24 Jun 2025 Susan Nora Elizabeth YOUNG · Prevention of Future Deaths report Norfolk
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Concerns raised 3
Failure to secure patients' own medication View source Lack of clinical handover to receiving wards View source Failure to pass on doctors' instructions for cardiac monitoring 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
Susan Nora Elizabeth YOUNG · 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
Susan Nora Elizabeth Young was admitted to hospital after taking overdoses of prescription medication on 22 and 23 August 2024. She was transferred to a ward with directions for cardiac monitoring, but no clinical handover or monitoring instructions were provided. She was later found unresponsive and not attached to monitoring, and resuscitation failed; unused medication was subsequently found among her belongings.
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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 secure patients' own medication
Wider context from the report “NO clinical handover to receiving ward. No instructions passed on from the doctor re cardiac monitoring. Patients own medication found in her belongings which had been with her , after her death allowing her the opportunity to take another overdose.
” Source location Susan Nora Elizabeth YOUNG · 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 clinical handover to receiving wards
Wider context from the report “NO clinical handover to receiving ward. No instructions passed on from the doctor re cardiac monitoring. Patients own medication found in her belongings which had been with her, after her death allowing her the opportunity to take another overdose.
” Source location Susan Nora Elizabeth YOUNG · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to pass on doctors' instructions for cardiac monitoring
Wider context from the report “NO clinical handover to receiving ward. No instructions passed on from the doctor re cardiac monitoring. Patients own medication found in her belongings which had been with her, after her death allowing her the opportunity to take another overdose.
” Source location Susan Nora Elizabeth YOUNG · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the updated Self-Harm Policy and patient-search procedure with Emergency Care staff and support acknowledgement of understanding.
Verbatim wording from the response “ii. Action C2 - To share the self-harm policy across Emergency Care with a reference to this patient safety incident once the addendum as above has been added.
I can confirm that the search policy has been shared with all ED clinical staff on the 16th April 2025 and was added to the self-harm policy as an addendum which is available on the intranet for all staff to access. Following this, a signatory list will be collected to ensure that all staff have read and understood the policy and its implications for patients presenting with self harm.” Source location Response from James Paget University Hospitals NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add a patient-search procedure to the Self-Harm Policy covering searches for medication and other items that could enable overdose or self-harm.
Verbatim wording from the response “I can confirm that the Trust's Self Harm Policy (copy attached) now includes an addendum (Appendix C) an SOP (Standard Operating Procedure) Search of Patients within the ED. The policy describes the rationale behind searching patients attending the ED in Mental Health crisis to reduce the risk of patients attempting further overdose or self-harm during their time in the ED. The updated policy has been uploaded to the Trust's intranet.” Source location Response from James Paget University Hospitals NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the updated Self Harm Policy and patient-search procedure to Emergency Care staff and promote its requirements through written and face-to-face communication.
Verbatim wording from the response “C2 Action Required – Local
To share the self-harm policy across Emergency Care with a reference to this patient safety incident once the addendum as above has been added.
Responsibility: Matron Urgent Care
Timescale: 30th July 2025
RAG: W” Source location Response from James Paget University NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add a patient-search procedure to the Self Harm Policy, covering removal and safe storage of medications and other harmful items in Emergency Department patients at risk.
Verbatim wording from the response “C1 Action Required – Local
To complete the agreed process for searching patients to maintain patient safety (this will form an addendum to the self-harm policy).
Responsibility: Matron Mental Health Liaison / Consultant
Timescale: 30th June 2025
RAG: A” Source location Response from James Paget University NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and implement a standard ED-to-EADU handover process and form that includes specialist requirements such as cardiac monitoring.
Verbatim wording from the response “vi. As a Trust, we are developing a communication process for handover with a task and finish group commencing 23rd May 2025. This includes leads from each department including ED and EADU. The flow chart is in the design phase, with an aim to commence the new process mid-June. Specialist requirements for the patient including cardiac monitoring will be included in the handover template. Once embedded, an audit will take place to monitor compliance and identify gaps needing further education and support.” Source location Response from James Paget University Hospitals NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit the implemented ED Patient Handover Form monthly from September until consistent compliance is demonstrated.
Verbatim wording from the response “To support and evidence our addressing of all three matters of concern raised, we have included the updated Trust Transfer Policy, including the trust handover process which has been communicated and promoted to staff, the summary of the policy expectations that has been communicated to ED staff, evidence of the associated staff training undertaken and a copy of the ED Patient Handover Form now in use for all patient transfers. An audit of the implemented ED Patient Handover Form is scheduled in September and will be ongoing monthly until results demonstrate good and consistent compliance.” Source location Response from James Paget University Hospitals NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit compliance with the ED patient handover form monthly after the scheduled September audit until consistent compliance is demonstrated.
Verbatim wording from the response “To support and evidence our addressing of all three matters of concern raised, we have included the updated Trust Transfer Policy, including the trust handover process which has been communicated and promoted to staff, the summary of the policy expectations that has been communicated to ED staff, evidence of the associated staff training undertaken and a copy of the ED Patient Handover Form now in use for all patient transfers. An audit of the implemented ED Patient Handover Form is scheduled in September and will be ongoing monthly until results demonstrate good and consistent compliance.” Source location Response from James Paget University NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce the ED patient handover process and form for transfers, including communication of cardiac monitoring and other specialist requirements.
Verbatim wording from the response “vi. As a Trust, we are developing a communication process for handover with a task and finish group commencing 23rd May 2025. This includes leads from each department including ED and EADU. The flow chart is in the design phase, with an aim to commence the new process mid-June. Specialist requirements for the patient including cardiac monitoring will be included in the handover template. Once embedded, an audit will take place to monitor compliance and identify gaps needing further education and support.” Source location Response from James Paget University NHS Foundation Trust
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26 Jun 2025 CALLAN NORMAN COLLINS ATKINS · Prevention of Future Deaths report Gloucestershire
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Concerns raised 2
Failure to enquire about additional resources when the local crisis team has no capacity View source Insufficient mental health crisis team staff capacity for same-day assessment when clinically required 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
CALLAN NORMAN COLLINS ATKINS · 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
Callan was found hanging at his home on 18 May 2023 and was confirmed dead at the scene. The report identified a missed opportunity for a face-to-face mental health assessment the previous day, although it found no possible or probable contribution to his death from this. Concerns were raised that crisis-team staff capacity could determine whether patients were assessed when clinically needed, and that additional resources might not be explored when the team lacked capacity.
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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 enquire about additional resources when the local crisis team has no capacity
Wider context from the report “That the Trust will not make any enquiries as to additional resources when their local Crisis team has no capacity .
” Source location CALLAN NORMAN COLLINS ATKINS · 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 Insufficient mental health crisis team staff capacity for same-day assessment when clinically required
Wider context from the report “That staff capacity of the mental health crisis team of the Gloucestershire Health and Care NHS Foundation Trust will dictate whether a patient is assessed on the same day when their clinical needs demand the.
” Source location CALLAN NORMAN COLLINS ATKINS · Prevention of Future Deaths report
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12 May 2025 Kenneth Foster · Prevention of Future Deaths report East London
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Concerns raised 1
Failure of governance and safety-review processes to identify, investigate, reflect upon, and remediate sub-optimal practice 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
Kenneth Foster · 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
Kenneth Foster, who had epilepsy following a traumatic brain injury in 2012, was admitted to hospital after prolonged seizure activity in September 2024. After interruption of clobazam administration following removal of his naso-gastric tube, his seizures resumed; he was later diagnosed with aspiration pneumonia, which led to his death. The report identified concerns about failures in governance and inadequate incident reporting, morbidity and mortality processes, and Patient Safety Incident Response Framework procedures.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of governance and safety-review processes to identify, investigate, reflect upon, and remediate sub-optimal practice
Wider context from the report “A. A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice.
In this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate.
” Source location Kenneth Foster · 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 Contact families during PSIRM reviews so their concerns inform the review and decision on the level of investigation required.
Verbatim wording from the response “As part of the learning from this PFD, the Whipps Cross Hospital Senior Leadership Team will ensure that families are contacted as part of the Patient Safety Incident Review Meeting (PSIRM) process to ensure that a more robust review is undertaken. Taking account of family concerns should be a key aspect to inform decision making around the level of investigation required. This action will also ensure reviews include the views of the patient’s family, in line with Patient Safety Incident Response Framework (PSIRF) compassionate engagement principles.” Source location 2025-0231-Response from Barts Health NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Report each new inquest in Datix, present it at PSIRM, and expedite any outstanding M&M review to inform the required learning response.
