26 Jul 2016 Rebecca Gilbank · Prevention of Future Deaths report Surrey
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Concerns raised 2
Failure to carry out required checks when staff are occupied with other service users View source Lack of staff knowledge about obtaining an outside telephone line to emergency services View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Rebecca Gilbank · 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
Rebecca Gilbank, a 25-year-old woman with severe myoclonic epilepsy and significant learning difficulties, was found unresponsive in bed at Clareville Lodge during the early hours of 12 May 2015. Staff were unable to obtain an outside telephone line from the office landline and used a personal mobile phone to call emergency services, while CPR was unsuccessful. The principal concerns were that a required 1.30am check had been missed because staff were attending to other service users, and that staff did not know how to obtain an outside line to emergency services, causing a delay of unknown duration.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to carry out required checks when staff are occupied with other service users
Wider context from the report “Lack of check at 1.30am on 12 May 2015
Evidence at inquest revealed that the check was not carried out because the two members of waking night staff were busy dealing with other service users . The court heard evidence that this was not an isolated occurrence and that checks had been missed on other occasions in circumstances in which staff were dealing with other service users .
” Source location Rebecca Gilbank · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of staff knowledge about obtaining an outside telephone line to emergency services
Wider context from the report “Lack of knowledge about how to obtain an outside telephone line
Evidence at the inquest revealed that the staff on duty did not know how to obtain an outside line to emergency services and, after trying, had to rely on a personal mobile phone. This resulted in a delay of unknown duration.
” Source location Rebecca Gilbank · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review available night staffing resources at services.
Verbatim wording from the response “We have considered the staff resources that are available at our services during the night. We believe that sufficient waking night staff are made available at our services. If an individual’s assessed needs mean that they require one to one support or a higher ratio of waking night staff to service users, we note that it is the responsibility of the local authority or CCG to arrange a care and support package which meets those assessed needs and to fund it appropriately.” Source location 2016-0266-Response-by-Independence-Homes
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remove the requirement to dial 9 for an outside telephone line.
Verbatim wording from the response “Independence Homes has taken action in relation to this matter. At a meeting on 14 July 2016, at which we considered the evidence provided during the inquest, we immediately sought to rectify the issue of dialling 9 for an outside line from some of our locations. On 26 July 2016 we contacted our telephone provider and we changed our contract so that there is no longer a need to dial 9 to obtain an outside line. This change was communicated to staff verbally, by email on 7 September 2016 and in the Clareville Lodge Communications Book. Please find a copy of the email enclosed.” Source location 2016-0266-Response-by-Independence-Homes
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate the changed outside-line procedure to staff verbally, by email and in the communications book.
Verbatim wording from the response “Independence Homes has taken action in relation to this matter. At a meeting on 14 July 2016, at which we considered the evidence provided during the inquest, we immediately sought to rectify the issue of dialling 9 for an outside line from some of our locations. On 26 July 2016 we contacted our telephone provider and we changed our contract so that there is no longer a need to dial 9 to obtain an outside line. This change was communicated to staff verbally, by email on 7 September 2016 and in the Clareville Lodge Communications Book. Please find a copy of the email enclosed.” Source location 2016-0266-Response-by-Independence-Homes
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local authorities or CCGs are responsible for arranging and funding higher staffing ratios required by assessed needs.
Verbatim wording from the response “We have considered the staff resources that are available at our services during the night. We believe that sufficient waking night staff are made available at our services. If an individual’s assessed needs mean that they require one to one support or a higher ratio of waking night staff to service users, we note that it is the responsibility of the local authority or CCG to arrange a care and support package which meets those assessed needs and to fund it appropriately.” Source location 2016-0266-Response-by-Independence-Homes
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing waking-night staffing is considered sufficient for assessed needs.
Verbatim wording from the response “We have considered the staff resources that are available at our services during the night. We believe that sufficient waking night staff are made available at our services. If an individual’s assessed needs mean that they require one to one support or a higher ratio of waking night staff to service users, we note that it is the responsibility of the local authority or CCG to arrange a care and support package which meets those assessed needs and to fund it appropriately.” Source location 2016-0266-Response-by-Independence-Homes
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clear guidance on obtaining an outside telephone line was already provided at the time of the death.
Verbatim wording from the response “I note that, at the time of Ms Gilbank’s death, clear and accessible guidance on how to obtain an outside line was provided. I understand that there was a sign on the noticeboard in the staff office at Clareville Lodge which stated that staff should dial 9 for an outside line.” Source location 2016-0266-Response-by-Independence-Homes
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25 May 2016 Christopher James B Sears · Prevention of Future Deaths report Surrey
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Concerns raised 6
Inability of schools to inform bus companies about concerns without a formal diagnosis View source Lack of requirements for contracted pupil-transport bus companies to ensure driver Basic Life Support training View source Failure to provide Basic Life Support training as routine secondary education View source
Lack of a Basic Life Support qualification requirement for pupil-transport drivers View source Absence of emergency-response protocols for drivers driving buses View source Inability to put protective measures in place for bus transport concerns View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Christopher James B Sears · 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
Christopher James B Sears, a 13-year-old boy, died on 13 November 2014 after a seizure-like episode on a school bus; resuscitation attempts were unsuccessful. The report raised concerns about the absence of Basic Life Support training and emergency protocols for school-bus drivers, delays in calling emergency services, and difficulties alerting the bus company where there was no formal diagnosis.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inability of schools to inform bus companies about concerns without a formal diagnosis
Wider context from the report “4. The school were unable to inform the bus company concerned without a formal diagnosis and to put protective measures in place.
” Source location Christopher James B Sears · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of requirements for contracted pupil-transport bus companies to ensure driver Basic Life Support training
Wider context from the report “1. There is no requirement for bus companies tendering for contracts from Local Authorities to transport pupils/students to ensure all their drivers have undergone training in Basic Life Support .
” Source location Christopher James B Sears · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide Basic Life Support training as routine secondary education
Wider context from the report “5. Basic Life Support training is not taught as a matter of course to young adults in secondary education and is not part of the national curriculum .
” Source location Christopher James B Sears · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a Basic Life Support qualification requirement for pupil-transport drivers
Wider context from the report “2. There is no requirement for drivers transporting pupils/students to hold a Basic Life Support qualification .
” Source location Christopher James B Sears · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Absence of emergency-response protocols for drivers driving buses
Wider context from the report “3. No protocols were in place to assist a driver as to what to do in an emergency situation whilst driving a bus including the need to call the emergency services at the earliest opportunity .
