7 May 2024 Peter Jason FANNING · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2
Insufficient availability of feeding-tube replacement services for patients with complex needs View source Failure to maintain nutrition after feeding-tube dislodgement View source
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AI-generated summary
Peter Jason FANNING · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter Jason FANNING, who had cerebral palsy, severe physical impairment, epilepsy and relied on a gastrostomy feeding tube, experienced repeated tube dislodgements and admissions for replacement. He developed pneumonia and died on 19 December 2023; concerns related to limited availability for complex feeding-tube replacements and maintaining nutrition after dislodgement.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient availability of feeding-tube replacement services for patients with complex needs
Wider context from the report “1. The inquest heard evidence that there is only one radiology list per week to accommodate replacement of feeding tubes in patients with complex needs . In Peter’s case this meant he had to wait a week for the tube to be replaced meaning he had suboptimal nutrition during this period. Consideration should be given to whether additional services are required for replacement of feeding tubes in patients with complex needs.
” Source location Peter Jason FANNING · Prevention of Future Deaths report
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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 nutrition after feeding-tube dislodgement
Wider context from the report “2. The inquest heard evidence that Peter’s nutritional status was suboptimal due to repeated tube dislodgments and waiting for radiology or theatre slots to be available. Consideration needs to be given as to how best to maintain patients’ nutrition after tube dislodgments when they rely on feeding tubes .
” Source location Peter Jason FANNING · Prevention of Future Deaths report
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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 Increase interventional radiology capacity to four weekly lists across three sites and provide three consultants for x-ray-guided feeding-tube insertion.
Verbatim wording from the response “X-ray guided tube insertion
The Interventional Radiology department has increased capacity from one to four intervention radiology (IR) lists per week across our Heartland’s, Good Hope and Solihull Hospital sites (HGS), which can accommodate x-ray guided feeding tube insertions. We also now have three IR consultants who are able to provide this service (increased from one previously) and these changes have been in place since April 2024.” Source location Response from University Hospitals Birmingham
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide a temporary additional interventional radiology theatre at Heartlands for two days per week using additional funding.
Verbatim wording from the response “Also, temporary funding has been made available to increase IR capacity on the Heartlands site and we have an additional IR theatre running in the Heartlands Treatment Centre for two days per week. A business case is currently being considered to support this becoming a full-time provision.” Source location Response from University Hospitals Birmingham
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider a business case to make the additional Heartlands interventional radiology theatre provision full time.
Verbatim wording from the response “Also, temporary funding has been made available to increase IR capacity on the Heartlands site and we have an additional IR theatre running in the Heartlands Treatment Centre for two days per week. A business case is currently being considered to support this becoming a full-time provision.” Source location Response from University Hospitals Birmingham
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2 Apr 2024 Andrew Ewin-Ripp · Prevention of Future Deaths report East London
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Concerns raised 7
Failure to require practitioners to pass essential epilepsy information to patients on discharge View source Lack of guidance on contacting the secondary care team after recurrent seizures View source Lack of discharge guidance on maintaining medication compliance despite prolonged seizure freedom View source
Lack of required annual epilepsy reviews in general practice View source Lack of a care pathway for urgent neurology reviews in response to patient concerns View source Lack of discharge guidance on notifying clinicians about recurrent seizures View source Lack of clear guidance on longer-term epilepsy monitoring and safe discharge timing View source See 4 more concerns
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AI-generated summary
Andrew Ewin-Ripp · 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
Andrew Ewin-Ripp, who had epilepsy, suffered a fit at home on 1 November 2022, was found in cardiac arrest, and died in hospital on 4 November 2022. The reported cause of death was sudden unexpected death in epilepsy (SUDEP). Concerns included lengthy waits for neurology care, the absence of clear guidance and systems for monitoring, discharge information, and urgent review after seizure recurrence.
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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 require practitioners to pass essential epilepsy information to patients on discharge
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this.
