was processed by support staff and a summary medications sent without referral to a clinician.
4. Godfrey Care were informed by Mr Burgess’ mother and the Neurology department of Royal Stoke University that the appropriate dose of Brivaracetam was 4ml twice daily. Medication was withheld between 22-26 July 2022 due to the information not being in writing from the prescriber, however the evidence at inquest was that 10ml twice daily was commenced on 26 July 2022 following a call to the 111 service.
” Source location Joshua Ethan BURGESS · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain a reliable written basis for Brivaracetam dosage administration
Wider context from the report “1. The Neurology department of the Royal Stoke University Hospital operated a system whereby it did not instruct the prescribing GP to amend the prescription of Brivaracetam when changes to dosage had been agreed with Mr Burgess’ mother. The evidence from the Consultant Neurologist was that an assumption was made that when changes to medication had been discussed and agreed that Mr Burgess’ mother would attend the GP surgery to discuss the changes in medication. The same witness gave evidence that it was assumed a pharmacist within the GP surgery would read the correspondence from the neurology department and make the necessary changes to prescriptions without express instructions to do so.
2. The “workflow” within the Brook Medical Centre was such that letters sent from the Neurology department discussing changes in medication (albeit not containing a request to amend the prescription) were processed by support staff and not referred to a clinician to consider and so no changes were made to the prescription.
3. The letter of 27 July 2022 from the Neurology department to Brook Medical Centre seeking clarification as to the correct dosage of Brivaracetam was processed by support staff and a summary medications sent without referral to a clinician.
4. Godfrey Care were informed by Mr Burgess’ mother and the Neurology department of Royal Stoke University that the appropriate dose of Brivaracetam was 4ml twice daily. Medication was withheld between 22-26 July 2022 due to the information not being in writing from the prescriber , however the evidence at inquest was that 10ml twice daily was commenced on 26 July 2022 following a call to the 111 service .
” Source location Joshua Ethan BURGESS · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a local medication policy covering medication receipt, transcription, altered labels, missed doses, written prescribing confirmation and triangulation between prescribers.
Verbatim wording from the response “Reviewed Policies and Procedures
The following actions will be implemented by 1st April 2024.” Source location Response from Godfrey Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review internal policies and procedures against the coroner’s concerns and identify necessary changes.
Verbatim wording from the response “Godfrey Care Response
We intend to review our internal policies and procedures considering the coroners concerns and identify where changes need to be made. Below, we respond to the coroner’s areas of concern, setting out what we have already done, what we are doing now, and what we intend to do in the future.” Source location Response from Godfrey Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update staff medication competency assessments to test clarification of unclear directions, MAR-label discrepancies and verbal medication changes.
Verbatim wording from the response “3 The Staff Medication Competency Assessment has been reviewed and now includes the following questions.” Source location Response from Godfrey Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Have a GP review and triage all neurology correspondence and clinic letters received by Brook Medical Centre.
Verbatim wording from the response “2. We have discussed the above process with nominated individuals from the ICS. Due to the timeframes that would be required for the creation of standardised template for clinic letters within the ‘Medisec’ system across the Trust, we are reiterating the Trust standards and ████████ has agreed, with immediate effect, that all clinic letters received from neurology will be reviewed by a GP at Brook Medical Centre. This has been implemented due to the acknowledgement that neurological conditions are often complex, and it is more likely that they will require frequent medication changes, titration and/or closer monitoring.” Source location Response from University Hospitals of North Midlands
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require GP review and triage of all neurology correspondence received by Brook Medical Centre.
Verbatim wording from the response “2. We have discussed the above process with nominated individuals from the ICS. Due to the timeframes that would be required for the creation of standardised template for clinic letters within the ‘Medisec’ system across the Trust, we are reiterating the Trust standards and ████████ has agreed, with immediate effect, that all clinic letters received from neurology will be reviewed by a GP at Brook Medical Centre. This has been implemented due to the acknowledgement that neurological conditions are often complex, and it is more likely that they will require frequent medication changes, titration and/or closer monitoring.” Source location Response from University Hospitals of North Midlands
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a standardised Medisec clinic-letter template specifying medication changes and clear prescribing actions for primary care.
Verbatim wording from the response “1. The Trust’s outpatient clinic letter standards describe the structure of clinic letters based on standard headings. You will recall that ████████ (GP) gave evidence at the inquest to the effect that there were areas in the acute Trust setting which already provided discharge information which he considered to be of a ‘gold standard.’ The Trust is committed to working towards improving compliance with these standards. To support this, we are working towards creation of a standardised template in our ‘Medisec’ system (system where letters are created). This will include a section for changes to medications and clear actions for those in the primary care setting, for example, instructions for the prescribing GP to amend prescriptions.” Source location Response from University Hospitals of North Midlands
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update weekly and monthly managers’ medication audits to verify written authorisation, dosage changes and timely receipt of replacement prescriptions.