” Source location Christopher James B Sears · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inability to put protective measures in place for bus transport concerns
Wider context from the report “4. The school were unable to inform the bus company concerned without a formal diagnosis and to put protective measures in place .
” Source location Christopher James B Sears · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consult on a revised version of the guidance on school transport.
Verbatim wording from the response “It is our intention that LAs should ensure that school bus drivers and escorts have training in basic life support skills and in the implementation of emergency protocols (your third ‘Matter of Concern’). We intend to consult on a revised version of the guidance on school transport in the autumn. Subject to any responses received in response to this consultation, we will consider whether we should further clarify both the description of the training that drivers should undertake and our expectation that training for bus drivers and escorts should include basic life support training alongside the implementation of healthcare protocols, including emergency protocols.” Source location 2016-0212-Response-by-Department-for-Education
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider clarifying training expectations for school bus drivers and escorts, including basic life support and emergency healthcare protocols.
Verbatim wording from the response “It is our intention that LAs should ensure that school bus drivers and escorts have training in basic life support skills and in the implementation of emergency protocols (your third ‘Matter of Concern’). We intend to consult on a revised version of the guidance on school transport in the autumn. Subject to any responses received in response to this consultation, we will consider whether we should further clarify both the description of the training that drivers should undertake and our expectation that training for bus drivers and escorts should include basic life support training alongside the implementation of healthcare protocols, including emergency protocols.” Source location 2016-0212-Response-by-Department-for-Education
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Promote a programme of study covering emergency procedures and basic first aid for young people.
Verbatim wording from the response “• Promoting a programme of study that teaches young people how to recognise and follow health and safety procedures and how to use emergency and basic first aid.” Source location 2016-0212-Response-by-Department-for-Education
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a statutory duty requiring governing bodies to support pupils with medical conditions.
Verbatim wording from the response “On your concern that the school did not, as a result of no medical diagnosis, have a medical plan in place, we have already introduced a new duty on governing bodies to support pupils with medical conditions. This was introduced by Section 100 of the Children and Families Act 2014 which came into force on 1 September 2014. Our aim is to give parents confidence that the right support and systems will be put in place to ensure that pupils receive the support they need. This is a clear signal to schools that supporting pupils with medical conditions is an important issue and will help them to meet their legal responsibilities.” Source location 2016-0212-Response-by-Department-for-Education
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add a reference to medical-support planning advice in home-to-school transport guidance.
Verbatim wording from the response “We believe this provides the right level of guidance to schools to ensure that effective healthcare plans are put in place, whilst allowing the flexibility they need when handling an individual pupil’s needs. We will, however, ensure that there is a reference to this advice within our guidance on home to school transport so that LAs are aware of the responsibilities of schools in drawing up such plans.” Source location 2016-0212-Response-by-Department-for-Education
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue statutory guidance setting minimum expectations for school policies, procedures and individual healthcare plans for pupils with medical conditions.
Verbatim wording from the response “The statutory guidance came into force alongside the new duty on 1 September 2014 and is available at https://www.gov.uk/government/publications/supporting-pupils-at-school-with-medical-conditions--3. The guidance sets out our minimum expectations of schools, and covers the preparation and implementation of school policies for supporting pupils with medical conditions and the use of individual care plans. Schools must have a ‘supporting pupils with medical conditions’ policy. The governing board should ensure that policies, plans, procedures and systems are properly and effectively implemented.” Source location 2016-0212-Response-by-Department-for-Education
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for requiring bus companies to provide drivers with basic life support training rests with the Department for Transport.
Verbatim wording from the response “Your concern that LA contractual arrangements do not require tendering bus companies to ensure that their drivers are qualified in basic life support skills is a matter for the Department for Transport (DfT), and we understand that Andrew Jones is replying separately to you on this issue.” Source location 2016-0212-Response-by-Department-for-Education
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mandatory basic life-support training for bus drivers is not proposed because existing guidance and flexible Driver CPC arrangements are considered sufficient.
Verbatim wording from the response “The Driver CPC is purposely designed to be flexible in its application – no specific part of the periodic training syllabus is mandatory, and the Department believes that this is important to ensure that training can be focussed on every individual’s specific training needs. In 2014/15 275,900 drivers chose to undertake training courses that taught them either basic or more advanced first aid techniques; while that total includes both bus and HGV drivers, it nevertheless suggests strong take-up.” Source location 2016-0212-Response-by-Department-for-Transport
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing voluntary PSHE arrangements, guidance and promoted resources are considered sufficient to support pupils’ first-aid and emergency medical training.
Verbatim wording from the response “Finally, on your concern that basic life support training is not taught as a matter of course to young adults, whilst schools are not under a statutory duty to provide emergency life skills teaching, many do teach it as part of personal, social, health and economic (PSHE) education.” Source location 2016-0212-Response-by-Department-for-Education
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29 Apr 2015 Jorge Emanuel Mousinho Assabay E Castro · Prevention of Future Deaths report Manchester West
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Concerns raised 3
Failure to review hospital consultant alerts about medication adherence View source Lack of systems to identify and highlight outstanding prescriptions View source Failure to review patients’ non-collection of prescribed medication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jorge Emanuel Mousinho Assabay E Castro · 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
Jorge Emanuel Mousinho Assabay E Castro died at home on 16 October 2014 after being found collapsed and unresponsive. He had post-traumatic epilepsy but had not received sodium valproate after 3 July 2014, despite attending his GP practice three times without the medication issue being reviewed. The principal concerns were the lack of systems to identify uncollected prescriptions and to alert GPs to medication-adherence concerns, particularly for vulnerable patients.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to review hospital consultant alerts about medication adherence
Wider context from the report “1. During the Inquest evidence was heard that:
i. Jorge had not received sodium valproate medication for administration after 3rd July 2014 and he had been diagnosed with post traumatic epilepsy in February 2014 requiring regular treatment with sodium valproate as an anti-epileptic medication.
ii. Jorge had been seen by General Practitioners at the Springfield Medical Centre on three occasions after the 3rd July 2014 without any review of the fact that he had not collected prescriptions for sodium valproate and the fact that the General Practitioner had received a letter from ████████ alerting the General Practitioner to an issue in relation to his regular adherence with his anti-epileptic medication.
iii. Jorge was known to be a vulnerable person, who consumed excess amounts of alcohol on a regular basis and who was being treated with Citalopram for depression prior to his injuries on the 20th June 2013 and subsequently on the 18th September 2014 prior to his death.
iv. The General Practitioner’s surgery at Springfield Medical Centre does not appear to have any systems to identify and highlight a patient who has not collected prescriptions, particularly in relation to vulnerable patients who will be dependent on medication for the control of a diagnosed condition and, as in the case of Jorge, to reduce the risk of episodes of seizure.
