Epilepsy, 19 Sep 2013 – 19 Jun 2026

Epilepsy-related Prevention of Future Deaths reports

All dates19 Sep 2013 – 7 Sep 2026

Custom range

Based on PFD publication date. Dates are available up to the published snapshot: 7 Sep 2026. Preset periods end on this date.

90All reports 19SUDEP 68Non-SUDEP

Select SUDEP or Non-SUDEP to filter concerns and reports. 3 reports could not be assigned and remain in All only. Counts are PFD reports, not deaths.

About this dataset

We searched all 6,433 reports in the published corpus using a fixed text-search method, then assessed 317 candidates against source-based inclusion criteria. Ninety reports were included. Epilepsy had to be materially relevant to the death or a substantive coroner’s concern; incidental mentions were excluded.

Eligibility and SUDEP assignment were assessed with GPT-5.6 Sol and checked for valid source quotations. Assignment uses a balance-of-probabilities threshold: SUDEP or non-SUDEP must be more likely than not on the report’s evidence. The exact term SUDEP need not appear. Genuinely unclear eligible reports remain in All only. These are model-assisted documentary assessments, not independently validated clinical diagnoses.

The search can miss reports with sparse terminology or incomplete source text. This dataset does not represent all epilepsy deaths. Recurring concerns and responses are taken from the existing published evidence. Published corpus snapshot: 7 September 2026. Cohort selection updated 5 November 2026. The title shows the first and last included reports’ publication dates.

Reports over time

Matching reports published each year within the selected date range.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Matching reports sent to each recipient.

Department of Health and Social Care8
NHS England6
Department for Transport4
HM Prison and Probation Service4
Association Of British Neurologists2
Care Quality Commission2
College of Policing2
General Medical Council2
London Ambulance Service NHS Trust2
Ministry of Justice2
National Police Chiefs’ Council2
Royal College of Paediatrics and Child Health2
Aneurin Bevan University LHB1
BNF Publications1
Barts Health NHS Trust1
Betsi Cadwaladr University LHB1
Bournemouth, Christchurch and Poole Council1
Brook Medical Centre1
Caring Limited1
Central and North West London NHS Foundation Trust1
Choice Support1
Cleveland Police1
Coastal Homecare – Hove Branch1
Community Disability Nurse1
DW Fitness First1
Department for Business, Energy & Industrial Strategy1
Department for Education1
Disclosure and Barring Service1
Dorset County Council1
Dorset Healthcare University NHS Foundation Trust1
Dorset Police1
Driver and Vehicle Licensing Agency1
Dwf LLP1
East Lancashire Hospitals NHS Trust1
East Midlands Ambulance Service NHS Trust1
Emsworth Surgery1
Epilepsy Action1
Epsom and St Helier University Hospitals NHS Trust1
Forest Bank Prison1
General Pharmaceutical Council1
Gloucestershire Health and Care NHS Foundation Trust1
Godfrey Care1
Grant Shapps MP1
Greater Manchester Health and Social Care Partnership1
Grosvenor Medical Centre1
Grupo de Turismo Gaviota S.A.1
Hampshire and Isle of Wight Healthcare NHS Foundation Trust1
Hazelmere Medical Centre1
Health and Safety Executive1
High Down Prison1
Home Office1
Independent Futures1
James Paget University Hospitals NHS Foundation Trust1
Kendal Calling1
Kettering General Hospital1
King Street Medical Centre1
Lewisham and Greenwich NHS Trust1
Lindholme Prison1
Medway NHS Foundation Trust1
Mid and South Essex NHS Foundation Trust1
Midway Pharmacy1
Ministry of Housing, Communities and Local Government1
NHS Birmingham and Solihull Integrated Care Board1
NHS Dorset Integrated Care Board1
NHS Greater Manchester Integrated Care Board1
NHS Leicester, Leicestershire and Rutland Integrated Care Board1
NHS South West London Integrated Care Board1
National Institute for Health and Care Excellence1
Norfolk and Suffolk NHS Foundation Trust1
North London NHS Foundation Trust1
Northfield Medical Centre1
Office of the Chief Coroner1
Oxleas NHS Foundation Trust1
Parc Prison and Young Offender Institute1
Pennine Care NHS Foundation Trust1
Pentree Lodge1
Practice Plus Group1
Recipient name withheld1
Richmond Medical Centre (Solihull)1
Rochester Prison1
Royal College of General Practitioners1
Royal College of Psychiatrists1
Royal College of Surgeons of England1
Sheffield Health Partnership University NHS Foundation Trust1
Sherwood Forest Hospitals NHS Foundation Trust1
Skills for Care Ltd1
Sodexo1
South Tees Hospitals NHS Foundation Trust1
Southwinds1
Springbank Care Home Limited1
St Edward's School1
St George'S University Hospitals NHS Foundation Trust1
Stepping Hill Hospital1
Suffolk County Council1
Sussex Community NHS Foundation Trust1
Sussex Police1
Tameside Borough Council1
Tameside General Hospital1
Tameside and Glossop Integrated Care NHS Foundation Trust1
Tees, Esk and Wear Valleys NHS Foundation Trust1
Tewkesbury Borough Council1
Thameside Prison1
The Roehampton Surgery1
The Society Of British Neurological Surgeons1
Thomas Cook Tour Operations Limited1
Transport for London1
UCB Pharma1
University College London Hospitals NHS Foundation Trust1
University Hospitals Birmingham NHS Foundation Trust1
University Hospitals Dorset NHS Foundation Trust1
University Hospitals of North Midlands NHS Trust1
Wm Morrison Supermarkets plc1
Worcestershire Acute Hospitals NHS Trust1
ukactive1

Most commonly raised concerns

Non-SUDEP 68 reports 19 Sep 2013 – 7 Sep 2026

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  1. Incomplete, inaccurate or unavailable clinical and care recordsClinical and care records are incomplete, inaccurate, inconsistent, unavailable or otherwise unreliable for safe care.5 reportsSelected
  2. Unsafe medication administrationA recurring failure of the medication-administration system to ensure that medicines are administered safely, accurately, promptly and as prescribed.5 reportsSelected
  3. Inadequate driver licensing controls for road safetyDriver licensing systems do not reliably identify, record, review or restrict drivers whose inexperience, health or vehicle-related risk requires additional safeguards.4 reportsSelected
  4. Unreliable seizure care and managementControls dedicated to recognising, assessing, monitoring, responding to and managing seizures are not reliably provided.4 reportsSelected
  5. Failure to communicate clinically important information reliably between care servicesRecurring concern that clinically important guidance, decisions and patient information are not kept accurate, current and available to the clinicians and emergency services who need them.3 reportsSelected
  6. Failure to ensure clinical investigation results are reliably available, interpreted and acted uponRecurring deficiency in the end-to-end management of clinical investigation results, including their availability, transmission, checking, review, interpretation, follow-up and escalation when needed.3 reportsSelected
  7. Failure to provide required medication promptly when clinically neededThe anchor identifies delayed prescribing of a patient's usual medication after an unexpected admission, while another report identifies delayed prescribing and non-provision of urgent therapeutic medication. These support a recurring concern about timely provision of clinically required medication rather than only the anchor's admission or prescribing-step failure.3 reportsSelected
  8. Insufficient police training for safe recognition and response to mental-health and behaviour-related medical crisesReports identify insufficient police training to recognise and respond safely to mental-health crises and behaviour-related medical emergencies.3 reportsSelected
  9. Insufficient qualified healthcare staffing capacityHealthcare services lack enough appropriately qualified staff to provide the required clinical coverage and patient care safely for the workload, acuity and specialist needs.3 reportsSelected
  10. Unreliable DVLA medical fitness notification arrangementsThe anchor identifies limited professional awareness and uncertain effectiveness of guidance for notifying the DVLA about medically relevant driving risks. A different report identifies clinicians failing to advise patients with cough syncope to stop driving and notify the DVLA, while another identifies failure to notify the DVLA of relevant medical conditions. These support the named DVLA medical-fitness notification process rather than guidance awareness alone.3 reportsSelected
  11. Electronic patient records failing to make relevant clinical information available and actionableRecurring concern that electronic patient-record systems do not reliably present, preserve, share or prompt action on clinically relevant information across the patient’s care.2 reportsSelected
  12. Failure to conduct required welfare checks on people in distressThe anchor identifies a risk that care home staff will not check a resident in distress, while a different canonical report identifies failure to conduct a later welfare check on a person left in potential medical distress. Together these support a recurring concern about welfare checks not being completed when a person may require assistance.2 reportsSelected
  13. Failure to identify and address recurring safety issues through organisational learningDifferent reports identify failures of reporting, review and learning arrangements to retain, recognise and address substantive or recurring patient-safety issues, rather than merely failures to complete one specific corrective action.2 reportsSelected
  14. Failure to reliably learn from medication incidents and implement safeguardsThe medication incident learning process is unreliable: incidents are not consistently followed up or reviewed to identify, communicate and implement safeguards that protect patients from recurrence.2 reportsSelected
  15. Failure to reliably recognise and respond to acute clinical deteriorationClinical deterioration is not reliably recognised, monitored, escalated and acted upon with the urgency it requires.2 reportsSelected
  16. Failure to seek medical attention when a person's condition warrants itReports identify an unreliable escalation control in which care staff or other responders do not promptly seek medical or paramedic assistance when a person's injury, pain, fall or deterioration warrants clinical attention.2 reportsSelected
  17. Inadequate control of illicit substance use and supply in secure institutionsThe anchor identifies an ongoing failure to mitigate illicit substance entry, distribution and use in a secure hospital, while assertions from different reports identify continuing illicit-drug influx, widespread access and weak supply-reduction controls in prisons. These distinct manifestations support a bounded concern about controlling illicit substances in secure institutional settings, rather than only room searches, drug testing or a prison-specific strategy.2 reportsSelected
  18. Inadequate controls on contraband mobile phones in prisonsDifferent reports identify failures in the prison control system for preventing and mitigating access to contraband mobile phones, including their easy availability to prisoners and their use to facilitate drug dealing and other prison-security risks.2 reportsSelected
  19. Inadequate recording of medication prescribing decisionsReports identify unreliable medication prescribing records that can obscure prescribing status, rationale, changes or safety-critical decisions and thereby allow unsafe medication to be prescribed or administered.2 reportsSelected
  20. Inadequate staff competence to provide first aidReports identify an unsafe first-aid capability condition across healthcare, care, custody and other staff. The recurring concern is the unreliability of staff competence to recognise emergencies and provide appropriate first aid, rather than any single training, refresher, assessment or practical-performance failure.2 reportsSelected
  21. Unreliable Care Programme Approach care coordinationReports identify different failures within the named Care Programme Approach, including the absence of a structured medication review and failures to allocate coordinators, complete required reviews, maintain care plans and follow up patients. Together these support a recurring concern with the reliable operation of CPA care coordination rather than medication review alone.2 reportsSelected
  22. Unreliable RIO clinical-record functionsThe anchor identifies an unclear timeliness standard for RIO entries, while different reports identify failures of RIO to support complete information capture, cross-team access and usable observation records. Together these support a recurring concern with the reliability of the named RIO clinical-record system rather than only one entry-timing or documentation manifestation.2 reportsSelected
  23. Unreliable communication of patient-care information between clinical staffClinical staff responsible for the same patient's care do not reliably exchange relevant information about care, treatment and risk.2 reportsSelected
  24. Unreliable escalation by care staff for required medical attentionCare staff do not reliably recognise and escalate deterioration, pain or other safety concerns to obtain timely medical assessment or advice.2 reportsSelected
  25. Unreliable healthcare patient transfer processesHealthcare transfers do not reliably provide the procedures, responsibility, documentation and clinical information needed for safe movement and continuity of care.2 reportsSelected
  26. Unreliable hospital discharge processesHospital discharge does not reliably bring together planning, clinical readiness, relevant organisations, safe execution and required follow-up.2 reportsSelected
  27. Unreliable implementation of medication changesReports identify different failures in the medication-change process, including failure to act on a prescribed reduction, failure to ensure carers acknowledge changes, and difficulty implementing specialist-directed changes accurately. Together these support the wider unsafe condition that medication changes are not reliably implemented across prescribing, communication and follow-up controls.2 reportsSelected
  28. Unreliable medication dosage verification and communicationReports identify unsafe failures to ensure that medication dosages are accurately verified, clarified and communicated across prescribing, dispensing and administration activities.2 reportsSelected
  29. Unreliable mental health referral pathwaysReports identify different failures within the mental health referral process, including referrals not being made when indicated, received referrals not being actioned, and frontline practitioners lacking clarity about when and where to refer. These support a recurring concern with the reliability of mental health referral pathways rather than any single referral or awareness failure.2 reportsSelected
  30. Unreliable patient observation arrangementsPatient observation systems do not reliably set, support and deliver the observation level required by assessed safety risk.2 reportsSelected
  31. Unreliable review and action on clinically significant incoming correspondenceReports identify failures across the incoming clinical-correspondence process, including failure to identify GP medication-review requests, failure to bring action-requiring correspondence to medical staff, and correspondence being filed without GP review or action. The shared unsafe condition is that clinically significant correspondence may not reliably reach the responsible clinician or trigger the required clinical response.2 reportsSelected
  32. Unreliable safety CCTV monitoring systemsDifferent reports identify failures in the operation of CCTV used as a safety control, including absent staff access arrangements, inadequate coverage, non-working cameras, insufficient monitoring and unclear staff instructions. Together these support the reliability of safety CCTV monitoring as the parent concern rather than any single access, coverage, equipment or training failure.2 reportsSelected
  33. Unsafe medication prescribingReports identify unsafe prescribing decisions in which the medication, indication, dose or relevant clinical circumstances are not adequately evaluated before prescribing.2 reportsSelected