Verbatim wording from the response “Since December 2024, at Whipps Cross Hospital, each new inquest opened is reported via the incident reporting system (Datix). The cases are presented at the Patient Safety Incident Response Meeting (PSIRM) and where a Mortality and Morbidity Meeting (M&M) has not yet been held, arrangements are made to expedite this process to inform decision making around the type of learning response required in accordance with the Patient Safety Incident Response Plan.” Source location 2025-0231-Response from Barts Health NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a specialist review of governance processes relating to this case, engage the Foster family, and share the outcome with HM Coroner.
Verbatim wording from the response “In order to gain additional assurance, the Trust has commissioned a review to be undertaken by a specialist within the North London Integrated Care Board and supported by NHSE to review” Source location 2025-0231-Response from Barts Health NHS Foundation Trust
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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 Trusts are responsible for documenting patient safety incident response decisions and explaining when no specific learning response is undertaken.
Verbatim wording from the response “As such, under PSIRF, not all deaths will be investigated. This will include some which go to inquest. Decision-making regarding patient safety incident response should be documented by Trusts as part of a robust governance process. Where a specific learning response is not undertaken in relation to an incident discussed at inquest, the organisation should be able to explain why this was the case.” Source location 2025-0231-Response from The Department of Health and Social Care
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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 Under PSIRF, not all deaths require investigation; Trusts must document and explain decisions under the existing patient safety incident response governance process.
Verbatim wording from the response “While PSIRF represents a significant improvement to the way that the NHS responds to patient safety incidents, PSIRF does not alter the requirements set out in the National Learning from Deaths policy framework. These require a patient safety incident investigation to be undertaken into any event where problems in care are thought more likely than not to have led to the death of a patient.” Source location 2025-0231-Response from The Department of Health and Social Care
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Concerns raised 3
Failure of drivers with dementia to self-report medical conditions to the DVLA View source Failure to report multiple medical conditions requiring DVLA monitoring View source Under-recording of dementia in collision statistics View source
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
Sheila Margaret Edwards · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sheila Margaret Edwards was a front-seat passenger in a car whose driver became unresponsive, leading to a head-on collision on 8 January 2023. The report identified concerns that drivers with dementia and other conditions may not recognise or report them to the DVLA, creating risks to other road users, and that such conditions may be under-recorded in collision data.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of drivers with dementia to self-report medical conditions to the DVLA
Wider context from the report “1. Dementia affects approximately half a million sufferers in the United Kingdom of which the DVLA has only been notified of approximately 30,000 drivers. It would appear that there is significant underreporting of drivers who may suffer from dementia
2. The current system for vehicle licensing relies upon the self-awareness of a driver and their ability to self-report medical conditions to the DVLA . A system that relies upon the self-awareness of a person applying for a driving licence to self-report a medical condition of dementia where the condition itself is characterised by a lack of self-awareness is inherently unsafe and exposes other road users to the risk of death or serious injury
” Source location Sheila Margaret Edwards · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to report multiple medical conditions requiring DVLA monitoring
Wider context from the report “5. In this case, the driver suffered from focal epilepsy, which was the primary cause of the collision resulting Sheila Edwards' death. However, the memory deficit caused by dementia resulted in a lack of awareness of an underlying neurological condition. In such cases there is a substantial risk that neither of the conditions will be reported to the DVLA for monitoring . The result is that a driver with two conditions that should be monitored by the DVLA who is both unaware of their illnesses and the need to report themselves to the DVLA . This creates a substantial risk to other road users.
” Source location Sheila Margaret Edwards · Prevention of Future Deaths report
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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 Under-recording of dementia in collision statistics
Wider context from the report “4. As a result of the way in which collision data is collected using Stats 19, there is a significant likelihood that dementia is under recorded in collision statistics . The nation this point regarding collision data regarding the visual aspect of collisions, the PFD report into the deaths of Mary Cunningham, Grace Foulds, Anne Ferguson and Peter Westwell should be consulted.
” Source location Sheila Margaret Edwards · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider research and evidence, including any additional research needed, to inform potential future changes to the driver licensing system.
Verbatim wording from the response “Officials are considering the research and evidence provided and what additional research may be needed to inform potential future changes. These considerations include the system of self-declaration and the potential for the introduction of age-based testing. Consideration is also being given to policy options as part of the Government’s Road Safety Strategy, which is being developed and the details of which will be provided in due course.” Source location Response from Department for Transport
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with healthcare professionals, driving organisations and regulatory bodies to identify and assess people who pose road-safety risks because of unrecognised medical conditions.
Verbatim wording from the response “My Department will continue to work with healthcare professionals, driving organisations and regulatory bodies to enhance the safety of our roads and ensure that those who pose a risk to road safety due to lack of awareness of their medical condition are appropriately identified and assessed.” Source location Response from Department for Transport
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue engaging healthcare professionals and regulatory bodies to identify and address obstacles to reporting conditions when patients lack insight or capacity.
Verbatim wording from the response “Although the process for establishing that a driver meets the medical standards for driving is based on self-declaration, I recognise that this may be difficult for those drivers with conditions that may impair their insight into their health status. My department will continue to engage with healthcare professionals and their regulatory bodies to identify and address any obstacles that may hinder the reporting process, particularly where their patient lacks the insight or capacity to inform the DVLA of their condition themselves.” Source location Response from Department for Transport
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation STATS19 cannot capture all medical contributory factors because detailed identification would impose practical burdens on police officers.
Verbatim wording from the response “I note that you have raised concerns about the STATS19 system used in GB for collecting and reporting road traffic collision data. The Department acknowledges that STATS19 has limitations in identifying the causes of collisions in detail, particularly regarding the recording of medical conditions such as dementia or cognitive impairment as a contributory factor. These limitations are set out in the guidance provided (for example, the guidance on contributory factors). Contributory factors are based on the judgement of police officers at the scene of an accident or shortly afterwards. As a result, conditions such as those affecting cognitive function may go unrecorded, especially if the impairment is not immediately apparent or if the officer is unaware of the driver’s medical history.” Source location Response from Department for Transport
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4 Apr 2025 Mr Alexi Susiluoto · Prevention of Future Deaths report Inner North London
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Concerns raised 2
Failure to include homelessness-related care issues in the review of treatment for patients with dual diagnoses View source Fragmented provision of substance misuse and mental health treatment across different organisations View source
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
Mr Alexi Susiluoto · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Alexi Susiluoto, who had a history of mental health disorders, substance misuse and epilepsy, was found deceased in a hotel room on 22 May 2024. His death was attributed to alcohol misuse disorder resulting in acute ethanol toxicity, with epilepsy and prescribed medication as contributing factors. The report raised concerns about fragmented care for people with dual diagnoses who are homeless, including confusion over which services and local authority were responsible for care and funding.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to include homelessness-related care issues in the review of treatment for patients with dual diagnoses
Wider context from the report “1. I heard evidence that the Office for Health Improvement and Disparities is currently undertaking a review of how patients with dual diagnoses (substance misuse and mental health disorders) are treated. I was concerned by two related issues:
a. That substance misuse and mental health treatment is routinely provided by different organisations, despite close interplay between these conditions and that this can result in significant complexities for agencies caring for the same patient. I understand that this aspect is part of the current review;
b. However, I also heard that the review is not taking into consideration the additional issues that arise when a patient with dual diagnoses is also homeless . Evidence presented at the inquest set out that this already complex situation is often compounded by homelessness, since individuals are often moved between temporary accommodation and therefore between different mental health trust and substance misuse providers. In Mr Susiluoto’s case, this resulted in significant confusion as to who was providing his care and which local authority would fund potential substance misuse treatment.
” Source location Mr Alexi Susiluoto · Prevention of Future Deaths report
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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 Fragmented provision of substance misuse and mental health treatment across different organisations
Wider context from the report “1. I heard evidence that the Office for Health Improvement and Disparities is currently undertaking a review of how patients with dual diagnoses (substance misuse and mental health disorders) are treated. I was concerned by two related issues:
a. That substance misuse and mental health treatment is routinely provided by different organisations , despite close interplay between these conditions and that this can result in significant complexities for agencies caring for the same patient . I understand that this aspect is part of the current review;
b. However, I also heard that the review is not taking into consideration the additional issues that arise when a patient with dual diagnoses is also homeless. Evidence presented at the inquest set out that this already complex situation is often compounded by homelessness, since individuals are often moved between temporary accommodation and therefore between different mental health trust and substance misuse providers. In Mr Susiluoto’s case, this resulted in significant confusion as to who was providing his care and which local authority would fund potential substance misuse treatment.