In particular the computerised records do not have a system of highlighting any outstanding prescriptions at subsequent consultations so that a General Practitioner was not alerted to the fact that Jorge had not collected his prescriptions and would not have had a supply of his anti-epileptic medication after the 3rd July 2014 at any of the appointments following the 3rd July 2014.
v. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues.
2. I request you to consider the above concerns, particularly with regard to the following:
i. The procedures and systems to highlight and alert General Practitioners in relation to concerns or issues raised by a Hospital Consultant, namely in Jorge’s case by ████████ with regard to Jorge’s regular adherence with his anti-epileptic medication.
ii. A review of your systems and procedures to alert General Practitioners in relation to the issue of prescriptions and the failure of a patient to collect prescriptions for prescribed medications, particularly in relation to vulnerable patients who have not collected or received their prescriptions for a period of time.
iii. Training of all staff, both professional and administrative, in relation to record keeping and checks in relation to outstanding prescriptions, particularly when a vulnerable patient has not collected a prescription and has not received necessary and prescribed medications for a period of time.
” Source location Jorge Emanuel Mousinho Assabay E Castro · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of systems to identify and highlight outstanding prescriptions
Wider context from the report “1. During the Inquest evidence was heard that:
i. Jorge had not received sodium valproate medication for administration after 3rd July 2014 and he had been diagnosed with post traumatic epilepsy in February 2014 requiring regular treatment with sodium valproate as an anti-epileptic medication.
ii. Jorge had been seen by General Practitioners at the Springfield Medical Centre on three occasions after the 3rd July 2014 without any review of the fact that he had not collected prescriptions for sodium valproate and the fact that the General Practitioner had received a letter from ████████ alerting the General Practitioner to an issue in relation to his regular adherence with his anti-epileptic medication.
iii. Jorge was known to be a vulnerable person, who consumed excess amounts of alcohol on a regular basis and who was being treated with Citalopram for depression prior to his injuries on the 20th June 2013 and subsequently on the 18th September 2014 prior to his death.
iv. The General Practitioner’s surgery at Springfield Medical Centre does not appear to have any systems to identify and highlight a patient who has not collected prescriptions , particularly in relation to vulnerable patients who will be dependent on medication for the control of a diagnosed condition and, as in the case of Jorge, to reduce the risk of episodes of seizure.
In particular the computerised records do not have a system of highlighting any outstanding prescriptions at subsequent consultations so that a General Practitioner was not alerted to the fact that Jorge had not collected his prescriptions and would not have had a supply of his anti-epileptic medication after the 3rd July 2014 at any of the appointments following the 3rd July 2014.
v. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues.
2. I request you to consider the above concerns, particularly with regard to the following:
i. The procedures and systems to highlight and alert General Practitioners in relation to concerns or issues raised by a Hospital Consultant, namely in Jorge’s case by ████████ with regard to Jorge’s regular adherence with his anti-epileptic medication.
ii. A review of your systems and procedures to alert General Practitioners in relation to the issue of prescriptions and the failure of a patient to collect prescriptions for prescribed medications, particularly in relation to vulnerable patients who have not collected or received their prescriptions for a period of time.
iii. Training of all staff, both professional and administrative, in relation to record keeping and checks in relation to outstanding prescriptions, particularly when a vulnerable patient has not collected a prescription and has not received necessary and prescribed medications for a period of time.
” Source location Jorge Emanuel Mousinho Assabay E Castro · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to review patients’ non-collection of prescribed medication
Wider context from the report “1. During the Inquest evidence was heard that:
i. Jorge had not received sodium valproate medication for administration after 3rd July 2014 and he had been diagnosed with post traumatic epilepsy in February 2014 requiring regular treatment with sodium valproate as an anti-epileptic medication.
ii. Jorge had been seen by General Practitioners at the Springfield Medical Centre on three occasions after the 3rd July 2014 without any review of the fact that he had not collected prescriptions for sodium valproate and the fact that the General Practitioner had received a letter from ████████ alerting the General Practitioner to an issue in relation to his regular adherence with his anti-epileptic medication.
iii. Jorge was known to be a vulnerable person, who consumed excess amounts of alcohol on a regular basis and who was being treated with Citalopram for depression prior to his injuries on the 20th June 2013 and subsequently on the 18th September 2014 prior to his death.
iv. The General Practitioner’s surgery at Springfield Medical Centre does not appear to have any systems to identify and highlight a patient who has not collected prescriptions, particularly in relation to vulnerable patients who will be dependent on medication for the control of a diagnosed condition and, as in the case of Jorge, to reduce the risk of episodes of seizure.
In particular the computerised records do not have a system of highlighting any outstanding prescriptions at subsequent consultations so that a General Practitioner was not alerted to the fact that Jorge had not collected his prescriptions and would not have had a supply of his anti-epileptic medication after the 3rd July 2014 at any of the appointments following the 3rd July 2014.
v. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues.
2. I request you to consider the above concerns, particularly with regard to the following:
i. The procedures and systems to highlight and alert General Practitioners in relation to concerns or issues raised by a Hospital Consultant, namely in Jorge’s case by ████████ with regard to Jorge’s regular adherence with his anti-epileptic medication.
ii. A review of your systems and procedures to alert General Practitioners in relation to the issue of prescriptions and the failure of a patient to collect prescriptions for prescribed medications, particularly in relation to vulnerable patients who have not collected or received their prescriptions for a period of time.
iii. Training of all staff, both professional and administrative, in relation to record keeping and checks in relation to outstanding prescriptions, particularly when a vulnerable patient has not collected a prescription and has not received necessary and prescribed medications for a period of time.
” Source location Jorge Emanuel Mousinho Assabay E Castro · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a half-day training workshop for staff involved in repeat-prescription generation to support the revised systems and procedures.
Verbatim wording from the response “3. Training of all staff in relation to prescribing
As a practice we have taken this opportunity to look at our prescribing systems and the changes above do require staff training. However, we have also looked at the possibility of external facilitators who may bring further advice and expertise to the practice of effective management of repeat prescribing. We can confirm that a half-day workshop has been arranged for Thursday 25th June and we would be open to any further recommendations on this day.” Source location 2015-0170-Response-by-Springfield-Medical-Centre
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Notify and collaborate with local pharmacies regarding interruptions to weekly medication collection or supply, and disseminate the significant-event learning.
Verbatim wording from the response “Weekly prescriptions are all sent to the patient’s nominated pharmacy. We have written to our local pharmacies and asked them to kindly inform us if there is any interruption to any of these patients’ medication collection or supply.” Source location 2015-0170-Response-by-Springfield-Medical-Centre
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend the prescribing system to highlight overdue prescriptions after three months and prompt timely clinical follow-up.