Reports matching this classification

19 Sep 2013 – 7 Sep 2026 · 68 reports

Classification: non-sudep
Reset

Showing all concerns and their linked actions and positions from reports in this date range for non-sudep. Select a recurring concern above to narrow the evidence.

Actions and positions describe what recipients stated in published responses. Select a statement to read its source wording.

  1. Inner West London

    AI-generated summary

    Mrs Elsie Leaver · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mrs Elsie Leaver died on 23 August 2020, aged 89, from multiple organ failure following a mixed drug overdose. The report raised concerns about missing psychiatric history, inadequate psychiatric assessment and risk assessment, failure to access available health information, and the lack of formal psychiatric liaison cover at QMH.

    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 by SGH doctors to take a reasonable psychiatric history during clerking

    Wider context from the report

    “2. That doctors at SGH do not take a reasonable psychiatric history as part of their clerking and thus fail to make a proper holistic assessment of the patient and potentially miss the opportunity to manage risks such as those in this case which may lead to death. ”

    Source location

    Mrs Elsie Leaver · Prevention of Future Deaths report
    Page 4 · concerns

    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 formal psychiatric liaison cover at QMH

    Wider context from the report

    “4. That NHS South West London Integrated Care Board has made no formal provision for psychiatric liaison cover at QMH, despite there being such a clear clinical need for this that the team from psychiatric liaison have felt compelled to provide informal telephone advice for the last 10 years. ”

    Source location

    Mrs Elsie Leaver · Prevention of Future Deaths report
    Page 4 · concerns

    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

    Omission of pertinent psychiatric history from GP summaries

    Wider context from the report

    “1. That the GP summary did not contain pertinent psychiatric history that would have assisted the hospital clinicians to identify Mrs Leaver’s depression and specifically her suicidality. ”

    Source location

    Mrs Elsie Leaver · Prevention of Future Deaths report
    Page 4 · concerns

    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 SGH doctor training on HIE information and access

    Wider context from the report

    “3. That doctors at SGH need training on the information available on HIE and how to access it. ”

    Source location

    Mrs Elsie Leaver · Prevention of Future Deaths report
    Page 4 · concerns

    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 access pathway requiring physically frail QMH patients to travel by LAS ambulance to SGH A&E for psychiatric advice

    Wider context from the report

    “5. That the lack of formal psychiatric advice availability at QMH puts vulnerable patients at increased risk, since the only way to properly access such advice is for them to be sent by LAS ambulance to A&E at SGH, when they are physically frail, given that QMH is a rehabilitation unit. ”

    Source location

    Mrs Elsie Leaver · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report
  2. Mid Kent and Medway

    AI-generated summary

    John Allen Martin HENDERSON · 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

    John Allen Martin Henderson was found dead in his bunk at HMP Rochester on 27 May 2021. The inquest recorded natural causes, namely ischaemic heart disease, following a fatal haemorrhage into the wall of the left circumflex artery. Concerns included delayed medical investigations, the absence of a welfare check at the start of the day, and a lack of a clear process for sharing relevant medical information with front-line prison staff.

    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 provide closer monitoring for prisoners with seizure activity

    Wider context from the report

    “During the course of evidence, I also established that John was not being monitored any more closely than other prisoners due to his seizure activity. That was confirmed by ████████ ████████ in the course of their evidence. They indicated to me that sometimes they will be asked to monitor prisoners more closely but this had not been applied to John. Likewise, nobody had checked the welfare of John at the start of the day on 27 May 2021. ”

    Source location

    John Allen Martin HENDERSON · Prevention of Future Deaths report
    Page 2 · concerns

    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 conduct start-of-day prisoner welfare checks

    Wider context from the report

    “During the course of evidence, I also established that John was not being monitored any more closely than other prisoners due to his seizure activity. That was confirmed by ████████ ████████ in the course of their evidence. They indicated to me that sometimes they will be asked to monitor prisoners more closely but this had not been applied to John. Likewise, nobody had checked the welfare of John at the start of the day on 27 May 2021. ”

    Source location

    John Allen Martin HENDERSON · Prevention of Future Deaths report
    Page 2 · concerns

    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 a clear process for consent-based disclosure of prisoners' medical information to front line officers

    Wider context from the report

    “I asked additional questions of witnesses and asked to have sight of policies and procedures in respect of information sharing protocols and procedures in respect of prisoners with chronic conditions, (be is seizure activity, diabetes, cardiac issues). My concern being that there did not appear to be a clear process for prisoners to consent to disclosure of medical information to front line officers so that they could be made aware that a particular prisoner may be prone to sudden or unexpected medical episodes. My concern was that a prisoner could have a sudden (but perhaps predictable) acute medical episode and front line prison staff may not be made aware of what was causing the issue or how to respond thereto. ”

    Source location

    John Allen Martin HENDERSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 Personal Management Plans to obtain consent, share relevant medical alerts and guidance, record required observations, and review at multidisciplinary prison meetings.

    Verbatim wording from the response

    “Since this inquest, Oxleas NHS Foundation Trust has worked closely with HMPPS to introduce a Personal Management Plan (PMP) which provides a way of sharing information between healthcare staff and prison officers.”

    Source location

    Response from Oxleas Forensic and Offender Healthcare Services
    Page 1 · response
    Published 25 January 2023

    Open published response
  3. County Durham and Darlington

    AI-generated summary

    Charles William WHEATLEY · 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

    Charles William Wheatley died at the scene of a head-on road traffic collision on the A66 on 14 December 2021. The report identified concerns that he had no valid driving licence, had epilepsy and was not taking his anti-epileptic medication regularly, and that the system allows a person to own a car without a driving licence.

    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 of the vehicle ownership system to prevent purchase and retention of cars by unlicensed drivers

    Wider context from the report

    “While it may not have prevented Amy’s death, it seems illogical and indeed incomprehensible to me that the system allows a person to buy a car without having a licence to drive it. In this case there was no evidence that Mr Wheatley had ever held a driving licence. I recognise that currently, the DVLA are responsible for the statutory instrument 1999/2864 which covers matters around driving entitlements and that vehicle ownership/registered keepers are catered for under an Act of Parliament (the Vehicle Excise and Registration Act 1994) and therefore significant change in the law would be needed. However, I suspect that the public would find it difficult to understand how someone can buy and keep a car without having a licence to drive the vehicle. ”

    Source location

    Charles William WHEATLEY · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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 law does not require a driving licence to register or keep a vehicle, including where the keeper will not drive it.

    Verbatim wording from the response

    “I note that following the inquest, you have asked why an individual is able to purchase a vehicle when they do not hold a driving licence. It may help to explain that the purpose of the vehicle register held by the Driver and Vehicle Licensing Agency (DVLA), is to record details of vehicles and their registered keepers. While the DVLA requests proof of the applicant’s name and address when a vehicle is first registered, and for the driving licence number of a new keeper at subsequent keeper changes, there is no requirement in law to hold a driving licence to register a vehicle, or to become the keeper of an already registered vehicle.”

    Source location

    Response from Department for Transport
    Page 1 · response
    Published 7 October 2022

    Open published response
  4. Dorset

    AI-generated summary

    Gaia Kima Pope-Sutherland · 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

    Gaia Kima Pope-Sutherland, who had epilepsy and mental health conditions, left her aunt’s address in a psychotic state on 7 November 2017 and was later found deceased on 18 November 2017. The jury concluded that she probably died from hypothermia between 15.59 on 7 November and 10.00 on 8 November 2017. Principal concerns included under-resourcing and poor communication between epilepsy, neurology and mental health services, as well as issues concerning police training, missing-person policies and record keeping, and communication and information sharing within mental health services.