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures. There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge .
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication.
” Source location Andrew Ewin-Ripp · 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 guidance on contacting the secondary care team after recurrent seizures
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this.
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures . There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge.
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication.
” Source location Andrew Ewin-Ripp · 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 discharge guidance on maintaining medication compliance despite prolonged seizure freedom
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this.
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period ; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures. There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge.
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication.
” Source location Andrew Ewin-Ripp · 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 required annual epilepsy reviews in general practice
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients , as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this.
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures. There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge.
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication.
” Source location Andrew Ewin-Ripp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a care pathway for urgent neurology reviews in response to patient concerns
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this.
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures. There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge.
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns , such as a return of seizures or not tolerating medication.
” Source location Andrew Ewin-Ripp · 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 discharge guidance on notifying clinicians about recurrent seizures
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this.
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures. There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge.
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication.
” Source location Andrew Ewin-Ripp · 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 guidance on longer-term epilepsy monitoring and safe discharge timing
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy . How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this .
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures. There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge.
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication.
” Source location Andrew Ewin-Ripp · 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 Provide members with SUDEP and seizure-safety education, including epilepsy-review and safety-checklist resources.
Verbatim wording from the response “▪ SUDEP
We currently have a resource available to members specifically on SUDEP and Seizure Safety (first produced in 2016 and updated in 2021). https://sudep.org/article/sudep-action-rcgp-launch-sudep-e-learning. It emphasises the role of General Practice in carrying out Epilepsy reviews using video and case studies in a 30min online resource. It highlights the use of the SUDEP and Seizure safety checklist https://sudep.org/checklist with resources for both professionals and patients. This course is free to access to all 54,000 RCGP members.” Source location Response from Royal College of General Practitioners
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide an epilepsy diagnosis and management learning module and podcast promoting regular annual review.
Verbatim wording from the response “▪ Epilepsy Diagnosis and Management
We also have a series of regular Essential Knowledge Updates. In our Update 17 (April 2016 updated April 2024) there is a specific module on Epilepsy Diagnosis and management. A podcast freely available to all in which ████████ talks about and promotes the e learning module highlighting the importance of regular annual review (EKU17: Epilepsy https://podcasts.apple.com/gb/podcast/eku17-epilepsy/id1474942018?i=1000453462614 )” Source location Response from Royal College of General Practitioners
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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 GP practices are required to follow clinical guidelines that include annual epilepsy reviews.
Verbatim wording from the response “Your Report raised the concern that GP Practices are not required to carry out annual reviews of epilepsy patients. GP Practices required to follow and pay due regard to clinical guidelines. The National Institute for Health and Care Excellence (NICE) has issued clinical guidelines to general practice on annual reviews, including for Epilepsy.” Source location Response from NHS England
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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 Commissioning general practice services is the responsibility of NHS England, not the respondent.
Verbatim wording from the response “The College is not responsible for Commissioning Services from General Practice. In England this role falls to NHS England. General Practice has however been funded for Epilepsy management through the GMS contract and Quality and Outcomes Framework (QOF) since 2004. There is a requirement to maintain a register of adults receiving drug treatment for Epilepsy (EP001). Between 2004 and 2014 there were 2 additional indicators which fell out of the annual review process i.e. those who were seizure free (EP002) and the number of women receiving information and counselling about reproductive issues (EP003). The EP002 and EP003 indicators were retired in 2014 by NHS England. There has just been a Government Consultation which closed on the 7ᵗʰ March around the future of incentives in General Practice including QOF so there may be changes in coming years.” Source location Response from Royal College of General Practitioners
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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 NICE is responsible for guidelines on long-term epilepsy monitoring and urgent neurology review pathways.