Verbatim wording from the response “time period and the practice has made the necessary amendments so that in future any staff viewing a patient’s prescriptions will be alerted sooner (from 3 months) and appropriate action can be taken to mitigate any risk to the patient. This would include immediate notification to the General Practitioner who would then liaise with the patient, carers, family and pharmacy as appropriate. The practice can then work with all necessary individuals or agencies to help support the patient with compliance of their medication.” Source location 2015-0170-Response-by-Springfield-Medical-Centre
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement patient-record alerts when medication-compliance concerns are raised, with staff notifying management so alerts are activated.
Verbatim wording from the response “medication. As a practice we have considered how our IT system can support the practice team in alerting us to similar issues with patients. It is possible for an alert to flag up when any member of staff enters the patient’s records and this will now be implemented for any patients who, similar to Mr Castro, are known to have compliance issues with their medication. All practice staff, clinical and administrative, have been advised to inform the practice management team immediately of any patient where compliance issues have been raised by family, carers or any other health care professionals. The management team will then ensure that an alert is activated on the patient’s records.” Source location 2015-0170-Response-by-Springfield-Medical-Centre
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create and regularly update a register of patients receiving weekly prescriptions, with monthly administrative checks and GP review of omissions.
Verbatim wording from the response “However, even this system has its limitations, as it would only highlight the issue of overdue prescriptions when a member of the practice team is actually in the patient’s records and looking at the repeat medication screen. As a practice we have over 3000 patients on regular repeat medication. Each prescription is usually for 1 to 2 months duration. However, approximately 300 of these patients, like Mr Castro, are issued medications on a weekly basis. This system is usually for patient safety or as a compliance aid. We have thus decided to create a register of all patients who are receiving prescriptions on a weekly basis. These prescriptions are issued in 4 weekly batches and the administrative staff will be checking the prescriptions have been issued for each patient every month. Those that have not been issued will be passed to a General Practitioner for review.” Source location 2015-0170-Response-by-Springfield-Medical-Centre
Open published response
Concerns raised 5
Lack of a computer-driven system to flag prescription non-attendance View source Lack of a specific policy for prisoners requiring 24-hour medical observation where constant medical supervision is unavailable View source Lack of a computer-driven system to flag lapsed prescriptions View source
Distance and waiting times inhibiting prisoner attendance at the medical centre View source Failure of welfare checks to ascertain death View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Jason Edward Lawson · 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
Jason Edward Lawson, who had epilepsy and schizophrenia, was found dead in his prison cell at HMP Stocken on 17 March 2013; the time of death was uncertain but likely late on 16 March or early on 17 March. Concerns included welfare checks that did not establish that he had died, systems that did not reliably identify medication non-attendance or lapsed prescriptions, access delays to healthcare, and the absence of a specific policy for 24-hour medical observation where constant medical supervision was unavailable.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a computer-driven system to flag prescription non-attendance
Wider context from the report “3. The current system relies on healthcare staff/pharmacy staff recognising that prisoners have not attended to collect their prescription , without having a computer driven system to flag up non-attendance .
” Source location Jason Edward Lawson · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a specific policy for prisoners requiring 24-hour medical observation where constant medical supervision is unavailable
Wider context from the report “5. There is no specific policy to deal with the situation where a prisoner needs 24 hour observation from medical staff where the prison is not equipped for constant medical supervision .
” Source location Jason Edward Lawson · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a computer-driven system to flag lapsed prescriptions
Wider context from the report “4. The current system relies on healthcare staff/pharmacy staff recognising that prescriptions have lapsed without having a computer driven system to flag it up .
” Source location Jason Edward Lawson · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Distance and waiting times inhibiting prisoner attendance at the medical centre
Wider context from the report “2. On some wings there is still some distance to walk to the medical centre and the time to wait mitigates against prisoners bothering to do attend .
” Source location Jason Edward Lawson · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of welfare checks to ascertain death
Wider context from the report “1. The welfare check did not ascertain that he had died . He was certainly dead at the time of the check at 7.30am and 8.20am on the 17th March.
” Source location Jason Edward Lawson · Prevention of Future Deaths report
Open source report
16 Jun 2014 David Andrew Llewellyn O’GARRO · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4
Failure to accurately record cell occupancy suitability View source Failure to ensure reliable communication of healthcare cell-sharing instructions to prison officers View source Lack of staff knowledge and shared understanding of cell sharing risk assessment requirements View source
Failure to complete and retain cell sharing risk assessments View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
David Andrew Llewellyn O’GARRO · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Andrew Llewellyn O’Garro suffered a sudden death in epilepsy while occupying a single cell at HMP Pentonville, with nobody present to raise the alarm during what was likely his final seizure. Concerns included the failure to complete or locate a cell sharing risk assessment and a lack of clarity and shared understanding among prison staff about ensuring prisoners with epilepsy had a cellmate.
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 accurately record cell occupancy suitability
Wider context from the report “The nurse who carried out the first reception screen of Mr O’Garro did not complete a cell sharing risk assessment (CSRA) indicating that he should share a cell, though she told me she knew that a person with epilepsy should not occupy a cell alone. She completed the computer record indicating that he was fit for any cell occupancy.
No HMP Pentonville CSRA was ever found for Mr O’Garro.
During the inquest:
- one prison nurse appeared at times completely unfamiliar with the CSRA, and wholly unclear as to how to ensure (in 2012 or now) that prisoners with epilepsy would have a cellmate;
- a prison doctor said that a locum doctor working at the prison might not even complete a CSRA because s/he would not know how the prison works;
- one of the prison officers was unsure how a message from healthcare regarding cell sharing would reach any particular officer if s/he was away on the day it was entered into the observation book.
Whilst I appreciate that you are making significant changes to the reception process for new prisoners, there appeared at inquest to be a lack of clarity and shared understanding among those working at HMP Pentonville.
” Source location David Andrew Llewellyn O’GARRO · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure reliable communication of healthcare cell-sharing instructions to prison officers
Wider context from the report “The nurse who carried out the first reception screen of Mr O’Garro did not complete a cell sharing risk assessment (CSRA) indicating that he should share a cell, though she told me she knew that a person with epilepsy should not occupy a cell alone. She completed the computer record indicating that he was fit for any cell occupancy.
No HMP Pentonville CSRA was ever found for Mr O’Garro.