    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 of Mental Health teams to provide assessment information directly to GPs

    Wider context from the report

    “x. As per paragraph 1(xiii) above, when a Mental Health Act assessment is undertaken, there is a possibility that information may not be fed back to the GP in the best way or in a timely manner, if it is not fed back by those from the Mental Health team, and I therefore request that consideration is given to the DHUFT representatives forwarding information, directly to the GP, rather than through the discharging team at the acute hospital. This may include their RiO record notes, or their assessment notes. ”

    Source location

    Gaia Kima Pope-Sutherland · Prevention of Future Deaths report
    Page 7 · concerns

    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 policy for handling sexual harassment or assault in DHUFT inpatient units

    Wider context from the report

    “vi. As per paragraph 1(ix) above, the occurrence of sexual harassment or assault whilst an inpatient at one of DHUFT’s inpatient units could have a detrimental effect on a person’s mental health which could have fatal consequences. I request that consideration is given to a policy being put into place to provide guidance to staff as to how to deal with this situation. ”

    Source location

    Gaia Kima Pope-Sutherland · Prevention of Future Deaths report
    Page 2 · concerns

    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 police officer knowledge of life-threatening illnesses and their behavioural impact

    Wider context from the report

    “iii. As per paragraph 1(iv) above, there could be future deaths due to the lack of knowledge Police Officers in England and Wales have around life threatening illnesses, such as epilepsy and mental health illness, and I request that consideration is given by the College of Policing to providing national training to all staff across all police forces, on illnesses such as epilepsy and mental health illness, and the impact they have on individuals and their behaviour. I also request consideration to be given to these topics forming part of the syllabus for the College of Policing induction training for Police Officers. ”

    Source location

    Gaia Kima Pope-Sutherland · Prevention of Future Deaths report
    Page 6 · concerns

    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 flag key information on DHUFT RiO records

    Wider context from the report

    “viii. As per paragraph 1(xi) above, information could be lost on lengthy RiO records held by DHUFT if there is a significant number of records, and I therefore request that consideration is given to a guidance document dealing with how and what information should be flagged on RiO which could be provided to all staff at DHUFT. I would further request consideration is given to training staff how to record information, so it is flagged on the record. ”

    Source location

    Gaia Kima Pope-Sutherland · Prevention of Future Deaths report
    Page 7 · concerns

    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

    Ambiguity in Dorset Police policies for welfare concerns, missing persons, and call handling, grading and deployment

    Wider context from the report

    “iv. As per paragraphs 1(v-vi) above, there could be future deaths that occur as a result of current Dorset Police policies around concern for welfare reports, missing persons reports, and the call handling, grading and deployment of resources and I request that consideration is given to a thorough review of these policies to reduce ambiguity and prevent future deaths. I would further request that consideration is given to providing a comprehensive training package to all Police Officers and control room staff within Dorset Police, around the missing persons policy, concern for welfare policy, and for control room staff only, the call handling, grading and deployment policy. ”

    Source location

    Gaia Kima Pope-Sutherland · Prevention of Future Deaths report
    Page 6 · concerns

    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 DHUFT policy for contact with patients’ families

    Wider context from the report

    “vii. As per paragraph 1(x) above, there is no specific policy in place within DHUFT around how to engage with the family or dealing with the Think Family approach. A lack of contact with family members, who know the patient best, could lead to information gaps, which could lead to future deaths. I request that consideration is given to a policy being created around contact both to, and from, a patient’s family. ”

    Source location

    Gaia Kima Pope-Sutherland · Prevention of Future Deaths report
    Page 7 · concerns

    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 create, complete and store Dorset Police records appropriately

    Wider context from the report

    “v. As per paragraphs 1(vii-viii) above, there is currently a risk that Dorset Police records are not being created, completed or stored in an appropriate way. This could result in a lack of detail, or incorrect information being recorded and relied upon, which could lead to a future death. I therefore request that consideration is given to reviewing how all Dorset Police records are held, to ensure integrity of the information, and that consideration is given to providing a training session on record keeping for all Dorset Police staff, across all areas of the Force. ”

    Source location

    Gaia Kima Pope-Sutherland · Prevention of Future Deaths report
    Page 6 · concerns

    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

    Delay in AMHP feedback of Mental Health Act assessment information to GPs

    Wider context from the report

    “xi. As per paragraph 1(xiv) above, in respect of the feeding back of information to the GP by the AMHP which is detailed at paragraph 2.10 of Standard Operating Procedure for the flow of information following Mental Health Act assessments, I would request that consideration is given by Dorset County Council, BCP Council and DHUFT to reducing this timeframe from 7 days to 72 hours. Although this is a decision for Dorset County Council and BCP Council, the document is a DHUFT document and so will require their consideration too. ”

    Source location

    Gaia Kima Pope-Sutherland · Prevention of Future Deaths report
    Page 7 · concerns

    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 staff knowledge of Dorset Police welfare, missing persons, and call handling policies

    Wider context from the report

    “iv. As per paragraphs 1(v-vi) above, there could be future deaths that occur as a result of current Dorset Police policies around concern for welfare reports, missing persons reports, and the call handling, grading and deployment of resources and I request that consideration is given to a thorough review of these policies to reduce ambiguity and prevent future deaths. I would further request that consideration is given to providing a comprehensive training package to all Police Officers and control room staff within Dorset Police, around the missing persons policy, concern for welfare policy, and for control room staff only, the call handling, grading and deployment policy. ”

    Source location

    Gaia Kima Pope-Sutherland · Prevention of Future Deaths report
    Page 6 · concerns

    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 resourcing of epilepsy services

    Wider context from the report

    “i. As per paragraphs 1(i-iii) above, there could be future deaths locally and across the country due to the lack of resourcing of epilepsy services. I request consideration is given to a review of the nursing resources in epilepsy care locally in Dorset Epilepsy Service, and generally nationally across England and Wales. ”

    Source location

    Gaia Kima Pope-Sutherland · Prevention of Future Deaths report
    Page 6 · concerns

    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

    Ambiguity and inconsistency in access to Community Mental Health care processes

    Wider context from the report

    “ix. As per paragraph 1(xii) above, I would request that consideration is given to providing training to all staff on the access to Community Mental Health services which could also cover the processes regarding discharge planning from the care of the mental health teams. ”

    Source location

    Gaia Kima Pope-Sutherland · Prevention of Future Deaths report
    Page 2 · concerns

    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 communication between neurology and psychiatric teams

    Wider context from the report

    “ii. Further I am concerned that there could be future deaths as a result of the lack of communication between neurology and psychiatric teams and request that there is consideration as to how to ensure effective lines of communication between the 2 disciplines. ”

    Source location

    Gaia Kima Pope-Sutherland · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

    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 and implement a RiO template for Section 12 doctors to send key Mental Health Act assessment information directly to GPs, with corresponding guidance and SOP amendments.

    Verbatim wording from the response

    “This requirement has been considered by ████████ Deputy Chief Medical Officer. You heard during the course of the inquest (and as part of Dorset Council’s evidence) that relevant information and a report following the assessment will be provided to the GP by the Approved Mental Health Professional (AMHP), who is part of and coordinates the assessing team. Dr ████████ has met with his clinical colleagues and it has been agreed that (in addition to this information provided by the AMHP):”

    Source location

    Response from NHS Dorset Healthcare University
    Page 5 · response
    Published 28 September 2022

    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

    Implement an updated standard operating procedure governing information flow after Mental Health Act assessments.

    Verbatim wording from the response

    “In respect of the care provided to Gaia, the Trust remains of the view set out in the RCA report (and reiterated by Trust witnesses), that Gaia did not meet the eligibility criteria for CMHT care on the occasions she was discharged from CMHT care in December 2016 and March 2017, and also at the point she was assessed under the Mental Health Act (“MHA”) in October 2017. That is not to diminish the difficulties Gaia faced, or her level of distress. We do not dispute that the failure to refer Gaia to Steps to Wellbeing (“STWB”) for her Post Traumatic Stress Disorder in December 2016 was a missed opportunity. There were also missed opportunities in terms of the assessment and onward plan of care following the MHA assessment in October 2017, which are acknowledged by the Trust and formed part of the jury’s conclusions.”

    Source location

    Response from NHS Dorset Healthcare University
    Page 4 · response
    Published 28 September 2022

    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

    Continue applying the 72-hour requirement for distributing completed Mental Health Act assessment reports.

    Verbatim wording from the response

    “• The AMHP must then complete their full (or final) report within 2 hours of completing their assessment (or by the end of their shift if they are an out of hours worker) and again distribute this to the receiving Ward (if relevant), the Mental Health Legislation office, General Practitioner, Care Co-ordinator, the Medics involved in the assessment and the AMHP Lead within 72 hours.”

    Source location

    Response from BCP Council
    Page 2 · response
    Published 28 September 2022

    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

    Discuss with Approved Mental Health Professionals how to succinctly share information with GPs, highlighting information of immediate relevance.

    Verbatim wording from the response

    “We are also in the process of discussing with AMHP's how they could succinctly share information with GP’s, and in particular highlighting that information which is of most immediate relevant to them.”

    Source location

    Response from BCP Council
    Page 2 · response
    Published 28 September 2022

    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

    Engage with Dorset Healthcare Trust to agree amendments to the Pan-Dorset Standard Operating Procedure for information distribution.

    Verbatim wording from the response

    “We are actively engaging with Dorset Healthcare Trust to agree the necessary amendments to the Pan-Dorset Standard Operating Procedure. We are of the view that the Standard Operating Procedure standard for distributing information is too slow and we will continue to apply the requirement of 72 hours.”

    Source location

    Response from BCP Council
    Page 2 · response
    Published 28 September 2022

    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

    Implement internal reporting to monitor 72-hour initial reports, track full reports, and share monthly performance information with senior managers.

    Verbatim wording from the response

    “Dorset Council has reduced the recommendation to reduce the timeframe from 7 days to 72 hours to forward the completed AMHP report to the assessed persons GP. From the 1st of August 2022 Dorset Council put in place a new internal data reporting system. This system now enables the AMHP duty manager and business support, for the AMHP’s, to monitor that the initial AMHP report is completed and emailed to the GP within 72 hours. This also ensures that there is tracking of the full AMHP report, which is then sent by secure e-mail to the GP within 7 days of a person having had a Mental Health Act”

    Source location

    Response from Dorset Council
    Page 1 · response
    Published 28 September 2022

    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

    Require AMHPs to complete mandatory internal training on confidential information sharing following Mental Health Act assessments.

    Verbatim wording from the response

    “There is a Continuing Professional Development record which all AMHPs must complete to evidence their registration and approval as an AMHP. The Council also now requires AMHPs to have internal mandatory training about the sharing of confidential information in relation to the Mental Health Act assessment.”

    Source location

    Response from Dorset Council
    Page 2 · response
    Published 28 September 2022

    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

    Reduce the timeframe for forwarding the initial completed AMHP report to the assessed person’s GP from seven days to 72 hours.

    Verbatim wording from the response

    “Dorset Council has reduced the recommendation to reduce the timeframe from 7 days to 72 hours to forward the completed AMHP report to the assessed persons GP. From the 1st of August 2022 Dorset Council put in place a new internal data reporting system. This system now enables the AMHP duty manager and business support, for the AMHP’s, to monitor that the initial AMHP report is completed and emailed to the GP within 72 hours. This also ensures that there is tracking of the full AMHP report, which is then sent by secure e-mail to the GP within 7 days of a person having had a Mental Health Act”

    Source location

    Response from Dorset Council
    Page 1 · response
    Published 28 September 2022

    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, approve and disseminate a procedure for supporting patients affected by sexual violence and responding to reported sexual incidents.

    Verbatim wording from the response

    “1. To introduce a Trust procedure that deals with victims of sexual violence when they come onto a ward, in terms of safeguarding them from future incidents / deterioration on the ward. In addition to consider specific guidance for staff as to how to support a patient following a sexual incident.”

    Source location

    Response from NHS Dorset Healthcare University
    Page 2 · response
    Published 28 September 2022

    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

    Update the Safeguarding policy and add appendices covering responses to sexual abuse disclosures in hospital and community settings.

    Verbatim wording from the response

    “████████ has asked me to confirm to you that he is satisfied that he has met this action. The Trust’s Safeguarding policy has been updated to highlight the response needed when an adult discloses they have experienced sexual abuse. This may be in a hospital or community setting. In addition, two appendix documents have been added to the policy setting out further details which I enclose for your reference. ████████ has advised me that the ‘guidance for staff in relation to historical sexual abuse fits in with the ‘Making Safeguarding Personal’ agenda. It’s important to determine what an individual wants to do, while encouraging them and supporting them to report it. Every situation is different so care for patients who disclose historical abuse will be planned on a case by case basis’.”