” Source location Mr Alexi Susiluoto · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a comprehensive action plan to improve provision for people with co-occurring substance-use and mental-health needs.
Verbatim wording from the response “Your report mentions a review my department is taking into treatment for people with substance use and mental health conditions, and you raise concerns that the review is not considering the additional complexities and issues that occur when someone is also experiencing, or at risk of, homelessness. My department recognises the vital importance of high-quality integrated care for those with co-occurring conditions and who sleep rough, or who are at risk of sleeping rough. To clarify, we have not undertaken a formal review but, following recommendation from Dame Carol Black’s independent review of drugs, have been developing a comprehensive action plan to set out a path to improving service provision for those with co-occurring substance use and mental health needs.” Source location Response from DHSC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with NHS England to improve integrated care for people with substance-use and mental-health needs.
Verbatim wording from the response “Thank you for bringing these concerns to my attention. I want to assure you my department and NHSE recognise these issues and are continuing to work closely together to improve integrated care for those with substance use issues. I hope this response is helpful.” Source location Response from DHSC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish UK clinical guidelines on alcohol treatment, including recommendations for co-occurring conditions, multidisciplinary assessment, care planning and care coordination.
Verbatim wording from the response “- DHSC will soon publish the UK clinical guidelines on alcohol treatment to support and improve the quality of treatment for people with alcohol dependence. The guidelines include chapters on working with people with co-occurring alcohol dependence and mental health and/or physical health conditions. They also include recommendations on multi-disciplinary assessment, care planning and care co-ordination.” Source location Response from DHSC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the Department of Health and Social Care to improve access to mental health services and coordination across health services for people experiencing homelessness.
Verbatim wording from the response “I am leading cross-government efforts to deliver the long-term solutions we need to get us back on track to ending all forms of homelessness. This includes chairing a dedicated Inter-Ministerial Group (IMG), bringing together Ministers from across Government to develop a long-term strategy. DHSC Ministers attend the IMG, and we are working closely with the DHSC to address the health needs of people experiencing homelessness and rough sleeping. This includes improving access to mental health services and improving join-up between all services across the health system to ensure people experiencing homelessness are supported with all their health needs. We expect to publish our Homelessness Strategy following the conclusion of Phase 2 of the Spending Review.” Source location Response from MHCLG
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Department of Health and Social Care will respond separately on matters relevant to its department, including the needs review.
Verbatim wording from the response “I understand the Parliamentary Under-Secretary of State for Public Health and Prevention in the DHSC will be responding separately on matters relevant to their department that your report raises,” Source location Response from MHCLG
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing actions and the cross-government homelessness strategy are considered sufficient, so no further Ministry action is proposed.
Verbatim wording from the response “Given the actions and relevant cross-government strategy being already undertaken and led by my department, I am proposing that no further action is taken by the Ministry of Housing, Communities and Local Government in relation to this case.” Source location Response from MHCLG
Open published response
24 Jan 2025 Charlie Marriage · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6
Failure to maintain medical oversight of medication-dependent patients until appropriately medicated View source Failure to recognise and communicate medication-related crisis vulnerability in medical records View source Failure to provide appropriately urgent clinical support and safety-netting for medication-related crisis risk View source
Failure to ensure medication-dependent patients understand medication-related death risks and plan emergency action View source Failure to account for unreliable local pharmacy availability of urgently needed medication View source Provision of generic safety-netting advice to patients at risk of sudden medication-related crisis 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
Charlie Marriage · 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
Charlie Marriage, who had epilepsy controlled with Fycompa, was unable to obtain his repeat medication after being told to self-isolate for Covid and encountering difficulties with his GP practice, pharmacy and 111. He suffered a fatal seizure at home after going without medication. The report identified concerns about whether patients with medication-dependent, “cliff-edge conditions” are recognised, prioritised and given appropriate safety-netting and access to emergency supplies.
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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 maintain medical oversight of medication-dependent patients until appropriately medicated
Wider context from the report “(1) There are cohorts of patients who are medication dependant. For some their underlying condition is such that absent this medication they are at significant risk of a sudden crisis, and potentially death e.g. SUDEP, or Diabetic Ketoacidosis etc. These were described at the inquest as “cliff-edge conditions”.
(2) It is not apparent that these patients are currently identified within the health system as being at risk of a sudden crisis and death (absent their medication) so as to manage the following concerns giving rise to a risk of future deaths:
(a) that such patients may not be fully aware of the risks of death associated with not being medicated and therefore may (i) not fully understand the importance of avoiding the risk that this scenario arises, and (ii) not have planned the likely best course of action in the event that it does (e.g. to go to A&E, or to approach an identified pharmacy for an emergency supply);
(b) that the potential urgency and level of danger is not quickly identified and understood in the scenario where they seek medical advice and/or medication (i.e. that their potential vulnerability is not well recognised and communicated on/within the medical records accessed by those in the health sector, such that patients are not supported with appropriate urgency or safety-netting advice);
(c) that it is not recognised that sending to them to a pharmacy may not reliably mitigate their risks quickly where it is unlikely the medication can be expected to be in stock (i.e. the risk that it may not be identified that for some patients their medication is not likely easily available on an ad hoc local basis); and
(d) that they are given generic safety-netting/worsening advice, whereas such patients may not present with any developing or new before suffering a sudden crisis and therefore remain at significant risk without medical oversight until appropriately medicated .
” Source location Charlie Marriage · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to recognise and communicate medication-related crisis vulnerability in medical records
Wider context from the report “(1) There are cohorts of patients who are medication dependant. For some their underlying condition is such that absent this medication they are at significant risk of a sudden crisis, and potentially death e.g. SUDEP, or Diabetic Ketoacidosis etc. These were described at the inquest as “cliff-edge conditions”.
(2) It is not apparent that these patients are currently identified within the health system as being at risk of a sudden crisis and death (absent their medication) so as to manage the following concerns giving rise to a risk of future deaths:
(a) that such patients may not be fully aware of the risks of death associated with not being medicated and therefore may (i) not fully understand the importance of avoiding the risk that this scenario arises, and (ii) not have planned the likely best course of action in the event that it does (e.g. to go to A&E, or to approach an identified pharmacy for an emergency supply);
(b) that the potential urgency and level of danger is not quickly identified and understood in the scenario where they seek medical advice and/or medication (i.e. that their potential vulnerability is not well recognised and communicated on/within the medical records accessed by those in the health sector , such that patients are not supported with appropriate urgency or safety-netting advice);
(c) that it is not recognised that sending to them to a pharmacy may not reliably mitigate their risks quickly where it is unlikely the medication can be expected to be in stock (i.e. the risk that it may not be identified that for some patients their medication is not likely easily available on an ad hoc local basis); and
(d) that they are given generic safety-netting/worsening advice, whereas such patients may not present with any developing or new before suffering a sudden crisis and therefore remain at significant risk without medical oversight until appropriately medicated.
” Source location Charlie Marriage · 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 appropriately urgent clinical support and safety-netting for medication-related crisis risk
Wider context from the report “(1) There are cohorts of patients who are medication dependant. For some their underlying condition is such that absent this medication they are at significant risk of a sudden crisis, and potentially death e.g. SUDEP, or Diabetic Ketoacidosis etc. These were described at the inquest as “cliff-edge conditions”.
(2) It is not apparent that these patients are currently identified within the health system as being at risk of a sudden crisis and death (absent their medication) so as to manage the following concerns giving rise to a risk of future deaths:
(a) that such patients may not be fully aware of the risks of death associated with not being medicated and therefore may (i) not fully understand the importance of avoiding the risk that this scenario arises, and (ii) not have planned the likely best course of action in the event that it does (e.g. to go to A&E, or to approach an identified pharmacy for an emergency supply);
(b) that the potential urgency and level of danger is not quickly identified and understood in the scenario where they seek medical advice and/or medication (i.e. that their potential vulnerability is not well recognised and communicated on/within the medical records accessed by those in the health sector, such that patients are not supported with appropriate urgency or safety-netting advice );
(c) that it is not recognised that sending to them to a pharmacy may not reliably mitigate their risks quickly where it is unlikely the medication can be expected to be in stock (i.e. the risk that it may not be identified that for some patients their medication is not likely easily available on an ad hoc local basis); and
(d) that they are given generic safety-netting/worsening advice, whereas such patients may not present with any developing or new before suffering a sudden crisis and therefore remain at significant risk without medical oversight until appropriately medicated.