During the inquest:
- one prison nurse appeared at times completely unfamiliar with the CSRA, and wholly unclear as to how to ensure (in 2012 or now) that prisoners with epilepsy would have a cellmate;
- a prison doctor said that a locum doctor working at the prison might not even complete a CSRA because s/he would not know how the prison works;
- one of the prison officers was unsure how a message from healthcare regarding cell sharing would reach any particular officer if s/he was away on the day it was entered into the observation book.
Whilst I appreciate that you are making significant changes to the reception process for new prisoners, there appeared at inquest to be a lack of clarity and shared understanding among those working at HMP Pentonville.
” Source location David Andrew Llewellyn O’GARRO · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of staff knowledge and shared understanding of cell sharing risk assessment requirements
Wider context from the report “The nurse who carried out the first reception screen of Mr O’Garro did not complete a cell sharing risk assessment (CSRA) indicating that he should share a cell, though she told me she knew that a person with epilepsy should not occupy a cell alone. She completed the computer record indicating that he was fit for any cell occupancy.
No HMP Pentonville CSRA was ever found for Mr O’Garro.
During the inquest:
- one prison nurse appeared at times completely unfamiliar with the CSRA, and wholly unclear as to how to ensure (in 2012 or now) that prisoners with epilepsy would have a cellmate ;
- a prison doctor said that a locum doctor working at the prison might not even complete a CSRA because s/he would not know how the prison works ;
- one of the prison officers was unsure how a message from healthcare regarding cell sharing would reach any particular officer if s/he was away on the day it was entered into the observation book.
Whilst I appreciate that you are making significant changes to the reception process for new prisoners, there appeared at inquest to be a lack of clarity and shared understanding among those working at HMP Pentonville .
” Source location David Andrew Llewellyn O’GARRO · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to complete and retain cell sharing risk assessments
Wider context from the report “The nurse who carried out the first reception screen of Mr O’Garro did not complete a cell sharing risk assessment (CSRA) indicating that he should share a cell , though she told me she knew that a person with epilepsy should not occupy a cell alone. She completed the computer record indicating that he was fit for any cell occupancy.
No HMP Pentonville CSRA was ever found for Mr O’Garro .
During the inquest:
- one prison nurse appeared at times completely unfamiliar with the CSRA, and wholly unclear as to how to ensure (in 2012 or now) that prisoners with epilepsy would have a cellmate;
- a prison doctor said that a locum doctor working at the prison might not even complete a CSRA because s/he would not know how the prison works;
- one of the prison officers was unsure how a message from healthcare regarding cell sharing would reach any particular officer if s/he was away on the day it was entered into the observation book.
Whilst I appreciate that you are making significant changes to the reception process for new prisoners, there appeared at inquest to be a lack of clarity and shared understanding among those working at HMP Pentonville.
” Source location David Andrew Llewellyn O’GARRO · Prevention of Future Deaths report
Open source report
2 Jun 2014 Aimee Sarah VARNEY · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 1
Failure to follow NICE referral guidelines for patients with suspected epilepsy to a Specialist Tertiary Centre View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Aimee Sarah VARNEY · 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
Aimee Sarah VARNEY died following a seizure from Sudden Unexpected Death in Epilepsy at her home address. The report identifies a concern that NICE guidance on referring patients with suspected epilepsy to a Specialist Tertiary Centre was not followed, and states that this represented a lost opportunity to diagnose and further treat her condition.
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 follow NICE referral guidelines for patients with suspected epilepsy to a Specialist Tertiary Centre
Wider context from the report “1. That the NICE Guidelines for referring a patient with suspected epilepsy to a Specialist Tertiary Centre were not followed .
” Source location Aimee Sarah VARNEY · Prevention of Future Deaths report
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 Existing systems for logging, disseminating and monitoring NICE guidelines are considered appropriate.
Verbatim wording from the response “The Medical Director is responsible for ensuring every new NICE guideline is allocated to the relevant speciality. The appropriate Clinical Audit and Effectiveness Committee (CAEC) Lead, the Finance and the Clinical Director all receive copies for discussion and dissemination. As for all NHS bodies there are occasions where the hospital cannot immediately comply with NICE guidance. This can be due to resources and requires negotiation with our commissioners to fund, for example, high value new drug therapies.” Source location 2014-0249-Response-by-Luton-Dunstable-University-Hospital
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 NICE guidelines do not require rigid compliance; clinicians may appropriately depart from recommendations using professional clinical judgment.
Verbatim wording from the response “However it must be emphasised that they are guidelines, not tramlines that the treating clinician must rigidly follow. NICE state “...health and social care professionals are actively encouraged to follow our recommendations to help them deliver the highest quality care. Of course, our recommendations are not intended to replace the professional expertise and clinical judgement of health professionals, as they discuss treatment options with their patients.” There will be individual patients where the treating clinician uses their own judgement and does not follow the absolute guidance.” Source location 2014-0249-Response-by-Luton-Dunstable-University-Hospital
Open published response
6 Jan 2014 Billy Paul Thomas Salton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 13
Failure to complete MEDACS assessment forms and care plans accurately View source Failure to document non-assessment and avoid misleading medical records View source Failure to obtain and review detained persons’ relevant medical information View source
Lack of understanding of required custody observation levels and rationale View source Failure to accurately document custody cell checks View source Failure to complete prisoner transfer documentation accurately View source Failure to staff the Prisoner Processing Unit overnight View source Lack of staff knowledge of MEDACS policies and protocols View source Failure to transfer and replicate medical observation information during GEO AMEY custody View source Lack of specific instructions and effective positioning for CCTV cell monitoring View source Ineffective or absent handovers between custody staff View source Failure to accurately record custody visits and checks View source Failure to record custody risk assessments and rationale for unchanged assessments View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Billy Paul Thomas Salton · 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
Billy Paul Thomas Salton, who had epilepsy and was intermittently non-compliant with his medication, was detained at Cheadle Police Station without initially receiving his medication. He experienced seizures in custody and was later found collapsed in a cell at Stockport Magistrates’ Court; he died after being taken to hospital. The report identified concerns about medication verification and administration, recording and handovers, observation levels and cell checks, custody delays, and the accuracy and communication of medical and escort information.
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 complete MEDACS assessment forms and care plans accurately
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan . Such a form should be completed accurately including any negative answers to questions asked .
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” Source location Billy Paul Thomas Salton · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to document non-assessment and avoid misleading medical records
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded .
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” Source location Billy Paul Thomas Salton · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to obtain and review detained persons’ relevant medical information
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition . Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody .
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” Source location Billy Paul Thomas Salton · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of understanding of required custody observation levels and rationale
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations . It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” Source location Billy Paul Thomas Salton · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to accurately document custody cell checks
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented .
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” Source location Billy Paul Thomas Salton · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to complete prisoner transfer documentation accurately
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed . The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” Source location Billy Paul Thomas Salton · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to staff the Prisoner Processing Unit overnight
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy .
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” Source location Billy Paul Thomas Salton · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of staff knowledge of MEDACS policies and protocols
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols , where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy ).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” Source location Billy Paul Thomas Salton · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to transfer and replicate medical observation information during GEO AMEY custody
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person . This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY .
” Source location Billy Paul Thomas Salton · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of specific instructions and effective positioning for CCTV cell monitoring
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell . The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen .
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” Source location Billy Paul Thomas Salton · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Ineffective or absent handovers between custody staff
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff . Important information was missed or lost in translation . Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” Source location Billy Paul Thomas Salton · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to accurately record custody visits and checks
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record .
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” Source location Billy Paul Thomas Salton · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to record custody risk assessments and rationale for unchanged assessments
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done . If there are no changes to a risk assessment then this should be recorded and any rationale noted .
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” Source location Billy Paul Thomas Salton · Prevention of Future Deaths report
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 Print clinicians’ electronic care plans for custody sergeants to reduce discrepancies between clinical and police records.
Verbatim wording from the response “The electronic record system means that the clinicians Care Plan is printed out and given to the custody sergeant: this reduces the risk of different information being written in the clinician’s own records, to that written on the paperwork for the police.” Source location 2014-0002-Response-by-Medacs
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 electronic medical-record system to determine whether screening tools and mandatory completion controls should be added.
Verbatim wording from the response “Medacs are in the process of reviewing the electronic MedacsFME system to include screening tools and dropdown boxes that will make it impossible to move onto the next section without completing the information.” Source location 2014-0002-Response-by-Medacs
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 Conduct annual audits of clinicians’ medical-note quality, address concerns individually and complete the scheduled re-audit.
Verbatim wording from the response “Lead Doctors and Lead Nurses have been tasked with completing annual audits of the quality of the medical notes of all clinicians in their teams, and have been asked to address any concerns on an individual basis with staff. A re-audit is due in June 2014.” Source location 2014-0002-Response-by-Medacs
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 Train and audit clinicians on completing the electronic medical record, including care plans and significant negative answers.
Verbatim wording from the response “I note your advice to remind staff of the importance of recording information on the Medacs assessment form, including a care plan and any negative answers to questions asked. I agree with you that it is important for staff to record significant negatives answers, as the tendency can sometimes be to record the positive answers they receive only. Unfortunately, it is not possible for staff to make a record of every question asked, and every answer given, or refused to be given, but the significant information must be recorded.” Source location 2014-0002-Response-by-Medacs
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 Conduct weekly electronic-record-use audits and address issues identified with clinicians.
Verbatim wording from the response “In May 2013 Medacs commenced a weekly audit of the ‘use of computer system’ The Client Service Managers address any issues identified with the clinicians. This is a continuing task.” Source location 2014-0002-Response-by-Medacs
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 a computerised MEDACS clinical-record system requiring typed 708e forms and direct transcription into the ICIS custody system.
Verbatim wording from the response “GMP has reviewed its arrangements for communication between custody and clinical staff to negate the practice of MEDACS staff working on two separate records of notes and to improve the continuity of care provided to detainees with health needs.” Source location 2014-0002-Response-by-Greater-Manchester-Police
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 Enable MEDACS clinicians to enter care plans directly into the custody system.
Verbatim wording from the response “To improve clarity on levels of observations we have amended the ‘drop down’ menus accessible to the MEDACS clinicians attending custody suites. Plans are in place to enable MEDACS to directly input their care plans onto our custody system which will further improve communication between custody and clinical practitioners.” Source location 2014-0002-Response-by-Greater-Manchester-Police
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 Use electronic records instead of handwritten forms, removing the requirement to label examinations as completed or refused.
Verbatim wording from the response “I note your recommendation that if a clinician is unable to complete an assessment that this should be explained and ‘any potential misleading information should not be recorded’. Given the nature of the work in police custody, our healthcare staff frequently attend to assess detainees who refuse to co-operate. In most cases it is for the detainee to decide whether they consent to an assessment, or choose to refuse, or answer questions about their health. Our investigation report identified that in this case a nurse circled “completed” on the handwritten form re: “examination/observations completed/refused”. Mr Salton had answered some questions, but refused to answer others. The handwritten forms are no longer used, and the electronic record system does not ask the staff member to select either ‘complete’ or ‘refused’.” Source location 2014-0002-Response-by-Medacs
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 clinicians to obtain custody-sergeant handovers and follow pre- and post-assessment guidance to review relevant medical history, medication and previous entries.
Verbatim wording from the response “You advise that Medacs clinicians should receive as much information as possible from the custody staff about the detainee’s medical condition and that even if they are there to solely administer medication, they should read any previous medical notes from the same day in custody. I am also keen to ensure that medical staff have all the relevant information that they require in order to administer medication, and that they read other relevant information which is available. Medacs staff are required to receive a verbal handover from the custody sergeant before seeing any detainee. This has been explained more fully in policy, and is included specifically in the Medacs Foundation course.” Source location 2014-0002-Response-by-Medacs
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 Amend MEDACS observation-level dropdown menus to improve clarity.
Verbatim wording from the response “To improve clarity on levels of observations we have amended the ‘drop down’ menus accessible to the MEDACS clinicians attending custody suites. Plans are in place to enable MEDACS to directly input their care plans onto our custody system which will further improve communication between custody and clinical practitioners.” Source location 2014-0002-Response-by-Greater-Manchester-Police
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 Provide staff inputs using case studies to reinforce recording risk-assessment rationales and custody actions accurately.
Verbatim wording from the response “I do agree with this but can see how this can degrade into quite significant events not being accurately recorded. We will, therefore, shortly be giving a series of inputs to staff which will” Source location 2014-0002-Response-by-Greater-Manchester-Police
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 Issue and check improved guidance for sergeants on completing, timing and signing off Prisoner Escort forms.
Verbatim wording from the response “Since your observations we have put out improved guidance on completion of the PER form to sergeants which include what to record, when it is to be done and how it is to be signed off. This has been extensively checked and has led to improvements in standards.” Source location 2014-0002-Response-by-Greater-Manchester-Police
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 hard-copy and electronic policy access in every custody suite and disseminate revised policies through lead clinicians.