    Source location

    Response from NHS Dorset Healthcare University (3)
    Page 2 · response
    Published 28 September 2022

    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

    Complete consideration of higher-level medical-condition training and conclude that the current policing approach remains appropriate.

    Verbatim wording from the response

    “We have recently considered this question in relation to other conditions, such as neuro diversity, and further concluded that seeking to give a higher level of expertise is unfortunately not practical. Policing deals with an almost limitless variety of incidents, some situations or medical issues may only being encountered by officers very rarely – their training would be almost irrelevant because of the time that had lapsed between the training and the time the knowledge was needed to deal with the incident.”

    Source location

    Response from College of Policing
    Page 2 · response
    Published 28 September 2022

    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

    Include epilepsy, psychosis, medical conditions, medication and associated risks in operational first-aid training.

    Verbatim wording from the response

    “The content of Vulnerability 4 will also be built into initial training for Police Officers, Call Handlers and PCSOs to ensure ongoing development of new staff into the Organisation. Furthermore, in 2023, there will be a similar opportunity to raise awareness further in relation to epilepsy, psychosis, medical conditions, medication and the effect of such on and individual and subsequent risks. The Organisation will work with the clinical lead to ensure such are covered in the First Aid Training which is rolled out to operational officers and staff.”

    Source location

    Response from Dorset Police
    Page 3 · response
    Published 28 September 2022

    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

    Update RiO training and provide a standalone e-learning module on using the alerts system, promoting it to existing users and staff.

    Verbatim wording from the response

    “In response to this concern, the Trust will develop a guidance document on viewing, adding and removing alerts on RiO and upload this to the Trust intranet by 30th September 2022. The existing RiO e-learning and classroom-based learning courses, which are a mandatory requirement for new staff who will be using RiO as part of their role, will also be updated to orientate staff to the existence of the guidance and to demonstrate how and when to use the alerts system on RiO. This will be updated by 31st October 2022. This training will also be available as a standalone e-learning module, which will be available to all existing RiO users in the Trust. The e-learning module will be promoted to staff via email and via dissemination at the CMHT Team Leaders workshop. This will be available and disseminated by 31st October 2022.”

    Source location

    Response from NHS Dorset Healthcare University
    Page 3 · response
    Published 28 September 2022

    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 and publish RiO guidance explaining how to view, add and remove alerts.

    Verbatim wording from the response

    “In response to this concern, the Trust will develop a guidance document on viewing, adding and removing alerts on RiO and upload this to the Trust intranet by 30th September 2022. The existing RiO e-learning and classroom-based learning courses, which are a mandatory requirement for new staff who will be using RiO as part of their role, will also be updated to orientate staff to the existence of the guidance and to demonstrate how and when to use the alerts system on RiO. This will be updated by 31st October 2022. This training will also be available as a standalone e-learning module, which will be available to all existing RiO users in the Trust. The e-learning module will be promoted to staff via email and via dissemination at the CMHT Team Leaders workshop. This will be available and disseminated by 31st October 2022.”

    Source location

    Response from NHS Dorset Healthcare University
    Page 3 · response
    Published 28 September 2022

    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

    Embed the adopted missing-person policy changes into working practice.

    Verbatim wording from the response

    “The latest review of the missing person policy was in the process of being finalised during Gaia’s inquest. I enclose a copy of the finalised policy, which is now adopted, and work is ongoing to embed the changes in working practice. I highlight a few aspects of the updated policy that were relevant to the matters explored in the course of Gaia’s inquest:”

    Source location

    Response from Dorset Police
    Page 2 · response
    Published 28 September 2022

    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

    Review the concern-for-welfare policy to incorporate current physical and mental ill-health trends and professional guidance.

    Verbatim wording from the response

    “The Dorset Police concern for welfare policy is designed, in consultation with partner agencies, to ensure that the public get the right service to meet their specific needs at the first point of contact. The current version is subject to a review led by the Prevention Department to capture the latest physical and mental ill health trends and guidance from key professionals. The initial draft of the policy is close to completion.”

    Source location

    Response from Dorset Police
    Page 3 · response
    Published 28 September 2022

    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

    Implement revised call-handling, deployment and grading policies with risk assessment and performance monitoring.

    Verbatim wording from the response

    “The Organisation reviewed and updated the call handling, deployment and grading policy in 2021 and implemented changes in March 2022. The Deployment Policy has been recently reviewed in line with national guidance to ensure that each public contact is risk assessed to inform the appropriate police response. The revised grading of incidents is now a key performance measure with regular reviews and evaluation to ensure compliance. As part of the implementation process, we have now moved to the evaluation stage to understand how the changes in the policy have translated into deployment decision making. The Organisation has commissioned an external audit conducted by the South West Audit Partnership which has been taking place over the summer. A full report is due this Autumn which will inform ongoing developments.”

    Source location

    Response from Dorset Police
    Page 3 · response
    Published 28 September 2022

    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

    Evaluate how revised policies affect deployment decisions and complete the commissioned external audit.

    Verbatim wording from the response

    “The Organisation reviewed and updated the call handling, deployment and grading policy in 2021 and implemented changes in March 2022. The Deployment Policy has been recently reviewed in line with national guidance to ensure that each public contact is risk assessed to inform the appropriate police response. The revised grading of incidents is now a key performance measure with regular reviews and evaluation to ensure compliance. As part of the implementation process, we have now moved to the evaluation stage to understand how the changes in the policy have translated into deployment decision making. The Organisation has commissioned an external audit conducted by the South West Audit Partnership which has been taking place over the summer. A full report is due this Autumn which will inform ongoing developments.”

    Source location

    Response from Dorset Police
    Page 3 · response
    Published 28 September 2022

    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

    Establish a working group to co-produce, ratify and circulate a Working with Families and Carers policy covering communication, engagement and the Think Family approach.

    Verbatim wording from the response

    “In response to this concern, we will establish a working group led by ████████, Interim Deputy Chief Nursing Officer, to develop a policy on Working with Families and Carers. The policy will cover expectations in respect of communication and engagement with and from families and carers that a patient wishes to involve in their care. The policy will also explain clearly what the Think Family safeguarding approach is and how staff can work within this approach when there are safeguarding concerns. The development of the policy will be a co-produced piece of work between professionals working in services and people with lived experience of using mental health services and of supporting someone living with a mental health condition.”

    Source location

    Response from NHS Dorset Healthcare University
    Page 2 · response
    Published 28 September 2022

    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

    Include log-keeping and recording in Vulnerability 4 training.

    Verbatim wording from the response

    “The Organisation’s record management system, ‘Niche’ was upgraded in August 2022. The Niche training has been utilised to reinforce the expectations and importance record management and data quality. POLSA and LPSM trained staff have been directed to use Niche to log their decisions and key information. Niche can be accessed remotely via mobile technology and once an entry is made it cannot be amended retrospectively. If information changes or details are recorded in error an additional chronological entry can be made highlighting any amendments and this can be cross referenced to the original entry. Once created, logs are also locked and cannot be amended. As previously noted Vulnerability 4 training will include a session on log keeping and recording.”

    Source location

    Response from Dorset Police
    Page 4 · response
    Published 28 September 2022

    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

    Send organisation-wide guidance reminding staff and officers about accurate and transparent record keeping.

    Verbatim wording from the response

    “At the submission of the Organisation’s response to the Preventing Future Deaths Report I propose to send out a further Organisation-wide message to all staff and officers providing a reminder along with guidance about the importance of accurate and transparent record keeping.”

    Source location

    Response from Dorset Police
    Page 5 · response
    Published 28 September 2022

    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

    Upgrade Niche and require relevant staff to record decisions and key information in locked, chronological logs.

    Verbatim wording from the response

    “The Organisation’s record management system, ‘Niche’ was upgraded in August 2022. The Niche training has been utilised to reinforce the expectations and importance record management and data quality. POLSA and LPSM trained staff have been directed to use Niche to log their decisions and key information. Niche can be accessed remotely via mobile technology and once an entry is made it cannot be amended retrospectively. If information changes or details are recorded in error an additional chronological entry can be made highlighting any amendments and this can be cross referenced to the original entry. Once created, logs are also locked and cannot be amended. As previously noted Vulnerability 4 training will include a session on log keeping and recording.”

    Source location

    Response from Dorset Police
    Page 4 · response
    Published 28 September 2022

    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

    Deliver Vulnerability 4 training on welfare, missing-person and deployment policies to relevant staff and officers.

    Verbatim wording from the response

    “The next stage of the Vulnerability Programme is the ‘Vulnerability 4’ training package, scheduled for delivery between January and April 2023. The Vulnerability 4 training will include updates on the concern for welfare, missing people and the call handling, grading and deployment policies. It will be provided to police officers and staff, including control room call handlers, senior officers up to the rank of Chief Inspector and role-specific training to the ranks above Chief Inspector.”

    Source location

    Response from Dorset Police
    Page 3 · response
    Published 28 September 2022

    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

    Disseminate the updated missing-person policy and provide recurring contact-centre refresher training.

    Verbatim wording from the response

    “In the meantime, the updated version of the missing person policy has been disseminated locally through Commanders and Inspectors, who are cascading the learning to frontline officers and ensuring the policy has been read and understood. Force Contact Centre training on the new missing person policy begins from the 19th September on the current 10 week cycle for all staff. Every training cycle will include refresher training on missing people and concern for welfare matters for the foreseeable future.”

    Source location

    Response from Dorset Police
    Page 3 · response
    Published 28 September 2022

    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

    Recruit a temporary part-time Band 7 specialist epilepsy nurse for one day per week, supporting transition to adult epilepsy care.

    Verbatim wording from the response

    “In addition, the Trust is currently in the process of recruiting to the epilepsy team a part time 1 day a week Band 7 specialist nurse. This is a temporary post with funding for 12 months. The successful candidate has a long track record of dealing with Children & Young Persons who suffer from epilepsy which will be of great assistance to young people transitioning to adult epilepsy care. Whilst this individual is employed through our bank, we will be reviewing the impact, with the aim of developing a substantive model and funding, as part of the system working through the Integrated Care Board’s review.”

    Source location

    Response from NHS Dorset Healthcare University (2)
    Page 2 · response
    Published 28 September 2022

    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

    Appoint and establish a full-time Band 4 epilepsy coordinator role supporting the specialist epilepsy nurses and patient care.

    Verbatim wording from the response

    “I am pleased to inform you that since the Gaia Pope-Sutherland inquest concluded the Trust has appointed a new full time Band 4 epilepsy co-ordinator to the team, who directly supports the two epilepsy specialist nurses. It is anticipated that the successful candidate will commence in post on 1st October 2022. The main duties of this role include:”

    Source location

    Response from NHS Dorset Healthcare University (2)
    Page 2 · response
    Published 28 September 2022

    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

    Work collaboratively with the Integrated Care Board to assist its review of the epilepsy and neurology service.