” Source location Charlie Marriage · 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 medication-dependent patients understand medication-related death risks and plan emergency action
Wider context from the report “(1) There are cohorts of patients who are medication dependant. For some their underlying condition is such that absent this medication they are at significant risk of a sudden crisis, and potentially death e.g. SUDEP, or Diabetic Ketoacidosis etc. These were described at the inquest as “cliff-edge conditions”.
(2) It is not apparent that these patients are currently identified within the health system as being at risk of a sudden crisis and death (absent their medication) so as to manage the following concerns giving rise to a risk of future deaths:
(a) that such patients may not be fully aware of the risks of death associated with not being medicated and therefore may (i) not fully understand the importance of avoiding the risk that this scenario arises, and (ii) not have planned the likely best course of action in the event that it does (e.g. to go to A&E, or to approach an identified pharmacy for an emergency supply);
(b) that the potential urgency and level of danger is not quickly identified and understood in the scenario where they seek medical advice and/or medication (i.e. that their potential vulnerability is not well recognised and communicated on/within the medical records accessed by those in the health sector, such that patients are not supported with appropriate urgency or safety-netting advice);
(c) that it is not recognised that sending to them to a pharmacy may not reliably mitigate their risks quickly where it is unlikely the medication can be expected to be in stock (i.e. the risk that it may not be identified that for some patients their medication is not likely easily available on an ad hoc local basis); and
(d) that they are given generic safety-netting/worsening advice, whereas such patients may not present with any developing or new before suffering a sudden crisis and therefore remain at significant risk without medical oversight until appropriately medicated.
” Source location Charlie Marriage · 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 account for unreliable local pharmacy availability of urgently needed medication
Wider context from the report “(1) There are cohorts of patients who are medication dependant. For some their underlying condition is such that absent this medication they are at significant risk of a sudden crisis, and potentially death e.g. SUDEP, or Diabetic Ketoacidosis etc. These were described at the inquest as “cliff-edge conditions”.
(2) It is not apparent that these patients are currently identified within the health system as being at risk of a sudden crisis and death (absent their medication) so as to manage the following concerns giving rise to a risk of future deaths:
(a) that such patients may not be fully aware of the risks of death associated with not being medicated and therefore may (i) not fully understand the importance of avoiding the risk that this scenario arises, and (ii) not have planned the likely best course of action in the event that it does (e.g. to go to A&E, or to approach an identified pharmacy for an emergency supply);
(b) that the potential urgency and level of danger is not quickly identified and understood in the scenario where they seek medical advice and/or medication (i.e. that their potential vulnerability is not well recognised and communicated on/within the medical records accessed by those in the health sector, such that patients are not supported with appropriate urgency or safety-netting advice);
(c) that it is not recognised that sending to them to a pharmacy may not reliably mitigate their risks quickly where it is unlikely the medication can be expected to be in stock (i.e. the risk that it may not be identified that for some patients their medication is not likely easily available on an ad hoc local basis ); and
(d) that they are given generic safety-netting/worsening advice, whereas such patients may not present with any developing or new before suffering a sudden crisis and therefore remain at significant risk without medical oversight until appropriately medicated.
” Source location Charlie Marriage · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Provision of generic safety-netting advice to patients at risk of sudden medication-related crisis
Wider context from the report “(1) There are cohorts of patients who are medication dependant. For some their underlying condition is such that absent this medication they are at significant risk of a sudden crisis, and potentially death e.g. SUDEP, or Diabetic Ketoacidosis etc. These were described at the inquest as “cliff-edge conditions”.
(2) It is not apparent that these patients are currently identified within the health system as being at risk of a sudden crisis and death (absent their medication) so as to manage the following concerns giving rise to a risk of future deaths:
(a) that such patients may not be fully aware of the risks of death associated with not being medicated and therefore may (i) not fully understand the importance of avoiding the risk that this scenario arises, and (ii) not have planned the likely best course of action in the event that it does (e.g. to go to A&E, or to approach an identified pharmacy for an emergency supply);
(b) that the potential urgency and level of danger is not quickly identified and understood in the scenario where they seek medical advice and/or medication (i.e. that their potential vulnerability is not well recognised and communicated on/within the medical records accessed by those in the health sector, such that patients are not supported with appropriate urgency or safety-netting advice);
(c) that it is not recognised that sending to them to a pharmacy may not reliably mitigate their risks quickly where it is unlikely the medication can be expected to be in stock (i.e. the risk that it may not be identified that for some patients their medication is not likely easily available on an ad hoc local basis); and
(d) that they are given generic safety-netting/worsening advice , whereas such patients may not present with any developing or new before suffering a sudden crisis and therefore remain at significant risk without medical oversight until appropriately medicated.
” Source location Charlie Marriage · 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 Commission and launch the Pharmacy First service to support timely access to urgently required medicines.
Verbatim wording from the response “This guidance is further supported by the service specification for the NHS Pharmacy First service that was launched on 31 January 2024 (NHS England » Launch of NHS Pharmacy First advanced service). In cases where medication that is urgently required is not in stock at the pharmacy, the service specification states that, with the agreement of the patient, the pharmacist should identify another pharmacy that provides the service and forward the electronic referral to them (see 4.19). If the patient is unable to get to the premises, the pharmacist must ensure that the patient is able to obtain the supply in a timely manner by discussing all reasonable options for accessing their medicines (see 4.20).” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Investigate technology to track medication stocks across community pharmacies and improve management of high-impact national shortages.
Verbatim wording from the response “Current technology does not allow the tracking of stocks of medication across community pharmacies. This is being investigated as a strategy to better manage high-impact national shortages of medication.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the Medicines Safety Improvement Programme to improve access to time-critical medicines for people with cliff-edge conditions, including epilepsy, and incorporate learning from Charlie’s death.
Verbatim wording from the response “NHS England has instigated the Medicines Safety Improvement Programme which has been working to improve access to “Time Critical Medicines”. The focus of attention is to identify people with “cliff-edge conditions” and then to ensure they have the time critical medicines they need to prevent rapid deterioration. The programme started in 2024 and has identified a small number of “cliff-edge conditions” that may benefit from improved processes. Epilepsy is one of the conditions identified, and a key ambition of the programme is to improve care for people with epilepsy. This programme is being delivered in partnership with Epilepsy Action and Parkinson’s UK (alongside other charities) and is planned to run until March 2027. It will take into account the learning from Charlie’s death.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation It is not safely possible to differentiate medication urgency because of variable uses, brand names and alternative condition descriptions.
Verbatim wording from the response “All medications are treated with the same high priority. Due to the variable use of medications for different presentations, the use of brand names and alternative descriptions for conditions, it is not safely possible to differentiate between different levels of urgency.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Current technology cannot track medication stocks across community pharmacies, limiting the ability to implement such tracking nationally.
Verbatim wording from the response “Current technology does not allow the tracking of stocks of medication across community pharmacies. This is being investigated as a strategy to better manage high-impact national shortages of medication.” Source location Response from NHS England
Open published response
31 Dec 2024 David Joseph Crompton · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 5
Failure to obtain and supply prescribed anti-epileptic medication promptly View source Lack of clear designated systems for dealing with medication supply shortages View source Failure to provide leaflets explaining roles during medication supply shortages View source
Failure to learn lessons from potentially dangerous medication supply intervals View source Failure of pharmacies to search for supplies when prescribed medication is unavailable View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Joseph Crompton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Joseph Crompton, who had epilepsy, was left without his prescribed Tegretol for approximately 10 days in April 2024 and again in December 2024. His falls in both periods occurred when he was without the medication, and the inquest recorded a fall downstairs on 13 December 2024, with causes of death including hypoxic ischaemic encephalopathy, out-of-hospital cardiac arrest and cervical spine injury. The principal concerns were delays in supplying essential anti-epileptic medication, reliance on family members to seek alternative supplies, and the absence of clear systems for managing medication shortages.