Verbatim wording from the response “I agree that it is important that all staff know where to look to seek guidance and where the policies are to refer to. I would like to reassure you that before they start work alone, all new healthcare staff complete a 3 day shadowing period with an experienced clinician. During this 3 day period they are made aware of the content of the Medacs policies and procedures and how these can be located whilst on duty and they are now required to sign to say they have had this information. All policies and procedures are located in every custody suite in both hard copies in a file and on the desktops of the medical room computers. Every time a policy is reviewed or revised a communication is disseminated from the Head of Clinical Services via all lead clinicians by e-mail and the relevant policy is updated in the folder and the desktop.” Source location 2014-0002-Response-by-Medacs
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 new healthcare staff to complete three-day clinical shadowing and sign that they received guidance on locating and using policies.
Verbatim wording from the response “I agree that it is important that all staff know where to look to seek guidance and where the policies are to refer to. I would like to reassure you that before they start work alone, all new healthcare staff complete a 3 day shadowing period with an experienced clinician. During this 3 day period they are made aware of the content of the Medacs policies and procedures and how these can be located whilst on duty and they are now required to sign to say they have had this information. All policies and procedures are located in every custody suite in both hard copies in a file and on the desktops of the medical room computers. Every time a policy is reviewed or revised a communication is disseminated from the Head of Clinical Services via all lead clinicians by e-mail and the relevant policy is updated in the folder and the desktop.” Source location 2014-0002-Response-by-Medacs
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a custody-office work system that improves CCTV monitoring coverage and accountability.
Verbatim wording from the response “The programme of work I described earlier in improving communication and management of the office is looking at every aspect of the roles staff undertake in Custody. The monitoring of CCTV is one of those roles and they will be looking for a system that matches or improves the coverage of CCTV we have and also provide greater accountability.” Source location 2014-0002-Response-by-Greater-Manchester-Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Standardise sergeant handovers around accurate Custody Summary Screens and communication of key detainee risk information.
Verbatim wording from the response “We have conducted a review of handovers between sergeants. As a result we have made it clear to sergeants that the handover need not be a comprehensive review of each detainee. Rather, they should have completed the Custody Summary Screen so that all the relevant detail is available on the ICIS system and the handover should contain key risk issues, for example medical conditions, medication required and so forth.” Source location 2014-0002-Response-by-Greater-Manchester-Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require recording of unchanged risk assessments and monitor compliance through Custody Inspector dip sampling.
Verbatim wording from the response “You are right to point out that all risk assessments, including those where there is no change in the detainee’s circumstances, should also be recorded. This requirement has been communicated to custody staff and is currently being monitored by Custody Inspectors undertaking dip sampling of custody records.” Source location 2014-0002-Response-by-Greater-Manchester-Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Staff cannot record every question, answer or refusal, but must record significant information.
Verbatim wording from the response “I note your advice to remind staff of the importance of recording information on the Medacs assessment form, including a care plan and any negative answers to questions asked. I agree with you that it is important for staff to record significant negatives answers, as the tendency can sometimes be to record the positive answers they receive only. Unfortunately, it is not possible for staff to make a record of every question asked, and every answer given, or refused to be given, but the significant information must be recorded.” Source location 2014-0002-Response-by-Medacs
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assessments cannot always be completed because detainees may refuse to cooperate or answer health questions.
Verbatim wording from the response “I note your recommendation that if a clinician is unable to complete an assessment that this should be explained and ‘any potential misleading information should not be recorded’. Given the nature of the work in police custody, our healthcare staff frequently attend to assess detainees who refuse to co-operate. In most cases it is for the detainee to decide whether they consent to an assessment, or choose to refuse, or answer questions about their health. Our investigation report identified that in this case a nurse circled “completed” on the handwritten form re: “examination/observations completed/refused”. Mr Salton had answered some questions, but refused to answer others. The handwritten forms are no longer used, and the electronic record system does not ask the staff member to select either ‘complete’ or ‘refused’.” Source location 2014-0002-Response-by-Medacs
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing CCTV arrangements are considered sufficient; staff will not be specifically instructed to observe the screen for Level 2 observations.
Verbatim wording from the response “At present we remain satisfied with our current arrangements for CCTV usage. We do use CCTV for constant observations in some cases. However, in the case with Mr Salton, the level of observations was at Level 2.” Source location 2014-0002-Response-by-Greater-Manchester-Police
Open published response
Concerns raised 3
Failure to notify Social Services of discharge contrary to their recommendations View source Lack of clarity in communicating post-discharge supervision expectations to informal carers View source Failure to maintain complete and accurate records of discharge decisions and timing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
ROSEMARY BRONWYN FERGUSON · 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
ROSEMARY BRONWYN FERGUSON, who had a long-standing history of epilepsy, was admitted after a head injury from a fall and was assessed as unfit for discharge because of risks associated with further falls. Despite recommendations that she remain in hospital, she was discharged to the care of a friend and was found deceased alone at home on 11 March 2013; the medical cause of death was recorded as sudden unexpected death in epilepsy. The principal concerns were that Social Services were not notified of the discharge, the friend’s expected role was unclear, and hospital records did not adequately document key communications and the date of discharge.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to notify Social Services of discharge contrary to their recommendations
Wider context from the report “(1) The social workers left work on Friday 8th March, 2013 believing that, following their recommendations, Ms Ferguson would remain in hospital over the weekend and accordingly they did not put into place any support measures for her. The clinician’s decision to discharge her before support measures could be put in place was not communicated to Social Services. If it had been, this would have given an opportunity for them to take urgent supportive action. As it transpired, Ms Ferguson died from Natural causes rather than, for example, Injuries sustained in a further fall, or a deterioration of her earlier head injury, but I apprehend danger in the future if discharge occurs contrary to Social Service recommendations without the discharge being notified to them.
” Source location ROSEMARY BRONWYN FERGUSON · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clarity in communicating post-discharge supervision expectations to informal carers
Wider context from the report “(2) The clinician discharged Ms Ferguson based on clinical issues and NICE guidelines. She was discharged to the care of her friend ████████ The only conversation between the clinicians and ████████ was a telephone call in which it was arranged for Ms Ferguson to be driven straight to his home on leaving hospital. This duly took place, but ████████ did not understand that the clinician expected him to remain in her company for at least the next 24 hours in order to watch for any significant changes in her condition and accordingly, he did not remain with her constantly. There was clearly a difference of perception about his role, possibly as a result of lack of clarity in the conversation between himself and the clinician. I am concerned that a repetition of this in other cases may lead to danger.