Verbatim wording from the response “• Run through the reviewed managers monthly medication audit to ensure expectations are clear.” Source location Response from Godfrey Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a standardised clinic-letter template specifying medication changes and clear actions for prescribing GPs.
Verbatim wording from the response “1. The Trust’s outpatient clinic letter standards describe the structure of clinic letters based on standard headings. You will recall that ████████ (GP) gave evidence at the inquest to the effect that there were areas in the acute Trust settings which already provided discharge information which he considered to be of a ‘gold standard.’ The Trust is committed to working towards improving compliance with these standards. To support this, we are working towards creation of a standardised template in our ‘Medisec’ system (system where letters are created). This will include a section for changes to medications and clear actions for those in the primary care setting, for example, instructions for the prescribing GP to amend prescriptions.” Source location Response from University Hospitals of North Midlands
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A standardised clinic-letter template cannot be created immediately because implementation across the Trust requires substantial timeframes.
Verbatim wording from the response “2. We have discussed the above process with nominated individuals from the ICS. Due to the timeframes that would be required for the creation of standardised template for clinic letters within the ‘Medisec’ system across the Trust, we are reiterating the Trust standards and ████████ has agreed, with immediate effect, that all clinic letters received from neurology will be reviewed by a GP at Brook Medical Centre. This has been implemented due to the acknowledgement that neurological conditions are often complex, and it is more likely that they will require frequent medication changes, titration and/or closer monitoring.” Source location Response from University Hospitals of North Midlands
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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 The delay in administering medication did not contribute to the death.
Verbatim wording from the response “4. Whilst this concern is not directly addressed to the acute Trust (UHNM) or Brook medical Centre, it has been considered as part of the wider learning following Joshua’s death. Medications for epilepsy is considered across the healthcare economy to be ‘critical’. The National Patient Safety Agency (2010) defined critical medicines as ‘medicines which can result in patient death or serious harm if there are delays in their administration’. Whist the Coroner found that the delay in administering medications on this occasion did not contribute to Joshua’s death, we believe that further education within the care home setting is required. With this in mind, we will work together with the local authority to ensure that up to date communications are shared across the Stoke on Trent and North Staffordshire health and social care economy to reiterate this message.” Source location Response from University Hospitals of North Midlands
Open published response
18 Dec 2023 Nuel-Junior DZERNJO · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1
Lack of clear guidance on the appropriate route of Acyclovir treatment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Nuel-Junior DZERNJO · 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
Nuel-Junior Dzernjo, who was receiving high-dose steroids and was immunosuppressed, developed chicken pox and deteriorated after being assessed at hospital on 21 February 2023. He was discharged despite ongoing abnormal observations, inability to mobilise and confusion, then deteriorated at home and died after collapsing the following day. The investigation identified unclear guidance on treatment, including whether intravenous rather than oral Acyclovir was indicated.
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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 clear guidance on the appropriate route of Acyclovir treatment
Wider context from the report “During the course of my investigation into the death of Nuel-Junior I instructed an independent paediatric expert to review his management and opine on causation. During the course of hearing the evidence from the expert and all of the treating clinicians it became clear that there was some potentially relevant guidance available but it lacked clarity . Here intravenous Acyclovir, if prescribed, may have prevented Nuel-Junior's death but he was instead prescribed oral Acyclovir which was unlikely to have made a difference . Had clear guidance been available then Nuel-Junior's death may have been prevented.
” Source location Nuel-Junior DZERNJO · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share report-derived information and local improvement suggestions with paediatric members through the patient safety portal, including promoting BNFC guidance.
Verbatim wording from the response “The College will be sharing information and suggestions for local improvement from your report with our paediatric members via its patient safety portal, including the promotion of the BNFC guidance to improve awareness across the profession. The information within your report will also be shared for discussion with the RCPCH Clinical Quality in Practice group in early Spring, where further actions may be identified.” Source location Response from Royal College of Paediatrics and Child health
Open published response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Developing guidance on chickenpox and covering every clinical circumstance falls outside NICE’s requested scope and recommendations.