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 obtain and supply prescribed anti-epileptic medication promptly
Wider context from the report “(1) It is important that when anti-epileptic medication is prescribed by a GP that this is obtained and supplied promptly by the dispensing pharmacy . It is a matter of concern that for relatively lengthy periods on two occasions Mr Crompton was left without this important medication .
” Source location David Joseph Crompton · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clear designated systems for dealing with medication supply shortages
Wider context from the report “(4) Comment was made at the inquest to the effect that the pharmaceutical profession should have clear designated systems to deal with any shortages of supply encountered ; for example, reference to hospital departments to ensure patients are not left without important medications . Leaflets explaining the role of those concerned in this situation were not provided.
” Source location David Joseph Crompton · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide leaflets explaining roles during medication supply shortages
Wider context from the report “(4) Comment was made at the inquest to the effect that the pharmaceutical profession should have clear designated systems to deal with any shortages of supply encountered; for example, reference to hospital departments to ensure patients are not left without important medications. Leaflets explaining the role of those concerned in this situation were not provided .
” Source location David Joseph Crompton · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to learn lessons from potentially dangerous medication supply intervals
Wider context from the report “(3) The inquest was informed that following the April 2024 episode, hospital specialists commented that the absence of Tegretol for around 10 days “will likely have contributed to your seizure activity”. It is questionable whether lessons were learnt from this potentially dangerous interval .
” Source location David Joseph Crompton · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of pharmacies to search for supplies when prescribed medication is unavailable
Wider context from the report “(2) The evidence given by family members at the inquest was that when the pharmacy was unable to supply the prescribed Tegretol medication, it was left to them to contact other pharmacies to see if they could obtain it, rather than for the pharmacy to search for supplies .
” Source location David Joseph Crompton · Prevention of Future Deaths report
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 Inspect the pharmacy’s systems for managing out-of-stock medicines and supply issues.
Verbatim wording from the response “The particular pharmacy has been inspected by our Inspection Team, who looked for evidence that the pharmacy was meeting our Standards for Registered Pharmacies. The purpose of these standards is to create and maintain the right environment in pharmacies to protect and improve people’s health and wellbeing. The inspection included looking for evidence about the systems in place to manage medicines which were out of stock at the pharmacy and where there were supply issues at the wholesalers. This was to ensure practices in the pharmacy relating to stock management were appropriate.” Source location Response from General Pharmaceutical Council
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 Publish guidance explaining how pharmacies should respond when prescribed medicines are unavailable.
Verbatim wording from the response “In November 2024 we published an article about medicines shortage, https://www.pharmacyregulation.org/about-us/news-and-updates/regulate/struggle-around-medicines-shortages The article states that if the pharmacy is unable to supply a particular medicine stated on prescription then they should talk to the patient to discuss their options. The article outlines examples of steps that pharmacy should take.” Source location Response from General Pharmaceutical Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The pharmacy’s staged process sought medication supplies, and referral to other pharmacies followed unsuccessful attempts to obtain the prescribed brand.
Verbatim wording from the response “(2) The evidence given by family members at the inquest was that when the pharmacy was unable to supply the prescribed Tegretol medication, it was left to them to contact other pharmacies to see if they could obtain it, rather than for the pharmacy to search for supplies.” Source location Response from Midway Pharmacy
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 National medication shortages prevented the pharmacy from obtaining the prescribed Tegretol medication and require a national resolution.
Verbatim wording from the response “The process of managing owings is staged to ensure we obtain patients’ medications in a prompt and timely manner. On this occasion, only a single supplier (AAH Pharmaceuticals) had the medication in stock, and other Midway pharmacies could not obtain supplies. There was a clinical risk of changing the brand of medication supplied due to the condition being treated, and Mr Crompton was referred to other pharmacies that may have had the medication in stock.” Source location Response from Midway Pharmacy
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 Manufacturing medicines and wider supply and shortage issues fall outside the regulator’s direct role.
Verbatim wording from the response “We are aware of supply issues with some Tegretol products. While we do not have a direct role in the manufacturing of medicines or wider issues such as supply and shortages, we understand that medicines shortages can cause problems for patients and carers. We know that pharmacy professionals are also concerned and have to use their professional judgement and make decisions in challenging situations, balancing a range of factors such as individual patient needs and available supplies of medicines. Our standards require pharmacy professionals to deliver patient-centred care, which includes making the care of the patient their first concern and using their judgement to make professional decisions. This may include making decisions about providing medication in an emergency.” Source location Response from General Pharmaceutical Council
Open published response
14 Oct 2024 Mia Louise Gauci-Lamport · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 11
Lack of specialist NHS paediatric neuro-consultant oversight View source Failure to maintain comprehensive, understandable, accurate and contemporaneous medical records View source Failure to undertake regular Paediatric Early Warning Score assessments View source
Deficiencies in ongoing staff training View source Deficient clinical governance of management and investigation View source Failure to conduct regular audits of clinical practice View source Failure to provide sufficiently frequent direct night-time visual observations View source Failure to ensure robust procedures are in place View source Delays in fulfilling Duty of Candour obligations View source Failure to undertake regular multidisciplinary clinical reviews View source Lack of regular independent consultant oversight and coordination of investigations and multidisciplinary management View source See 8 more concerns
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. 16
Action
Strengthen NHS integration, referral pathways, and coordination with primary, secondary, and tertiary services for timely specialist care.
Stated by The Children's TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2024. View source
Action
Reduce reliance on private consultants by integrating ongoing specialist care, including epilepsy management, within NHS services.
Stated by The Children's TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2024. View source
Action
Undertake a comprehensive inspection of the service, including assessment of overnight observations, care planning, clinical monitoring and governance.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 14 October 2024. View source
Action
Audit medical records regularly against NHS standards and address ongoing health-record integration issues with system partners.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2024. View source
Action
Request monthly updates on monitoring-frequency and Paediatric Early Warning System audits to assess ongoing implementation and identify practice gaps.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 14 October 2024. View source
Action
Maintain clear, individualised, regularly updated care plans aligned with Paediatric Early Warning Scores and audit their implementation.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2024. View source
Action
Conduct overnight monitoring-practice audits and monthly quality walks to verify compliance with observation policies and care plans.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2024. View source
Action
Work with Tadworth Children’s Trust and stakeholders through Rapid Quality Review meetings to review care quality, identify risks, and formulate improvement plans.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2024. View source
Action
Refine the clinical governance structure and strengthen leadership oversight of care practices, protocols, and improvement implementation.
Stated by The Children's TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2024. View source
Action
Complete the thematic review of serious incidents and near misses and embed resulting quality-improvement workstreams in governance arrangements.
Stated by The Children's TrustStatus at responseThe respondent said that this action was partly complete when they made their response on 14 October 2024. View source
Action
Conduct regular audits of care quality, care-plan adherence, and monitoring effectiveness under internal and external scrutiny.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2024. View source
Action
Implement and embed a shift handover protocol communicating required supervision and observations and recording the preceding shift’s clinical observations.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2024. View source
Action
Align frequency-of-monitoring policy and clinical guidelines with national best practice through wider consultation and critique.
Stated by The Children's TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2024. View source
Action
Review and audit video surveillance, wearable sensors, and other monitoring tools to ensure appropriate use alongside direct checks.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2024. View source
Action
Consider duty-of-candour review findings alongside manager-regulation consultation findings while developing healthcare candour policy.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 14 October 2024. View source
Action
Review and improve the internal multidisciplinary care model across medical, nursing, care, and therapy services alongside broader NHS integration.
Stated by The Children's TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2024. View source See 13 more actions
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AI-generated summary
Mia Louise Gauci-Lamport · 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
Mia Louise Gauci-Lamport, who had treatment-resistant epilepsy and required full-time residential care, was found cyanotic and unresponsive at around 06.32 hours on 11 September 2023 after not being visually checked when a carer entered her room. Resuscitation was unsuccessful. The report raised concerns about inadequate night-time monitoring, incomplete medical records and insufficient clinical oversight and governance.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of specialist NHS paediatric neuro-consultant oversight
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented.
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs.
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting condition.
” Source location Mia Louise Gauci-Lamport · 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 comprehensive, understandable, accurate and contemporaneous medical records
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented .
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs.
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting condition.
” Source location Mia Louise Gauci-Lamport · 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 undertake regular Paediatric Early Warning Score assessments
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented.
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs.
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting condition.