    Verbatim wording from the response

    “In relation to your request for consideration of a review of the nursing resources in epilepsy care locally in the Dorset Epilepsy Service, I can confirm that the Integrated Care Board (ICB) are carrying out an 8 week review which started on 11 August 2022. The review team, informed by the Getting It Right First Time (GIRFT) reports for neurology and epilepsy, are looking at the entire Epilepsy and Neurology service. This will be specifically considering:”

    Source location

    Response from NHS Dorset Healthcare University (2)
    Page 3 · response
    Published 28 September 2022

    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

    Review the impact of the temporary Band 7 specialist nurse post to inform development of a substantive staffing model and funding.

    Verbatim wording from the response

    “In addition, the Trust is currently in the process of recruiting to the epilepsy team a part time 1 day a week Band 7 specialist nurse. This is a temporary post with funding for 12 months. The successful candidate has a long track record of dealing with Children & Young Persons who suffer from epilepsy which will be of great assistance to young people transitioning to adult epilepsy care. Whilst this individual is employed through our bank, we will be reviewing the impact, with the aim of developing a substantive model and funding, as part of the system working through the Integrated Care Board’s review.”

    Source location

    Response from NHS Dorset Healthcare University (2)
    Page 2 · response
    Published 28 September 2022

    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

    Undertake an eight-week review of Dorset epilepsy nursing resources, provision across care settings, relevant specialty interactions, and neurology–psychiatry communication processes.

    Verbatim wording from the response

    “1. As per Paragraph 2 (i) of your report outlining your concerns, a review will be undertaken of the nursing resources in epilepsy care locally within the Dorset Epilepsy Service. The review will:”

    Source location

    Response from NHS Dorset Integrated Care
    Page 1 · response
    Published 28 September 2022

    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

    Request the Epilepsy Advisory Group’s views on epilepsy nursing numbers, resourcing, and how additional resources could work.

    Verbatim wording from the response

    “The ABN does not have access to the numbers of epilepsy nurses but the ABN Epilepsy Advisory Group may be able to comment on numbers and the level of resourcing. To this end I have asked the Epilepsy AG for comment on this and how the system could work with more resource.”

    Source location

    Response from Association of British Neurologists
    Page 1 · response
    Published 28 September 2022

    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

    Continue implementing the CMHT/STWB interface and screening meetings through an updated standard operating procedure.

    Verbatim wording from the response

    “In respect of the care provided to Gaia, the Trust remains of the view set out in the RCA report (and reiterated by Trust witnesses), that Gaia did not meet the eligibility criteria for CMHT care on the occasions she was discharged from CMHT care in December 2016 and March 2017, and also at the point she was assessed under the Mental Health Act (“MHA”) in October 2017. That is not to diminish the difficulties Gaia faced, or her level of distress. We do not dispute that the failure to refer Gaia to Steps to Wellbeing (“STWB”) for her Post Traumatic Stress Disorder in December 2016 was a missed opportunity. There were also missed opportunities in terms of the assessment and onward plan of care following the MHA assessment in October 2017, which are acknowledged by the Trust and formed part of the jury’s conclusions.”

    Source location

    Response from NHS Dorset Healthcare University
    Page 4 · response
    Published 28 September 2022

    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

    Participate in co-designing a new integrated community mental health operational model through the MHICC transformation programme.

    Verbatim wording from the response

    “It is our belief that the issues highlighted will be addressed through the transformation work that the Trust is closely engaged with, which was touched upon in the evidence of ████████. The NHS Long Term Plan and the Commissioning Framework for Community Mental Health sets out a new vision of mental health support provided by health, social care and voluntary, community and social enterprise (VCSE) organisations, beyond the model of CMHT care. In Dorset, the multi-agency, co-produced project to deliver this vision is known as the Mental Health Integrated Community Care (MHICC) programme. The programme has reached the stage where it is co-designing a new operational model of care, to begin implementation in 2023 / 2024.”

    Source location

    Response from NHS Dorset Healthcare University
    Page 4 · response
    Published 28 September 2022

    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

    Support solutions to poor integration and communication between neurological and mental health services.

    Verbatim wording from the response

    “There are some solutions to the poor integration and communication between services that we have been supporting as a Faculty. The NHSE National Neurosciences Advisory Group will be publishing the Optimum Pathways for Neurological Conditions imminently (https://www.nnag.org.uk/optimum-clinical-pathways). These include exemplary pathways for epilepsy and also a Mental Health Crosscutting Theme that highlights where the interface between neuroscience and mental health services needs to be considered, what good looks like and some of the evidence for treatment and rehabilitation. It is hoped that these publications will provide support to commissioning of integrated services in neurosciences in ICSs.”

    Source location

    Response from Royal College of Psychiatrists
    Page 2 · response
    Published 28 September 2022

    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

    Discuss with the Royal College of Psychiatrists’ President how to improve communication between psychiatric and neurology teams.

    Verbatim wording from the response

    “I will also bring communicate these views with Prof ████████ President of the Royal College of Psychiatrists, to discuss how to improve these lines of communication.”

    Source location

    Response from Association of British Neurologists
    Page 2 · response
    Published 28 September 2022

    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

    Existing AMHP requirements and quality assurance arrangements already require recording and sharing assessment outcomes within specified timescales.

    Verbatim wording from the response

    “The BCP Council Approved Mental Health Professionals (AMHP) Service uses the Mental Health Act 1983 (amended 2007) and the Code of Practice to inform practice standard, which are monitored through an AMHP Quality Assurance Framework.”

    Source location

    Response from BCP Council
    Page 1 · response
    Published 28 September 2022

    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 Trust’s discharge-information procedure and statutory Mental Health Act guidance are relied upon to address communication after mental health assessments.

    Verbatim wording from the response

    “With regard to Ms Pope-Sutherland’s discharge from hospital, my officials have informed me that the Trust has introduced a Standard Operating Procedure in May 2022, which covers the provision of information following Mental Health Act assessments. In addition, the”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 28 September 2022

    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

    Full AMHP reports cannot be completed within 72 hours because shift patterns and rota arrangements prevent timely completion.

    Verbatim wording from the response

    “Dorset Council has reduced the recommendation to reduce the timeframe from 7 days to 72 hours to forward the completed AMHP report to the assessed persons GP. From the 1st of August 2022 Dorset Council put in place a new internal data reporting system. This system now enables the AMHP duty manager and business support, for the AMHP’s, to monitor that the initial AMHP report is completed and emailed to the GP within 72 hours. This also ensures that there is tracking of the full AMHP report, which is then sent by secure e-mail to the GP within 7 days of a person having had a Mental Health Act”

    Source location

    Response from Dorset Council
    Page 1 · response
    Published 28 September 2022

    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

    Comprehensive training on epilepsy and mental health conditions is considered impractical because medical conditions and missing-person circumstances are too complex and variable.

    Verbatim wording from the response

    “Additionally, the College is committed to providing the highest standards of training for those working in policing however, that training also must be accessible and practicable. Medical conditions can be very complex, those conditions in themselves can be variable and they do not exist in isolation. Different conditions have differing levels of severity that interact with the myriad of circumstances in which people go missing. The quantity of variables is simply too great to reasonably and effectively train.”

    Source location

    Response from College of Policing
    Page 1 · response
    Published 28 September 2022

    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

    Existing first aid, vulnerability training and authorised professional practice are considered proportionate and appropriate for responding to medical risks.

    Verbatim wording from the response

    “We recognise that policing must have some medical knowledge and this is provided through our first aid programme. This programme and medical knowledge makes explicit links to our vulnerability training. To ensure police responders are equipped to effectively respond to missing persons, our training focuses on managing the full spectrum of vulnerabilities through effective and proportionate risk management. In reality, this means that College standards require front line responders to ask good questions that enable an informed understanding of the range or risks affecting a missing person, on a case by case basis, to identify their severity and impact. Additionally, police responders should seek information from informed sources, such as family or doctor, to understand the impact and degree of any medical conditions potentially affecting a missing person.”

    Source location

    Response from College of Policing
    Page 1 · response
    Published 28 September 2022

    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

    Responsibility for national training updates on life-threatening illnesses rests with the College of Policing through its clinical governance process.

    Verbatim wording from the response

    “This concern is directed to Chief Constable ████████ at the College of Policing. I wish to formally record my support for the learning from the inquest in relation to life-threatening illnesses to be shared with the College to inform National knowledge and understanding. I have personally written to CC Marsh to offer to support this work and to utilise the Organisation’s learning from Gaia’s inquest to inform and enhance any National training provision. I am aware that any updates to training and information relating to medical issues would go through the College of Policing clinical governance group for appropriate oversight and to ensure guidance was implemented.”

    Source location

    Response from Dorset Police
    Page 1 · response
    Published 28 September 2022

    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

    No further action is identified for RiO significant-event flags because their use already forms part of the Trust’s training programme.

    Verbatim wording from the response

    “Please note we have focused our action on the alerts system on RiO. As outlined in the evidence given to you by ████████, there is also a separate function on RiO of flagging a progress note as a significant event, so that it informs the risk assessment. We have not identified any further actions for this function, as this already forms part of our RiO training programme.”

    Source location

    Response from NHS Dorset Healthcare University
    Page 3 · response
    Published 28 September 2022

    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

    A wholesale review of record keeping across all systems has not been undertaken because targeted improvements are considered a necessary and proportionate response.

    Verbatim wording from the response

    “The Organisation has carefully considered a proportionate and targeted response to the concerns raised through Gaia’s inquest in relation to record keeping. The Organisation holds millions of records and works across multiple systems and processes Organisation-wide, regionally and working with partner agencies. These processes are carefully mapped and overseen by business owners, with some areas inspected by HMICFRS and the Information Commissioner in relation to crime data integrity, record keeping and data protection.”

    Source location

    Response from Dorset Police
    Page 4 · response
    Published 28 September 2022

    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

    Reducing the information-feedback timeframe is a decision for Dorset Council and BCP Council, with the Trust able to update its SOP only after agreement.

    Verbatim wording from the response

    “6) As per paragraph 1(xiv) above, in respect of the feeding back of information to the GP by the AMHP which is detailed at paragraph 2.10 of the Standard Operating Procedure for the flow of information following Mental Health Act assessments, I would request that consideration is given by Dorset County Council, BCP Council and DHUFT to reducing this timeframe from 7 days to 72 hours. Although this is a decision for Dorset County Council and BCP Council, the document is a DHUFT document and so will require their consideration too.”

    Source location

    Response from NHS Dorset Healthcare University
    Page 5 · response
    Published 28 September 2022

    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

    Cannot assess epilepsy nursing numbers because the organisation lacks access to the relevant workforce data.

    Verbatim wording from the response

    “The ABN does not have access to the numbers of epilepsy nurses but the ABN Epilepsy Advisory Group may be able to comment on numbers and the level of resourcing. To this end I have asked the Epilepsy AG for comment on this and how the system could work with more resource.”

    Source location

    Response from Association of British Neurologists
    Page 1 · response
    Published 28 September 2022

    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 Trust maintains that the patient did not meet CMHT eligibility criteria at the identified discharge and assessment points.

    Verbatim wording from the response

    “In respect of the care provided to Gaia, the Trust remains of the view set out in the RCA report (and reiterated by Trust witnesses), that Gaia did not meet the eligibility criteria for CMHT care on the occasions she was discharged from CMHT care in December 2016 and March 2017, and also at the point she was assessed under the Mental Health Act (“MHA”) in October 2017. That is not to diminish the difficulties Gaia faced, or her level of distress. We do not dispute that the failure to refer Gaia to Steps to Wellbeing (“STWB”) for her Post Traumatic Stress Disorder in December 2016 was a missed opportunity. There were also missed opportunities in terms of the assessment and onward plan of care following the MHA assessment in October 2017, which are acknowledged by the Trust and formed part of the jury’s conclusions.”