Verbatim wording from the response “NICE have not published a guideline on managing chickenpox. We are not asked to develop guidance on all conditions and our recommendations do not cover all clinical circumstances.” Source location Response from National Institure for Health and Care Excellence
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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 The existing Clinical Knowledge Summary recommendation is considered clear about seeking specialist advice and determining intravenous aciclovir admission.
Verbatim wording from the response “There is a Clinical Knowledge Summary (CKS) published on our website on chickenpox, including a section on the management of chickenpox in people who are immunocompromised. The CKS are developed by an external company called Agilio Software and are designed to summarise the evidence on the treatment of specific health conditions. They use a variety of sources and may include NICE guidance, if there is any that is relevant, but they use many other sources too. We publish them on our website as a source of advice and information for health professionals working in primary care, but they do not constitute NICE guidance.” Source location Response from National Institure for Health and Care Excellence
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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 Agilio Software is responsible for providing further clarification about the Clinical Knowledge Summary topic’s content.
Verbatim wording from the response “As part of this process, we have shared this report with Agilio Software for their awareness, however, if further clarification is required on the content of the CKS topic, Agilio software can be contacted directly.” Source location Response from National Institure for Health and Care Excellence
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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 BNFC guidance for intravenous treatment of varicella in immunocompromised children is clear, contrary to the concern that guidance was unclear.
Verbatim wording from the response “Thank you for sharing your report with us regarding the tragic and untimely passing of Nuel-Junior. We were saddened to read the circumstances surrounding Nuel-Junior’s death and have discussed with senior colleagues within the RCPCH and the British Paediatric Allergy, Immunity and Infection Group (BPAIIG). Thank you for confirming in a separate correspondence that the doctors knew that Nuel-Junior was immunocompromised, and that he was initially not particularly "unwell" and presented with typical signs of chickenpox (including a temperature and spots/lesions). You described further that Dr Louis Grandjean, an independent paediatric expert instructed by the court, was of the view that the guidance was unclear.” Source location Response from Royal College of Paediatrics and Child health
Open published response
Concerns raised 1
Failure to measure the incision from the insular to the Temporal Horn at appropriate intra-operative times View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Tracy Gambrill · 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
Tracy Gambrill underwent neurosurgery on 7 November 2016 and sustained serious brain injury after excessively deep incisions were made while locating the temporal horn. She died in hospital on 19 November 2016. The principal concern was that it was not current and expected practice to measure the incision from the insular to the temporal horn at appropriate times during the operation.
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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 measure the incision from the insular to the Temporal Horn at appropriate intra-operative times
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
Each of the three surgical incisions were far too deep considering the average distance between the insular and the Temporal Horn. Only the second incision was measured intra operatively using a cannula and this was after the completion of the incision. From the evidence it is apparent that this operation is undertaken with surgeons relying on anatomical landmarks and head position to perform the procedure safely. The inquest did hear from an expert neurosurgical witness whose practice it was to measure the length of his incisions intra-operatively at appropriate times. This practice resulted in him having aborted an operation after failing to find the Temporal Horn within expected limits. Post-operatively he discovered that the patient’s head had moved from the correct position.
I am concerned that it remains the position that it is not current and expected practice to measure the incision from the insular to the Temporal Horn at appropriate times during the operation.
” Source location Tracy Gambrill · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the case précis and surgical safety advice to members performing amygdalohippocampectomy.
Verbatim wording from the response “On considering the coroner’s report, I consider that sharing a précis of the case, as presented to me, is appropriate so that points raised by the coroner can be considered by members performing amygdalohippocampectomy.” Source location Response from Society of British Neurological Surgeons
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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 Clinical procedure guidance falls outside the respondent’s role, which provides only high-level professional standards.
Verbatim wording from the response “You raise the concern in your report that it is not current and expected practice for surgeons to measure the incision from the insula to the temporal horn at appropriate times during a transsylvian amygdalohippocampectomy. We do not provide guidance on clinical procedures, and other organisations who hold the expert clinical knowledge will be better placed to address your concern more directly, but I will explain where our standards and guidance will support actions taken to address your concern.” Source location Response from General Medical Council
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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 Queries about specific procedure details should be directed to NICE, medical royal colleges, or specialty bodies.
Verbatim wording from the response “As the standards we set for medical education and practice don’t describe the details of specific procedures, we would refer queries on these to the National Institute for Clinical Excellence (NICE), medical royal colleges or specialty bodies. I note that The Society of British Neurological Surgeons (SBNS) has already responded to your concern with immediate action, writing to all SBNS members, asking them to recognise the importance of measuring depth intraoperatively, and empowering them to abort surgery when findings are not consistent with expectations.” Source location Response from General Medical Council
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