” Source location Mia Louise Gauci-Lamport · 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 Deficiencies in ongoing staff training
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death, delay in fulfilling the Duty of Candour’ obligations, ongoing staff training , ensuring robust procedures were in place alongside regular audits of clinical practice. These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” Source location Mia Louise Gauci-Lamport · 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 Deficient clinical governance of management and investigation
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death , delay in fulfilling the Duty of Candour’ obligations, ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice. These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” Source location Mia Louise Gauci-Lamport · 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 conduct regular audits of clinical practice
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death, delay in fulfilling the Duty of Candour’ obligations, ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice . These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” Source location Mia Louise Gauci-Lamport · 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 sufficiently frequent direct night-time visual observations
Wider context from the report “1. Lack of appropriate monitoring of Mia during the night :
Mia’s underlying illness caused seizures which were multifocal, complex and variable from tonic-clonic, myoclonic to cluster and absence seizures. Her care plan stipulated that carers should enter her room every 15 minutes to undertake visual observations throughout the night to ensure Mia was in a safe position, was breathing and not at risk of asphyxiation. However, this did not take place as frequently as specified . Moreover, it was common practice amongst some carers to review images from a video monitor placed over Mia’s cot rather than direct visualisation despite it being recognised that the monitor was insufficiently sensitive to reassure the carer that Mia was breathing, seizure free and safe from asphyxiation .
” Source location Mia Louise Gauci-Lamport · 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 robust procedures are in place
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death, delay in fulfilling the Duty of Candour’ obligations, ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice. These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” Source location Mia Louise Gauci-Lamport · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in fulfilling Duty of Candour obligations
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death, delay in fulfilling the Duty of Candour’ obligations , ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice. These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” Source location Mia Louise Gauci-Lamport · 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 undertake regular multidisciplinary clinical reviews
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented.
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs .
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting condition.
” Source location Mia Louise Gauci-Lamport · 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 regular independent consultant oversight and coordination of investigations and multidisciplinary management
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented.
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs.
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting condition.
” Source location Mia Louise Gauci-Lamport · 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 Strengthen NHS integration, referral pathways, and coordination with primary, secondary, and tertiary services for timely specialist care.
Verbatim wording from the response “○ Enhanced NHS Integration: The Children’s Trust is actively working with primary, secondary and tertiary NHS services to ensure that children in our care receive timely and regular access to care. We are working with the wider health and social care system to formalise clearer referral pathways and improving coordination with NHS specialists to ensure that all clinical needs are addressed promptly. This work has commenced and continues through existing NHS governance frameworks.” Source location Response from The Children's 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 Reduce reliance on private consultants by integrating ongoing specialist care, including epilepsy management, within NHS services.
Verbatim wording from the response “○ Reducing Reliance on Private Consultants: We are actively reducing our reliance on private consultants for ongoing care, particularly in areas such as epilepsy management, and are working to ensure that children receive care that is fully integrated within the NHS. We have required wider health and social care system support to ensure equitable access for the children and young people in our care and this work continues.” Source location Response from The Children's 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 Undertake a comprehensive inspection of the service, including assessment of overnight observations, care planning, clinical monitoring and governance.
Verbatim wording from the response “In December 2023 CQC had received key information and started to plan for an inspection in February. On February 20th to 21st 2024 the CQC undertook a comprehensive inspection of TCT as part of our regulatory response to the notification of Mia’s sad death. The inspection looked at all five key questions of whether TCT is Safe, Effective, Caring, Responsive and Well-led. (Please see attached PDF). CQC do not provide ratings for children’s homes that are registered with Ofsted, as per our policy.” Source location Response from CQC
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 medical records regularly against NHS standards and address ongoing health-record integration issues with system partners.
Verbatim wording from the response “○ Medical records: We continually audit our medical records in line with NHS standards and achieve high compliance against these. As an organisation sitting outside the NHS, health record integration is complex and an ongoing area of focus for us with our wider health and social care system partners. Medical record audits continue regularly to ensure our ongoing compliance in this area.” Source location Response from The Children's 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 Request monthly updates on monitoring-frequency and Paediatric Early Warning System audits to assess ongoing implementation and identify practice gaps.
Verbatim wording from the response “In July 2024 following the coroner’s inquest and information from the independent investigator report, CQC requested monthly updates from TCT regarding the providers audits of frequency of monitoring of children and their Paediatric Early Warning System (PEWS). The audits and actions taken, provided CQC with assurance the leadership team continued to take positive action to address any gaps in practice that the audits identified.” Source location Response from CQC
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 Maintain clear, individualised, regularly updated care plans aligned with Paediatric Early Warning Scores and audit their implementation.
Verbatim wording from the response “○ Individualised Care Plans: We have made certain that care plans are clear, individualised, and regularly updated based on the child’s current needs and challenges and aligned to the PEWS (Paediatric Early Warning Scores). These updates ensure that the monitoring of children is consistent, personalised, and aligned with the latest clinical guidelines. This initial work is complete and is now continuously reviewed and audited in line with our policy and best practice.” Source location Response from The Children's 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 overnight monitoring-practice audits and monthly quality walks to verify compliance with observation policies and care plans.
Verbatim wording from the response “○ Frequency of Monitoring and PEWS Practice Audits: We have implemented new Frequency of Monitoring Practice audits overnight, conducted by Clinical Site Managers. This ensures continued compliance with the monitoring and observations policies. These audits are complemented by monthly quality walks to ensure the consistent implementation of care plans and protocols. This additional assurance mechanism is built into roles and responsibilities and findings from these audits feed into the broader clinical governance framework.” Source location Response from The Children's 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 Work with Tadworth Children’s Trust and stakeholders through Rapid Quality Review meetings to review care quality, identify risks, and formulate improvement plans.
Verbatim wording from the response “Even though NHS England had no direct or commissioning oversight of Mia’s care, I should like to provide you and Mia’s family with some assurance that our regional Specialised Commissioning team has been working with TCT, alongside other stakeholders, to review the quality of care being provided. This has taken the form of Rapid Quality Review (RQR) meetings in accordance with the National Quality Boards guidance on risk response and escalation in ICSs where concerns are raised about a” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refine the clinical governance structure and strengthen leadership oversight of care practices, protocols, and improvement implementation.
Verbatim wording from the response “The Children’s Trust is committed to maintaining and improving robust governance and oversight systems. We have initiated a series of improvements:” Source location Response from The Children's 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 Complete the thematic review of serious incidents and near misses and embed resulting quality-improvement workstreams in governance arrangements.
Verbatim wording from the response “• Thematic review: We have undertaken a thematic review of all serious incidents and near misses within a specific timeframe. The themes and trends identified through this review have resulted in dedicated workstreams being embedded into the existing governance structure. The thematic review is currently in the final stages of completion and has focussed on the embedding of continuous quality improvements.” Source location Response from The Children's 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 regular audits of care quality, care-plan adherence, and monitoring effectiveness under internal and external scrutiny.
Verbatim wording from the response “○ Regular Audits and Reviews: To support sustained improvement, we have introduced regular audits to assess the quality of care, the implementation of and adherence to care plans, and the effectiveness of our monitoring practices. This work continues and is scrutinised both internally and by our external regulators and commissioners.” Source location Response from The Children's 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 and embed a shift handover protocol communicating required supervision and observations and recording the preceding shift’s clinical observations.
Verbatim wording from the response “○ Shift Handover Protocol: A revised Shift Handover Protocol has been introduced to ensure that the level of supervision and observation required for each child is understood and clearly communicated during shift changes. Additionally, the last set of clinical observations from the prior shift are recorded and discussed at handover, ensuring a seamless transition and continuity of care. This protocol has been embedded across The Children’s Trust and is subject to continuous review and audit to ensure compliance.” Source location Response from The Children's 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 Align frequency-of-monitoring policy and clinical guidelines with national best practice through wider consultation and critique.
Verbatim wording from the response “A comprehensive review of our monitoring protocols and individualised care planning process has been undertaken which has led to several critical actions being identified, all of which are now overseen by robust internal governance:” Source location Response from The Children's 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 Review and audit video surveillance, wearable sensors, and other monitoring tools to ensure appropriate use alongside direct checks.
Verbatim wording from the response “○ Monitoring Tools: A review of monitoring tools, including video surveillance and wearable sensors, has been completed. We continually ensure that these tools are appropriate for each child's needs and used correctly to provide effective oversight without replacing appropriate checks. This initial action is complete and is now continuously reviewed and audited in line with evidence-based practice.” Source location Response from The Children's 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 Consider duty-of-candour review findings alongside manager-regulation consultation findings while developing healthcare candour policy.