    Source location

    Response from NHS Dorset Healthcare University
    Page 4 · response
    Published 28 September 2022

    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 Trust considers transformation work a more effective response than training staff on the existing CMHT access model.

    Verbatim wording from the response

    “For these reasons and the transformation work being carried out as described in this letter, the Trust does not consider that implementing an action to train Trust staff on the access to CMHT’s would resolve the issues raised.”

    Source location

    Response from NHS Dorset Healthcare University
    Page 4 · response
    Published 28 September 2022

    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 Trust disputes that staff misunderstand or face ambiguity about accessing community mental health services or discharging patients.

    Verbatim wording from the response

    “I and my team note your concerns that you considered there to be “some ambiguity and inconsistency during the evidence regarding the content of the Integrated Community Mental Health Teams (ICMHT’s) operational policy, and the understanding and application of it”. The Trust team has considered carefully your recommendation that training be provided to all staff on access to Community Mental Health Services, including the process for discharge planning.”

    Source location

    Response from NHS Dorset Healthcare University
    Page 3 · response
    Published 28 September 2022

    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

    Existing national training, professional development and clinical guidance arrangements are relied upon to support community mental health practice and discharge planning.

    Verbatim wording from the response

    “With regard to your concerns related to the availability of training on access to community mental health services, including discharge planning – you may wish to note that NHSE provides funding and resources for continuous professional development for community mental health practice, together with supporting good care in all settings. HEE, working in partnership, also provides a range of quality training and resources for health care professionals, at all stages of their career; this is intended to support good practice. The training and resources provided by HEE align with policy direction and legislative frameworks, together with national clinical guidance such as that published by NICE (Transition between inpatient mental health settings and community or care home settings^5), which acknowledges its starting point.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 28 September 2022

    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

    Communication between neurology and psychiatric teams concerns national bodies rather than the Trust, so the Trust will not comment further.

    Verbatim wording from the response

    “I am also grateful to the court for providing clarification that the following specific concern relates to national bodies, as opposed to Dorset Healthcare University NHS Foundation Trust (“the Trust”), and therefore I will not comment further on this as part of my response:”

    Source location

    Response from NHS Dorset Healthcare University
    Page 1 · response
    Published 28 September 2022

    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

    Responsibility for improving communication between neurology and psychiatric teams lies nationally, not with the local Trust.

    Verbatim wording from the response

    “2(ii) Communication between neurology and psychiatric teams”

    Source location

    Response from NHS Dorset Healthcare University (2)
    Page 3 · response
    Published 28 September 2022

    Open published response
  5. South London

    AI-generated summary

    Raphael Jeffery Gill · 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

    Raphael Jeffery Gill was stopped by police, arrested for drug-related offences, and suffered multiple seizures, including seizures in police care and an ambulance. The inquest identified delays in ambulance response and hospital assessment, failure to recognise the combination of seizures and cocaine as a medical emergency, and omission or delay in carrying out a venous blood gas test. The medical cause of death was recorded as multiple seizures associated with an underlying seizure disorder, cocaine and prescribed medication.

    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 use emergency transport for a medical emergency

    Wider context from the report

    “(1) The evidence of the medical expert was that Mr Gill was so unwell by the time he arrived at hospital that it was more likely than not that his life was not rescuable with sooner treatment. Whilst Mr Gill was taken to hospital, it was not under blue lights and sirens, and the most senior clinician drove so was not on hand to provide emergency treatment that the technician was unqualified to provide. It was apparent that the ambulance crew were not aware that the combination of seizures and cocaine represented a medical emergency, a fact expressly found in the jury’s conclusion. (2) Whilst it was reasonable for the LAS staff to suspect a link between the arrest and seizures, the arrest unduly influenced the assessment of urgency. ”

    Source location

    Raphael Jeffery Gill · Prevention of Future Deaths report
    Page 2 · concerns

    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 prevent arrest-related bias from influencing assessment of urgency

    Wider context from the report

    “(1) The evidence of the medical expert was that Mr Gill was so unwell by the time he arrived at hospital that it was more likely than not that his life was not rescuable with sooner treatment. Whilst Mr Gill was taken to hospital, it was not under blue lights and sirens, and the most senior clinician drove so was not on hand to provide emergency treatment that the technician was unqualified to provide. It was apparent that the ambulance crew were not aware that the combination of seizures and cocaine represented a medical emergency, a fact expressly found in the jury’s conclusion. (2) Whilst it was reasonable for the LAS staff to suspect a link between the arrest and seizures, the arrest unduly influenced the assessment of urgency. ”

    Source location

    Raphael Jeffery Gill · Prevention of Future Deaths report
    Page 2 · concerns

    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 ensure a suitably qualified clinician is available to provide emergency treatment during transport

    Wider context from the report

    “(1) The evidence of the medical expert was that Mr Gill was so unwell by the time he arrived at hospital that it was more likely than not that his life was not rescuable with sooner treatment. Whilst Mr Gill was taken to hospital, it was not under blue lights and sirens, and the most senior clinician drove so was not on hand to provide emergency treatment that the technician was unqualified to provide. It was apparent that the ambulance crew were not aware that the combination of seizures and cocaine represented a medical emergency, a fact expressly found in the jury’s conclusion. (2) Whilst it was reasonable for the LAS staff to suspect a link between the arrest and seizures, the arrest unduly influenced the assessment of urgency. ”

    Source location

    Raphael Jeffery Gill · Prevention of Future Deaths report
    Page 2 · concerns

    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 recognise the combination of seizures and cocaine as a medical emergency

    Wider context from the report

    “(1) The evidence of the medical expert was that Mr Gill was so unwell by the time he arrived at hospital that it was more likely than not that his life was not rescuable with sooner treatment. Whilst Mr Gill was taken to hospital, it was not under blue lights and sirens, and the most senior clinician drove so was not on hand to provide emergency treatment that the technician was unqualified to provide. It was apparent that the ambulance crew were not aware that the combination of seizures and cocaine represented a medical emergency, a fact expressly found in the jury’s conclusion. (2) Whilst it was reasonable for the LAS staff to suspect a link between the arrest and seizures, the arrest unduly influenced the assessment of urgency. ”

    Source location

    Raphael Jeffery Gill · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 existing primacy-of-care guidance and improve its accessibility with examples of when paramedics should attend patients directly.

    Verbatim wording from the response

    “The LAS recognises that the paramedic drove the ambulance to the hospital while her clinically more junior, non-registered colleague remained in the back of the ambulance attending to Mr Gill. On balance, despite Mr Gill being fully conscious, there was a history of abnormal muscle rigidity and possible seizure activity. As such, we would be of the view that the paramedic should have attended to Mr Gill in the rear of the ambulance as they would have been immediately available in the case of deterioration. As you would be aware from the documentation provided to you at the close of the inquest, the LAS has a number of guidance notices and policies around the primacy of care. In addition, there is helpful documentation from the professional regulator on this subject.”

    Source location

    Response from London Ambulance Service
    Page 2 · response
    Published 5 May 2022

    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

    Share the PFD report with the JRCALC Chair for consideration of further review of guidance on cocaine use and seizure activity.

    Verbatim wording from the response

    “Whilst we note that there was no undue delay on the scene once the conveying ambulance had arrived, we are aware that your view is that the clinicians were unaware that seizures on the background of cocaine use may present a marked clinical concern. Our Consultant Paramedic has reviewed the guidance within the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) Clinical Guidelines and is of the view that these contain a detailed set of guidelines for the management of patients who have used cocaine and seizure activity is specifically detailed. Our Chief Medical Officer will share your PFD report with the Chair of the JRCALC to allow for consideration of further review of the guidance.”

    Source location

    Response from London Ambulance Service
    Page 3 · response
    Published 5 May 2022

    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

    Produce and publish an internal clinical refresher for frontline clinicians on cocaine-related risks and red-flag presentations.

    Verbatim wording from the response

    “In terms of the LAS, we will produce an internal clinical refresher for all frontline clinicians, which will be shared in our internal 'Clinical Update' publication around the risks associated with cocaine to continue highlighting the 'red flag' presentations in respect of patients who have used cocaine. This is planned to be published in early Autumn 2022.”

    Source location

    Response from London Ambulance Service
    Page 3 · response
    Published 5 May 2022

    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 care did not reflect a lack of urgency, and arrest did not influence the timeliness or appropriateness of assessment, management or care.

    Verbatim wording from the response

    “Mr Gill was appropriately assessed and promptly conveyed to the local emergency department. We have considered carefully if a pre-alert call (blue lights and sirens) was required. On balance, there is no absolute indication that a pre-alert call was required. Mr Gill was fully conscious and able to walk himself into the hospital. The time from the arrival of the conveying ambulance on the scene to leaving the scene for the hospital was 18 minutes; this is rapid and, on balance, could not have been quicker. Therefore, the LAS believes that this does not reflect a lack of urgency, that the time spent on the scene was not excessive and it does not follow that the fact Mr Gill was under arrest influenced the timeliness or appropriateness of his assessment, management or of his care.”

    Source location

    Response from London Ambulance Service
    Page 2 · response
    Published 5 May 2022

    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

    Existing JRCALC clinical guidelines already provide detailed guidance on cocaine use, including specifically addressing seizure activity.

    Verbatim wording from the response

    “Whilst we note that there was no undue delay on the scene once the conveying ambulance had arrived, we are aware that your view is that the clinicians were unaware that seizures on the background of cocaine use may present a marked clinical concern. Our Consultant Paramedic has reviewed the guidance within the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) Clinical Guidelines and is of the view that these contain a detailed set of guidelines for the management of patients who have used cocaine and seizure activity is specifically detailed. Our Chief Medical Officer will share your PFD report with the Chair of the JRCALC to allow for consideration of further review of the guidance.”

    Source location

    Response from London Ambulance Service
    Page 3 · response
    Published 5 May 2022

    Open published response
  6. Hertfordshire

    AI-generated summary

    John Paul SKINNER · 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

    John Paul SKINNER was admitted to Watford Hospital on 15 May 2020 after suffering tonic clonic seizures and was given phenytoin. A verbal communication failure led to 15 mg/kg being heard as 50 mg/kg, resulting in an overdose; he arrested and died. The principal concern was that unclear communication of dosage could lead to foreseeable medication errors in hospitals.

    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 use clear and non-confusable communication and expression of numbers for medication dosages

    Wider context from the report

    “(1) The Junior doctor instructed to administer phenytoin did not know the required dosage and asked his more senior colleague for advice. The senior doctor's reply 15mk/kg was heard by the junior doctor as 50mg/kg resulting in administration of a significant overdose. This is a readily foreseeable confusion which could apply in any hospital and could be avoided by use of clearer and less confusable means of communication and expression of number ”

    Source location

    John Paul SKINNER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  7. Northamptonshire

    AI-generated summary

    Alfie Stone · 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

    Alfie Stone, aged 12, died after prolonged seizures, status epilepticus, hypoxia and multiple organ failure following admission to hospital. Concerns included paramedics’ lack of training in buccal midazolam, inadequate oxygenation, no suction attempt, and insufficient evidence of training following an earlier Serious Incident Report.