” Source location ROSEMARY BRONWYN FERGUSON · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain complete and accurate records of discharge decisions and timing
Wider context from the report “(3) The Hospital Notes were scanty and there appear to be material omissions to record important decisions such as a detailed note of the telephone call between ████████ and the clinician, properly timed and recording clearly what was intended . Further, it was difficult to trace from the Notes, the actual day of discharge , the clinician believing it to be the 8th March and ████████ believing it was the 9th March. Some computer records were presented to the Court suggestive of a discharge on the 8th March, but this information appears to be missing from the actual hand-written Notes . I am concerned that such problems with communication can lead to misunderstandings to the detriment of all concerns.
” Source location ROSEMARY BRONWYN FERGUSON · Prevention of Future Deaths report
Open source report
19 Sep 2013 Daniel Onley · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 3
Insufficient supervision to safeguard safety and wellbeing View source Failure to manage risks associated with medication management View source Insufficient arrangements to support taking anti-convulsant medication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 11
Action
Review service staffing adequacy periodically through performance and contract monitoring.
Stated by The Camphill Village TrustStated plannedThe respondent said that this action was planned when they made their response on 19 September 2013. View source
Action
Establish General Manager and Care and Support Manager posts and appoint additional competent support staff at the Grange.
Stated by The Camphill Village TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2013. View source
Action
Remind managers to provide supervision at all times commensurate with each person’s assessed needs.
Stated by The Camphill Village TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2013. View source
Action
Share the Coroner’s concerns with operational managers to support open learning and required practice changes.
Stated by The Camphill Village TrustStated plannedThe respondent said that this action was planned when they made their response on 19 September 2013. View source
Action
Implement a Trust-wide Medicines Policy governing the obtaining, recording, handling, storage, administration and disposal of medicines.
Stated by The Camphill Village TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2013. View source
Action
Incorporate regular training on managing risks associated with medicines into the Trust staff training plan.
Stated by The Camphill Village TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2013. View source
Action
Audit risk-assessment, capacity-assessment and documented-medicine-support records at least every six months.
Stated by The Camphill Village TrustStated plannedThe respondent said that this action was planned when they made their response on 19 September 2013. View source
Action
Conduct internal medicines-management audits across all nine Trust communities to assess compliance with safety standards.
Stated by The Camphill Village TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2013. View source
Action
Implement common Trust-wide paperwork and work systems for identifying, assessing and managing medicine-related risks.
Stated by The Camphill Village TrustStated plannedThe respondent said that this action was planned when they made their response on 19 September 2013. View source
Action
Require documented medicine risk assessments, capacity assessments and support instructions, with six-monthly or trigger-based reviews.
Stated by The Camphill Village TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2013. View source
Action
Carry out medicines-policy compliance checks at least every six months under the Operations Director’s direction.
Stated by The Camphill Village TrustStated plannedThe respondent said that this action was planned when they made their response on 19 September 2013. View source See 8 more actions
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AI-generated summary
Daniel Onley · 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
Daniel Onley, a resident at Orchard House, was found face down in his bath on 22 June 2012 and was concluded to have died from sudden unexplained death in epilepsy. Concerns included insufficient support for taking anti-convulsant medication, inadequate management of medication-related risks, and insufficient evening supervision.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient supervision to safeguard safety and wellbeing
Wider context from the report “(3) The supervision provided to Daniel during the evening of Thursday 21st June 2012 was not sufficient to safeguard Daniel’s safety and wellbeing .
” Source location Daniel Onley · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to manage risks associated with medication management
Wider context from the report “(2) There had been a failure to manage risks associated with Daniel’s management of his medication .
” Source location Daniel Onley · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient arrangements to support taking anti-convulsant medication
Wider context from the report “(1) That the arrangements in place to support Daniel to take his anti-convulsant medication were insufficient .
” Source location Daniel Onley · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review service staffing adequacy periodically through performance and contract monitoring.
Verbatim wording from the response “Future audit of arrangements” Source location 2013-0208-Response-by-The-Camphill-Village-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish General Manager and Care and Support Manager posts and appoint additional competent support staff at the Grange.
Verbatim wording from the response “Specifically, with regard to arrangements in the Grange, i.e. the service where Daniel lived, the posts of General Manager and Care and Support Manager have been established and additional support staff have been appointed with the necessary competencies, knowledge, qualifications, skills and experience to ensure adequacy of staff cover and the safety of the service at all times.” Source location 2013-0208-Response-by-The-Camphill-Village-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind managers to provide supervision at all times commensurate with each person’s assessed needs.
Verbatim wording from the response “The supervision provided to Daniel during the evening of Thursday 21st June 2012 was not sufficient to safeguard Daniel’s safety and wellbeing” Source location 2013-0208-Response-by-The-Camphill-Village-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the Coroner’s concerns with operational managers to support open learning and required practice changes.
Verbatim wording from the response “6 Organisational Learning” Source location 2013-0208-Response-by-The-Camphill-Village-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a Trust-wide Medicines Policy governing the obtaining, recording, handling, storage, administration and disposal of medicines.
Verbatim wording from the response “Policy revision” Source location 2013-0208-Response-by-The-Camphill-Village-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incorporate regular training on managing risks associated with medicines into the Trust staff training plan.
Verbatim wording from the response “Regular training on the management of risks has been incorporated into the Trust’s staff training plan.” Source location 2013-0208-Response-by-The-Camphill-Village-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit risk-assessment, capacity-assessment and documented-medicine-support records at least every six months.
Verbatim wording from the response “Future audit of arrangements” Source location 2013-0208-Response-by-The-Camphill-Village-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct internal medicines-management audits across all nine Trust communities to assess compliance with safety standards.
Verbatim wording from the response “Audit of existing arrangements” Source location 2013-0208-Response-by-The-Camphill-Village-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement common Trust-wide paperwork and work systems for identifying, assessing and managing medicine-related risks.
Verbatim wording from the response “The concerns expressed by the Coroner have been shared with operational managers in order to ensure lessons are learned openly and frankly and any required changes to practice are made. For example, as a result of organisational learning, common paperwork has been implemented across the Trust regarding the identification; assessment and management of risks related to handing medicines. The introduction of such a common paperwork and systems of work will greatly assist risk mitigation, improve consistency in operational practice and also provides an essential benchmark for quality auditing purposes.” Source location 2013-0208-Response-by-The-Camphill-Village-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require documented medicine risk assessments, capacity assessments and support instructions, with six-monthly or trigger-based reviews.
Verbatim wording from the response “Improvements to the management of risks associated with the administration of medicines in trust services” Source location 2013-0208-Response-by-The-Camphill-Village-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Carry out medicines-policy compliance checks at least every six months under the Operations Director’s direction.
Verbatim wording from the response “Future audit of arrangements” Source location 2013-0208-Response-by-The-Camphill-Village-Trust
Open published response
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