Verbatim wording from the response “In relation to your point about the delay in fulfilling the duty of candour obligations, as you may be aware, the statutory duty of candour (organisational) places a direct obligation upon NHS trusts and all other health and social care providers registered with the CQC to be open and honest with patients, service users and their families, when a notifiable safety incident occurs. The Government is supportive of the review on the duty it inherited from the previous administration and will consider the findings, recently published on 26 November, following a call for evidence in April this year. The government will consider these findings alongside findings from the ongoing manager regulation consultation as it continues to develop policy on candour in healthcare.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and improve the internal multidisciplinary care model across medical, nursing, care, and therapy services alongside broader NHS integration.
Verbatim wording from the response “○ Multi-disciplinary Care Model: We are working with the broader NHS system to improve integration across the whole care pathway and ensure that this is multi-disciplinary across medical, nursing and care and therapy, and not focussed solely on the medical care for the children and young people. Whilst we have a strong internal multi-disciplinary care model focussed around the care of the children, we have also taken the opportunity to commence a detailed review of our internal model alongside broader integration.” Source location Response from The Children's Trust
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 NHS England had no direct or commissioning oversight of Mia’s care because it was local-authority-funded residential care, not specialised commissioning care.
Verbatim wording from the response “Your Report raises multiple concerns in relation to the medical care and appropriate monitoring of Mia, including concerns regarding the access to clinical consultant care and a lack of adherence to her care plan within the residential care setting at Tadworth Children’s Trust (TCT). Noting you have also sent your Report to TCT and CQC, some of the concerns you raise may be better addressed by those organisations. In this response, I have addressed the matters of concern where NHS England are able to contribute and provide some assurance.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Some concerns about Mia’s care are better addressed by Tadworth Children’s Trust and the Care Quality Commission.
Verbatim wording from the response “Your Report raises multiple concerns in relation to the medical care and appropriate monitoring of Mia, including concerns regarding the access to clinical consultant care and a lack of adherence to her care plan within the residential care setting at Tadworth Children’s Trust (TCT). Noting you have also sent your Report to TCT and CQC, some of the concerns you raise may be better addressed by those organisations. In this response, I have addressed the matters of concern where NHS England are able to contribute and provide some assurance.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing shared NHS neurological care, local and tertiary access, and monthly multidisciplinary case discussions were considered sufficient clinical oversight.
Verbatim wording from the response “As per ████████’s witness statement it is our understanding that Mia was not without specialist NHS paediatric neuro-consultant care at any time as the paediatric neurology department at St George's Hospital (SGH), Tooting is the tertiary centre for paediatric neurology in the region. There is a shared care arrangement between the neurology department and the SGH and the paediatric department at Epsom hospital, therefore if Mia had required any specialist neurological care this would have been provided by Epsom hospital.” Source location Response from CQC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Local Authority, not NHS England, is responsible for overseeing the quality of the residential care service because it commissioned the bed.
Verbatim wording from the response “Mia was in a residential care bed, which is commissioned instead by the Local Authority. The commissioning body, in this case the LA, has the responsibility for oversight of the quality of the service. NHSE have provided assurance that their regional team has been working with system and other partners on responding to risks and concerns in a joint approach at this provider, which will be set out in their response. In case of interest, NHSE’s guidance on specialised services can be found here: NHS commissioning » Specialised services.” Source location Response from DHSC
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 Strengthened monitoring policies, audits and governance arrangements were considered sufficient to address risks concerning night-time observations and safe care.
Verbatim wording from the response “Since the sad death of Connor Wellsted in 2022 and Mia’s death, CQC have undertaken three subsequent inspections which have demonstrated that TCT have taken the appropriate actions to ensure the governance processes around night time observations have been strengthened. CQC is assured with regard to its own regulatory functions, by the actions taken by TCT. Specifically this includes to strengthening the frequency of monitoring policy and increased their audits of the implementation of this policy.” Source location Response from CQC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The delay in executing the Duty of Candour was not considered a breach of the Health and Social Care Regulations.
Verbatim wording from the response “During the February 2024 inspection we found all staff had received the appropriate level of training relevant to their role and the healthcare activity they deliver. The education team provided child and young person specific training as the need arose.
We also noted that “staff demonstrated knowledge of the Duty of Candour, to be open and transparent with people including when things go wrong with their care and treatment”. In Mia’s case there was a delay in executing the Duty of Candour, however the CQC did not deem this instance to be a breach of Health and Social Care Regulations.” Source location Response from CQC
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 Tadworth Children’s Trust remains responsible for ensuring consistent multidisciplinary clinical support for all children in its care.
Verbatim wording from the response “Our NHS England Regional Medical Director has also offered to support with connecting TCT’s clinical team to specialists within the NHS that can offer peer support and further improvement work. However, it would remain TCT’s responsibility to ensure consistency of multi-disciplinary clinical support for all children in their care, whether accessed via NHS or privately funded.” Source location Response from NHS England
Open published response
Concerns raised 7
Failure of referral communication channels to provide reliable access and confirmation View source Delays in triaging and progressing referrals for mental health care View source Failure to communicate clinically relevant information between services about epilepsy and psychosis View source
Failure to send discharge summaries to the General Practitioner View source Failure to identify urgency in referrals involving paranoia, delusions and suicidal ideation View source Failure to carry out consultant review of antipsychotic medication alongside epilepsy medication View source Inappropriate rejection of referrals despite evidence of psychosis View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Bryan Andrews and Mary Andrews · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Bryan and Mary Andrews died at their home on 27 November 2022 from multiple stab wounds inflicted by their adult son. The principal concern was a lack of communication between services about the relationship between his epilepsy and psychotic symptoms, resulting in treatment delays, rejected referrals and failures to share important information.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of referral communication channels to provide reliable access and confirmation
Wider context from the report “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths.
This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation.
He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
” Source location Bryan Andrews and Mary Andrews · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in triaging and progressing referrals for mental health care
Wider context from the report “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths.
This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation.
He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
” Source location Bryan Andrews and Mary Andrews · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate clinically relevant information between services about epilepsy and psychosis
Wider context from the report “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths.
This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation.
He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
” Source location Bryan Andrews and Mary Andrews · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to send discharge summaries to the General Practitioner
Wider context from the report “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths.
This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation.
He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
” Source location Bryan Andrews and Mary Andrews · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to identify urgency in referrals involving paranoia, delusions and suicidal ideation
Wider context from the report “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths.
This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation.
He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
” Source location Bryan Andrews and Mary Andrews · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to carry out consultant review of antipsychotic medication alongside epilepsy medication
Wider context from the report “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths.
This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation.
He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
” Source location Bryan Andrews and Mary Andrews · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inappropriate rejection of referrals despite evidence of psychosis
Wider context from the report “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths.
This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation.
He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
” Source location Bryan Andrews and Mary Andrews · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Neurology Department with electronic crisis assessments and outcome plans for service users receiving neurological treatment.
Verbatim wording from the response “The Single Point of Access Service within SHSC is no longer in operation, following a transformation programme of our Urgent and Crisis Services. We have, therefore, not set out any actions in this response relating to how this service deals with referrals, given that referrals now go into each individual service. We are committed to taking the following actions:” Source location Response from Sheffield Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include discharge summaries in annual service record-keeping audits to verify timely transmission to GPs and required quality standards.
Verbatim wording from the response “2. Discharge summaries are electronically sent to GPs through our electronic patient record system. In this case, although the discharge summary was created on 9 May 2022, the day of discharge, it was further edited on 13 May 2022. It appears that because the discharge” Source location Response from Sheffield Health and Social Care
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 No further action is proposed for Single Point of Access referrals because that service no longer operates and referrals now enter individual services.