    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 accept recommendations to carry and administer buccal midazolam when necessary

    Wider context from the report

    “(5) East Midlands Ambulance Service were not accepting the recommendations 3 within the report to carry and administer Buccal Midazolam when necessary. ”

    Source location

    Alfie Stone · Prevention of Future Deaths report
    Page 1 · concerns

    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 ask parents whether the child had vomited

    Wider context from the report

    “(3) No suction attempted and the question was not asked of the parents as to whether the child had vomited. ”

    Source location

    Alfie Stone · Prevention of Future Deaths report
    Page 2 · concerns

    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 paramedic training in the use of buccal midazolam

    Wider context from the report

    “(1) Apparent lack of training of paramedics in the use of Buccal Midazolam ”

    Source location

    Alfie Stone · Prevention of Future Deaths report
    Page 2 · concerns

    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 evidence of paramedic training following an independent Serious Incident Report and agreed recommendations

    Wider context from the report

    “(4) No evidence of training to the paramedics who attended and gave evidence following an independent Serious Incident Report and its agreed recommendations ”

    Source location

    Alfie Stone · Prevention of Future Deaths report
    Page 2 · concerns

    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 attempt alternative oxygenation

    Wider context from the report

    “(2) No other form of oxygenation attempted such as bagging or the child being taken earlier to the ambulance to secure and deliver oxygen ”

    Source location

    Alfie Stone · Prevention of Future Deaths report
    Page 2 · concerns

    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 attempt suction

    Wider context from the report

    “(3) No suction attempted and the question was not asked of the parents as to whether the child had vomited. ”

    Source location

    Alfie Stone · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 and present a business case for moving to buccal midazolam, using gathered data and liaison with other ambulance trusts.

    Verbatim wording from the response

    “As in point 1 above, EMAS provides rectal diazepam (and intravenous diazepam) for the treatment of convulsions and both are recognised treatments within the UK ambulance service clinical practice guidelines, developed by JRCALC, and within NICE guidance. Due to the discontinuation of diazepam rectal tubes 2.5mg, EMAS made a recommendation at its Medicines Governance Group in November 2021 to gather data and build a business case regarding a move to buccal midazolam, liaising with other Ambulance Trusts.”

    Source location

    2022-0013-Response-from-East-Midlands-Ambulance-Service_Published
    Page 3 · response
    Published 20 January 2022

    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

    Begin the governance and legal process for transitioning from the current anticonvulsant medication to buccal midazolam.

    Verbatim wording from the response

    “Buccal Midazolam is on the agenda for the February Medicines Management Group, which is attended by senior Medical, Pharmacy and Quality leads. The intended timeline will be to start the process in April 2022, on the transition from our current anti-convulsant medication to Buccal Midazolam along with the legal processes we need to adopt to carry out this transition within the legal frameworks for this medication. The HM Coroner will be kept updated throughout this process.”

    Source location

    2022-0013-Response-from-East-Midlands-Ambulance-Service_Published
    Page 2 · response
    Published 20 January 2022

    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

    Add permission to administer buccal midazolam to the Scope of Practice Policy for paramedic staff.

    Verbatim wording from the response

    “this (where family/carer are unable to do so) according to JRCALC buccal midazolam guidance. This is a recent addition to EMAS JRCALC guidance which is available to EMAS staff to access as an ‘App’ on their phone, iPad or other electronic device. It is to be added to the EMAS Scope of Practice Policy to ensure clarity for paramedic staff that they can administer within EMAS guidance.”

    Source location

    2022-0013-Response-from-East-Midlands-Ambulance-Service_Published
    Page 2 · response
    Published 20 January 2022

    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 an action plan covering training for staff who access or administer buccal midazolam, including patient-held medication.

    Verbatim wording from the response

    “The Medicines Governance Group will develop an action plan that will consider training for all staff who would access and administer buccal midazolam in an emergency, as well as staff who may need to access and administer buccal midazolam not supplied by EMAS but held at the patient’s home or other facility.”

    Source location

    2022-0013-Response-from-East-Midlands-Ambulance-Service_Published
    Page 2 · response
    Published 20 January 2022

    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

    Assess the impact of adding buccal midazolam to the medicines formulary, including effectiveness, access, storage and alternative treatments.

    Verbatim wording from the response

    “Following a review of the concerns raised in the PFD notice received on 19 January 2022, the concerns relating specifically to midazolam will be discussed at the Medicines Governance Group in February 2022 to assess the impact of adding buccal midazolam to the EMAS medicines formulary. The impact will consider treatment effectiveness, timely access to midazolam on Trust ambulances as it will need to be securely stored in a cabinet only accessible by controlled key access and it may take longer to access in an emergency (due to this being a Schedule 3 controlled drug within the Misuse of Drugs Regulations 2001) and alternative treatments.”

    Source location

    2022-0013-Response-from-East-Midlands-Ambulance-Service_Published
    Page 2 · response
    Published 20 January 2022

    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 a clinical bulletin reinforcing systematic seizure management, aspiration assessment and maintenance of oxygenation during patient transfer.

    Verbatim wording from the response

    “In order to transport Alfie from his room down the stairs to the ambulance it would be technically challenging to ensure safe transfer and continual bagging of Alfie. EMAS accepts that it would have been beneficial to have maintained oxygenation via face mask during transfer to the ambulance from his bedroom. Following the outcome of this inquest, EMAS is keen to learn and embed lessons to ensure that all clinicians are reminded of the need to maintain oxygenation during the transfer of patients that are fitting. This will be covered in the bulletin stated below under question 3. To address seizure management, the HM Coroner will be provided with a copy of this bulletin when issued to our frontline staff.”

    Source location

    2022-0013-Response-from-East-Midlands-Ambulance-Service_Published
    Page 3 · response
    Published 20 January 2022

    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

    No audit of buccal midazolam training was required because it was not in the medicines formulary at the time.

    Verbatim wording from the response

    “Recommendation 3 of the Kettering report states: “EMAS should audit training and competencies of first responders in administration of buccal midazolam in children experiencing prolonged seizures in line with Joint Royal Colleges Ambulance Liaison Committee (JRCALC) guidance”.”

    Source location

    2022-0013-Response-from-East-Midlands-Ambulance-Service_Published
    Page 4 · response
    Published 20 January 2022

    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

    Suction was not required because the child did not vomit while the crew was present.

    Verbatim wording from the response

    “3. No suction attempted, and the question was not asked of the parents as to whether the child had vomited.”

    Source location

    2022-0013-Response-from-East-Midlands-Ambulance-Service_Published
    Page 3 · response
    Published 20 January 2022

    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

    Continual bagging during transfer was technically challenging because safe movement down the stairs could not be ensured.

    Verbatim wording from the response

    “In order to transport Alfie from his room down the stairs to the ambulance it would be technically challenging to ensure safe transfer and continual bagging of Alfie. EMAS accepts that it would have been beneficial to have maintained oxygenation via face mask during transfer to the ambulance from his bedroom. Following the outcome of this inquest, EMAS is keen to learn and embed lessons to ensure that all clinicians are reminded of the need to maintain oxygenation during the transfer of patients that are fitting. This will be covered in the bulletin stated below under question 3. To address seizure management, the HM Coroner will be provided with a copy of this bulletin when issued to our frontline staff.”

    Source location

    2022-0013-Response-from-East-Midlands-Ambulance-Service_Published
    Page 3 · response
    Published 20 January 2022

    Open published response
  8. Liverpool and the Wirral

    AI-generated summary

    Gary Williams · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Gary Williams died on 28 July 2017 after a pulmonary thromboembolism and deep venous thrombosis, with ictal automatism due to temporal lobe epilepsy also recorded as a cause. The report describes concerns about the lack of detailed information passed during handovers, omissions in medical records concerning restraint, use of force and injuries, and inconsistent communication between hospital departments. It also notes that ictal automatism was not included in College of Policing training materials on restraint.

    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

    Lack of training on temporal lobe epilepsy-related ictal automatism during restraint

    Wider context from the report

    “Gary Williams suffered from Temporal lobe epilepsy. He was a retired police officer who was a very friendly and polite gentleman, when not unwell. He had previously had absences. However, nothing that can compare with the events in the eleven days before his death on the 28th July 2017. On the 18th July 2017 he suffered from an extreme acute behavioural disturbance, described as what appeared to be a psychotic delusional state in which array and violence to life and property was demonstrated. This was Ictal automatism due to temporal lobe epilepsy. A neurologist explained at the inquest that he felt sorry for the police, as they did not know the patient or with what they were dealing. He explained that there was no way to rationalise with some in this state - they are like a zombie and though they do not feel pain the use of PAVA, baton strikes and restraint will be responded to by the person’s fight and flight instincts. It is important to approach such a person with calm. In a neurological ward, it can take four experience health care professional and a fifth to sedate to deal with such a presentation. There is no treatment as such for this presentation just sedation and if necessary critical care support until the person has recovered. This condition is not part of the college of policing training materials with regard to use of restraint. You may consider that it would be helpful to include it in the minimum of 12 hours future mandatory annual restraint refresher training undertaken by all officers. In this case, officers, members of the public and health care professionals were distressed and exhausted but fortunately officers, healthcare professionals and the public did not suffer permanent serious or fatal harm. ”

    Source location

    Gary Williams · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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 and circulate the ABD Training Package for UK police forces, directing immediate delivery of the revised package.

    Verbatim wording from the response

    “Subsequently the ABD Training Package for UK Police Forces was updated and circulated in March 2021 with a direction for Forces to deliver the revised ABD package with immediate effect. Additionally, The Royal College of Emergency Medicine Best practice Guidelines: Guidelines for the Management of Excited Delirium/Acute Behaviour Disturbance (ABD) May 2016, was also circulated to forces in September 2021 which contains a section on ‘restraint’ in relation to medical settings.”

    Source location

    2021-0401-Response-from-NPCC_Published
    Page 2 · response
    Published 29 November 2021

    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

    Circulate emergency medicine best-practice guidelines on excited delirium and acute behavioural disturbance to police forces.

    Verbatim wording from the response

    “Subsequently the ABD Training Package for UK Police Forces was updated and circulated in March 2021 with a direction for Forces to deliver the revised ABD package with immediate effect. Additionally, The Royal College of Emergency Medicine Best practice Guidelines: Guidelines for the Management of Excited Delirium/Acute Behaviour Disturbance (ABD) May 2016, was also circulated to forces in September 2021 which contains a section on ‘restraint’ in relation to medical settings.”

    Source location

    2021-0401-Response-from-NPCC_Published
    Page 2 · response
    Published 29 November 2021

    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

    Obtain specialist emergency and forensic medicine advice on ABD training materials and trainer guidance.

    Verbatim wording from the response

    “Specialist advice was sought from experts in emergency and forensic medicine who provided expert advice to SDAR relating to the ABD PowerPoint, notes for trainers and the National Personal Safety Manual.”

    Source location

    2021-0401-Response-from-NPCC_Published
    Page 2 · response
    Published 29 November 2021

    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

    Continue reviewing learning from coroners, oversight bodies, stakeholders and police forces to inform restraint and self-defence training.

    Verbatim wording from the response

    “The Self Defence Arrest and Restraint (SDAR) working group led by DAC ████████, works closely with the College of Policing. This group reviews the learning from coroners, the Independent Office of Police Conduct (IOPC), Her Majesty’s Inspectorate of Constabularies and Fire and Rescue Services (HMICFRS), stakeholders and police forces.”