Verbatim wording from the response “The Single Point of Access Service within SHSC is no longer in operation, following a transformation programme of our Urgent and Crisis Services. We have, therefore, not set out any actions in this response relating to how this service deals with referrals, given that referrals now go into each individual service. We are committed to taking the following actions:” Source location Response from Sheffield Health and Social Care
Open published response
26 Jan 2024 Michael Leslie PEGG · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 3
Crowded and noisy treatment areas ill-suited to proper patient treatment View source Insufficient clinician awareness and ability to apply NICE guidelines for adrenal insufficiency View source Failure to apply NICE steroid-treatment guidelines for adrenal insufficiency during intercurrent illness View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Michael Leslie PEGG · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Leslie Pegg, who lived with congenital adrenal insufficiency and epilepsy, was admitted to Worcestershire Royal Hospital after two significant seizures and died there on 15 January 2023 following deterioration and pneumonia. The report raised concerns that steroid treatment fell far short of relevant NICE guidelines, that staff awareness and application of the guidelines were insufficient, and that crowded treatment areas created difficulties in providing appropriate care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Crowded and noisy treatment areas ill-suited to proper patient treatment
Wider context from the report “3) For a substantial part of his time at Worcestershire Royal Hospital, Mr. Pegg was being treated in a bed in a corridor in the Emergency Department, and then in the Majors Overflow area, both busy, crowded and noisy areas ill-suited to the proper treatment of patients . In his evidence to the inquest about trying to ensure that the Trust’s staff are aware of these Guidelines, Dr Raven told the inquest:
“As long as we still have crowded settings, it is difficult to provide assurances that these guidelines will be followed , for example because we have a high turnover of locum clinicians and agency nursing staff.”
It is particularly concerning to hear that patients’ wellbeing may be put at risk because a hospital Trust may not be able properly to ensure that the staff it employs are aware of, and able to apply NICE Guidelines.
It is perhaps unfair to put responsibility for rectifying this situation solely at the door of the Worcestershire Acute Hospitals NHS Trust, which is why this report is also being sent to NHS England and Health Education England.
” Source location Michael Leslie PEGG · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient clinician awareness and ability to apply NICE guidelines for adrenal insufficiency
Wider context from the report “2) Although in this case, I was unable to conclude that the above omissions in steroid treatment probably caused or contributed to Mr. Pegg’s death, it was nonetheless concerning to hear that none of those treating him had sufficient awareness of the NICE Guidelines as to be able to apply them properly in his case . Unless action is taken to ensure clinicians employed by the Trust are aware of, and able to apply these Guidelines , there remains a risk that another patient with adrenal insufficiency may die in similar circumstances ;
” Source location Michael Leslie PEGG · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to apply NICE steroid-treatment guidelines for adrenal insufficiency during intercurrent illness
Wider context from the report “1) Over the two days that Mr. Pegg was at Worcestershire Royal Hospital, those treating him failed to apply the NICE guidelines which relate to the treatment of those with adrenal insufficiency conditions who are being treated for intercurrent illness . ████████, who conducted the Trust’s serious incident investigation into these events, told the inquest:
“There was a policy in place for administering steroids, as per the 2020 NICE guidelines – this advises:
(a) double dosing of oral steroids in cases of intercurrent illness until 48 hours after recovery (also known as Sick Day rule 1);
(b) if [the patient has ] significant trauma, prolonged vomiting or diarrhoea, then 100mg IV hydrocortisone [ should be administered ];
(c) if suspected adrenal crisis, 100mg IV hydrocortisone immediately.”
In fact, the steroid treatment provided to Mr. Pegg during this admission fell far short of those Guidelines , in that:
(a) He only received one double dose of his oral hydrocortisone medication , which he was usually required to take twice a day;
(b) He received no doses at all ( double or standard ) of his oral prednisolone medication , which he was usually required to take once a day;
(c) Although he did eventually receive a 100mg dose of IV hydrocortisone on 14.1.23, this should have been given much earlier that day when his condition seriously deteriorated .
” Source location Michael Leslie PEGG · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Close and discontinue use of the Emergency Department overflow area.
Verbatim wording from the response “• The “overflow area” of the ED is no longer being used, having closed in October 2023.” Source location Response from Worcestershire Acute Hospitals NHS Trust
Open published response
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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 Highlight steroid replacement in Emergency Department handovers and repeat the messaging to maintain medical staff awareness.
Verbatim wording from the response “• Steroid replacement (and other time critical meds) has been highlighted in effective handover in ED in 2023 and will be repeated (appendix 4) to raise and maintain awareness for all medical staff working in the ED.” Source location Response from Worcestershire Acute Hospitals NHS Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prioritise adrenal insufficiency and steroid replacement for Medical Examiner review, triggering further case review when concerns are identified.
Verbatim wording from the response “• The Medical Examiners, at the request of the Trust, are working with Adrenal Insufficiency/Steroid Replacement as one of their high priority conditions which means that any concerns identified with steroid replacement will trigger further case review. The focus therefore remains on this area and will continue to be so until we are fully assured that our processes for identifying and managing this condition are effective.” Source location Response from Worcestershire Acute Hospitals NHS Trust
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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 the updated Emergency Department adult patient document, which automatically includes highlighted steroid replacement as a time-critical medication for all adults.
Verbatim wording from the response “several occasions since Mr Pegg’s sad death. Discussions included the importance of the adult patient document in the Emergency Department which was updated in June 2023. This now includes a time critical medications (highlighted steroid replacement) (please see appendix 1 attached). This is automatically included for all adults presenting to the Emergency Department.” Source location Response from Worcestershire Acute Hospitals NHS Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate steroid replacement safety materials to Emergency and Medical staff and display them in the Emergency Department handover area.
Verbatim wording from the response “• A “detect and reflect” document and “time critical medication safety flash” have been circulated to all Emergency and Medical staff to raise awareness of the need for steroid replacement therapy (appendix 2, 3). These are displayed in the Emergency Department handover area.” Source location Response from Worcestershire Acute Hospitals NHS Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Have the Acting Chief Medical Officer highlight steroid replacement during induction for new doctors rotating into the hospitals.
Verbatim wording from the response “• The Acting Chief Medical Officer will be attending the Induction for new doctors in August in order to highlight this area of focus for the Trust for all junior doctors rotating into our hospitals.” Source location Response from Worcestershire Acute Hospitals NHS Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incorporate steroids and other time-critical medications into the Emergency Department electronic patient record.
Verbatim wording from the response “• The Trust is due to move to an electronic patient record in the Emergency Department in Autumn 2024 – time critical medications including steroids are due to be incorporated into this.” Source location Response from Worcestershire Acute Hospitals NHS Trust
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 Participate in the Royal College of Emergency Medicine audit of prescribing and administration of time-critical medicines, including steroids.
Verbatim wording from the response “• The Emergency Departments on both sites are participating in a Royal College of Emergency Medicine audit looking at the prescribing and administration of time critical medicines, including steroids. This audit will provide a “benchmark” for the Trust and also highlight areas where further improvement is required. The audit is still in data collection phase but results will be available later in the year.” Source location Response from Worcestershire Acute Hospitals NHS Trust
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 Publish guidance for preventing and managing adrenal insufficiency emergencies in adults.
Verbatim wording from the response “NHS England has also worked closely with the Society for Endocrinology and the Royal College of Physicians on the issue of under-recognition and treatment of adrenal insufficiency or crisis. This culminated in the publication of ‘Guidance for the prevention and emergency management of adult patients with adrenal insufficiency’ in July 2020, which outlines the causes of adrenal insufficiency, groups at risk of an adrenal crisis, emergency management and management for surgical procedures. As a result of work in this area, a new NHS Steroid Emergency Card was developed, to be carried by patients at risk of adrenal crisis and ensure the prompt delivery of steroids to those patients presenting within an emergency or acute medicine setting.” Source location Response from NHS England
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 the NHS Steroid Emergency Card for patients at risk of adrenal crisis.
Verbatim wording from the response “NHS England has also worked closely with the Society for Endocrinology and the Royal College of Physicians on the issue of under-recognition and treatment of adrenal insufficiency or crisis. This culminated in the publication of ‘Guidance for the prevention and emergency management of adult patients with adrenal insufficiency’ in July 2020, which outlines the causes of adrenal insufficiency, groups at risk of an adrenal crisis, emergency management and management for surgical procedures. As a result of work in this area, a new NHS Steroid Emergency Card was developed, to be carried by patients at risk of adrenal crisis and ensure the prompt delivery of steroids to those patients presenting within an emergency or acute medicine setting.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust is responsible for addressing local emergency department crowding, staffing, overflow-area and acuity concerns.
Verbatim wording from the response “NHS England would refer you to the Trust on what actions are being taken locally to address your concerns. We have been sighted on their Serious Investigation Report and Action Plan and note that they have taken learnings around Emergency Department crowding and improving end-of-life care for patients and are reviewing staffing levels in the Overflow Area and Acuity.” Source location Response from NHS England
Open published response