    Source location

    2021-0401-Response-from-NPCC_Published
    Page 2 · response
    Published 29 November 2021

    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

    Review and update the ABD PowerPoint and Personal Safety Training Manual with additional restraint training.

    Verbatim wording from the response

    “Following the Oak inquest, the SDAR group immediately reviewed and updated the existing ABD power point and the PST Manual. This included incorporating additional training which was identified and documented within our response to the coroner overseeing the proceedings in this case.”

    Source location

    2021-0401-Response-from-NPCC_Published
    Page 2 · response
    Published 29 November 2021

    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

    Existing ABD training materials and package updates address the concern, with the arrangements remaining subject to continual review.

    Verbatim wording from the response

    “Following the Oak inquest, the SDAR group immediately reviewed and updated the existing ABD power point and the PST Manual. This included incorporating additional training which was identified and documented within our response to the coroner overseeing the proceedings in this case.”

    Source location

    2021-0401-Response-from-NPCC_Published
    Page 2 · response
    Published 29 November 2021

    Open published response
  9. Manchester South

    AI-generated summary

    Alfred Jones · 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

    Alfred Jones was admitted to hospital after an accidental fall at home and sustained further vertebral fractures in a fall on the ward. While awaiting investigation and being medically optimised for discharge, he contracted Covid-19 in hospital and died on 7 September 2020 from bronchopneumonia in combination with Covid-19, with falls and vertebral fractures among the listed contributing conditions. The report raised concerns that shortages of MRI scanner availability and radiology staff prolonged his admission, contributing to the ward fall and Covid-19 infection.

    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

    Shortage of qualified radiology staff

    Wider context from the report

    “1. The inquest heard that his stay in hospital was prolonged due to a shortage of availability of slots for the MRI scanner. This the inquest was told is due to a shortage of MRI scanners both in the Trust and the wider NHS. This was compounded by a shortage of radiology staff which the inquest was told formed a wider issue of a national shortage of qualified radiologists and radiographers. This led to a prolonged admission in hospital whilst awaiting tests and led to him having a fall whilst on the ward and contracting Covid-19 whilst an inpatient. ”

    Source location

    Alfred Jones · Prevention of Future Deaths report
    Page 2 · concerns

    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 MRI scanner capacity and availability

    Wider context from the report

    “1. The inquest heard that his stay in hospital was prolonged due to a shortage of availability of slots for the MRI scanner. This the inquest was told is due to a shortage of MRI scanners both in the Trust and the wider NHS. This was compounded by a shortage of radiology staff which the inquest was told formed a wider issue of a national shortage of qualified radiologists and radiographers. This led to a prolonged admission in hospital whilst awaiting tests and led to him having a fall whilst on the ward and contracting Covid-19 whilst an inpatient. ”

    Source location

    Alfred Jones · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 an expanded imaging workforce, including increased radiographer and radiologist training, new Imaging Training Academies and innovative imaging technologies.

    Verbatim wording from the response

    “From a National perspective, in supporting the ambitions of the NHS Long Term Plan, NHS England & Improvement (NHSE&I) commissioned an independent review of diagnostic services. The recently published report (October 2020), Diagnostics: Recovery and Renewal conducted by ████████ also took into account the impact of the Covid-19 pandemic. The recommendations have been accepted by NHSE&I and work has already begun to address the recommendations made, which include an increase in both imaging equipment and imaging workforce in England.”

    Source location

    2021-0135-Response-from-NHS-England-and-NHS-Improvement-Redacted
    Page 2 · response
    Published 5 May 2021

    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

    Commission an independent review of diagnostic services to identify measures addressing diagnostic capacity and resilience.

    Verbatim wording from the response

    “From a National perspective, in supporting the ambitions of the NHS Long Term Plan, NHS England & Improvement (NHSE&I) commissioned an independent review of diagnostic services. The recently published report (October 2020), Diagnostics: Recovery and Renewal conducted by ████████ also took into account the impact of the Covid-19 pandemic. The recommendations have been accepted by NHSE&I and work has already begun to address the recommendations made, which include an increase in both imaging equipment and imaging workforce in England.”

    Source location

    2021-0135-Response-from-NHS-England-and-NHS-Improvement-Redacted
    Page 2 · response
    Published 5 May 2021

    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 the Greater Manchester Imaging Network to coordinate regional imaging workforce and infrastructure development.

    Verbatim wording from the response

    “Regional Collaboration and infrastructure to address the shortfall A Greater Manchester Imaging Network has been established, and there are several examples of interventions taking place across GM to address the imaging workforce challenges. However, it has been agreed that a regional approach should be taken which has resulted in the three NW Imaging Networks working collaboratively to develop a NW Imaging Workforce Strategy (out for consultation until 12/6/21).”

    Source location

    2021-0135-Response-from-GMCA-GMHSCP-Redacted
    Page 2 · response
    Published 5 May 2021

    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

    Increase the substantive radiologist workforce and establish additional advanced reporting and sonographer capacity.

    Verbatim wording from the response

    “Since this time, investment has been made to increase the clinical workforce, increasing the number of substantive Radiologist from three to five with a further two undertaking the CESR qualification (Certificate of Eligibility for Specialist Registration), there are also 3 locum consultants bringing a total establishment to 8.5 whole time equivalent. This is an increase of 3.5 in the last 18 months. In addition to this there is also a Consultant Sonographer and 5 Advance Practice Reporting Radiographers.”

    Source location

    2021-0135-Response-from-GMCA-GMHSCP-Redacted
    Page 2 · response
    Published 5 May 2021

    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 a five-year North West imaging workforce implementation plan to guide local implementation plans for the three integrated care systems.

    Verbatim wording from the response

    “To support delivery of the strategy, a NW implementation plan for the next 5 years will be developed, which will inform the local implementation plans for the three ICS.”

    Source location

    2021-0135-Response-from-GMCA-GMHSCP-Redacted
    Page 3 · response
    Published 5 May 2021

    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 the North West Imaging Workforce Strategy through collaboration among the three regional imaging networks.

    Verbatim wording from the response

    “Regional Collaboration and infrastructure to address the shortfall A Greater Manchester Imaging Network has been established, and there are several examples of interventions taking place across GM to address the imaging workforce challenges. However, it has been agreed that a regional approach should be taken which has resulted in the three NW Imaging Networks working collaboratively to develop a NW Imaging Workforce Strategy (out for consultation until 12/6/21).”

    Source location

    2021-0135-Response-from-GMCA-GMHSCP-Redacted
    Page 2 · response
    Published 5 May 2021

    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

    Prioritise Diagnostic Radiography in Greater Manchester Allied Health Professions career events during 2021–22.

    Verbatim wording from the response

    “Activity to promote Radiography as a career choice Throughout the year several activities take place where Allied Health Professions career are showcased and promoted to our communities in GM. We are committed to prioritising Diagnostic Radiography during career events in 21/22.”

    Source location

    2021-0135-Response-from-GMCA-GMHSCP-Redacted
    Page 3 · response
    Published 5 May 2021

    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

    Increase imaging equipment capacity in England to address diagnostic service demand.

    Verbatim wording from the response

    “From a National perspective, in supporting the ambitions of the NHS Long Term Plan, NHS England & Improvement (NHSE&I) commissioned an independent review of diagnostic services. The recently published report (October 2020), Diagnostics: Recovery and Renewal conducted by ████████ also took into account the impact of the Covid-19 pandemic. The recommendations have been accepted by NHSE&I and work has already begun to address the recommendations made, which include an increase in both imaging equipment and imaging workforce in England.”

    Source location

    2021-0135-Response-from-NHS-England-and-NHS-Improvement-Redacted
    Page 2 · response
    Published 5 May 2021

    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 community diagnostic hubs to expand access to MRI, CT, ultrasound and X-ray services, including for inpatient activity.

    Verbatim wording from the response

    “Funding within the 2021/22 spending review has been targeted to support diagnostics via the development of community diagnostic hubs which will in turn augment access for inpatient activity in acute hospital services through the movement of elective activity to community settings. It is anticipated that MRI, CT scanning, Ultrasound and X-ray services will be the core imaging offer for these new centres and will represent new additional imaging capacity.”

    Source location

    2021-0135-Response-from-NHS-England-and-NHS-Improvement-Redacted
    Page 2 · response
    Published 5 May 2021

    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

    Maintain additional outpatient MRI capacity through the mobile scanner, operating 12 hours daily, seven days a week.

    Verbatim wording from the response

    “Tameside and Glossop Integrated Care NHS FT At the time of Mr Jones’ referral, Tameside and Glossop Integrated Care NHS Foundation Trust (T&GIC FT) was sourcing additional scanner capacity by provision of a mobile MRI scanner. This was implemented on 20th September 2020, offering additional outpatient scanning capacity for 12 hours per day, 7 days per week. The mobile MRI van is still used currently to provide additional capacity. It is also worth noting that the Trust did not reduce or delay suspected cancer patient scans due to the pandemic, and therefore, the MRI scanner was being fully utilised.”

    Source location

    2021-0135-Response-from-GMCA-GMHSCP-Redacted
    Page 2 · response
    Published 5 May 2021

    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

    Each integrated care system’s workforce team is responsible for delivering local imaging workforce priorities.

    Verbatim wording from the response

    “Health Education England NW (HEE) has commissioned a programme of work to support and progress Diagnostic Radiographer (DRAD) workforce planning priorities across the region, through scoping activities and targeted actions/interventions. This will ultimately provide a North West (NW) imaging workforce framework and strategy. Although the overall approach is regional, each ICS has its own workforce team that will be required to deliver on local workforce priorities.”

    Source location

    2021-0135-Response-from-GMCA-GMHSCP-Redacted
    Page 2 · response
    Published 5 May 2021

    Open published response
  10. London (West)

    AI-generated summary

    Bathsheba Shepherd · 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

    Bathsheba Bianca Kay Shepherd, known as Kay, was fatally stabbed by her housemate at some point between 10 and 11 November 2015 and was pronounced deceased on 11 November 2015. The report identified concerns about her being housed with a dangerous and vulnerable housemate, failures in risk assessment and rehousing, and her lack of GP registration and associated support.

    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 of GP registration processes to enable registration without relevant documentary proof

    Wider context from the report

    “(2) I was concerned by evidence in the course of the Inquest that the disengagement of a person with known psychological illness from the process of registration with a GP by her failure to obtain relevant documentary proof to enable registration meant that she could not be registered. Registration with a regular GP would in my mind have provided additional support to her. This may have enabled her to raise concerns or fears relating to her accommodation and housemate. ”

    Source location

    Bathsheba Shepherd · Prevention of Future Deaths report
    Page 4 · concerns

    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 resolve the interagency Care Programme Approach process

    Wider context from the report

    “(1) I was concerned to find that even though 5 years had elapsed between Kay’s death and the hearing of the Inquest the issue of the way in which the Care Programme Approach was being conducted between the local authority and the NHS Trust was still the subject of discussion and had not been resolved to the satisfaction of the manager responsible for the process. The delay in my view represents a threat to the lives of others in similar situations. ”

    Source location

    Bathsheba Shepherd · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

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Classification: non-sudep19 Sep 2013 – 7 Sep 2026 (Publication date)Recurring concern: all recurring concerns
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