Verbatim wording from the response “Your Report also raises the concerns that there is no clear guidance for the long-term monitoring of patients with epilepsy and that there was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns. The National Institute for Health and Care Excellence (NICE) are responsible for the relevant guidelines: Epilepsies in children, young people and adults (nice.org.uk). Most patients with epilepsy will be discharged from follow-up once they are free of seizures for 12 months. At this point, their medication would only be changed if they had further seizures or other issues arise (such as possible adverse effects or consideration of pregnancy). Some patients with additional issues would be monitored for longer (see section 4.5.1 of the guidance).” Source location Response from NHS England
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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 Specific discharge timing recommendations cannot be made because appropriate timing depends on multiple patient-specific variables.
Verbatim wording from the response “• For guidance on longer term monitoring of people with epilepsy, and safe discharge timing it is not possible to provide guidance on this that suits all patients with epilepsy as it depends on many variables. The ABN therefore do not feel that it would be appropriate to make specific recommendations regarding timing for discharge. Many patients are now enrolled in patient-initiated follow-up schemes (or equivalent) rather than being fully discharged. Fewer routine reviews may aid seeing people when most needed.” Source location Response from Royal College of Physicians
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28 Feb 2024 Chloe Anne Tapp · Prevention of Future Deaths report Essex
View report summary
Concerns raised 15
Failure to implement identified actions addressing unsafe neurology practice View source Delays and unsafe processes in investigation reporting and results access View source Provision of medication tapering instructions based on incorrect doses View source
Chronic staffing shortages across neurology doctors, nurses and administrative staff View source Failure to establish medication doses and apply appropriate conversion factors View source Unsafe backlogs for neurology first and follow-up appointments View source Failure to deliver medication tapering information through a valid and timely communication channel View source Failure to make timely referrals to adult neurology services View source Worsening unsafe condition of the neurology department View source Failure to provide visual assessment when clinically required View source Failure to respond to patient communications requiring medication clarification View source Insufficient national neurologist capacity relative to demand View source Failure to answer patient and carer communications in a timely manner View source Failure to record medication tapering regimes in clinical notes View source Unsafe practice in the neurology department View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Chloe Anne Tapp · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Chloe Anne Tapp, a 20-year-old with epilepsy and other medical conditions, suffered seizures and respiratory and cardiac arrest on 7 October 2021 and died in hospital on 8 October 2021. The principal concerns included delays transferring her to adult neurology, a telephone consultation despite her being non-verbal, an incorrect and inadequately documented medication tapering regime, and unanswered attempts to obtain clarification. Broader concerns were raised about staffing shortages, unsafe backlogs and difficulties responding to patients and carers within the neurology department.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to implement identified actions addressing unsafe neurology practice
Wider context from the report “Notwithstanding Chloe’s death in 2021, the letter in July 2023 and follow-up in January 2024, many of the more significant actions identified remained as part of an Action Plan . Business cases were being drawn up for a number of areas (but not additional consultants) and these had not yet been approved, nor was it guaranteed that they would be .
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays and unsafe processes in investigation reporting and results access
Wider context from the report “The consultant in question gave evidence of a very bleak picture of ongoing practice in the neurology department; a letter from all four consultants in that department had been sent to the Trust in July 2023, where patient care was described as ‘sub-optimal’, and numerous concerns were set out including:
o Chronic staff shortages in respect of doctors, nurses and administrative staff within the neurology department
o Substantial and unsafe backlogs for first and follow up appointments
o Inability to answer, in a timely manner, the volume of phone calls, phone messages and emails from patients/carers raising queries.
o The delays / ways in which investigations are carried out and reported , and the way in which clinical staff can access results .
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Provision of medication tapering instructions based on incorrect doses
Wider context from the report “A handwritten note of a tapering regime based on incorrect doses was sent to Chloe.
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Chronic staffing shortages across neurology doctors, nurses and administrative staff
Wider context from the report “The consultant in question gave evidence of a very bleak picture of ongoing practice in the neurology department; a letter from all four consultants in that department had been sent to the Trust in July 2023, where patient care was described as ‘sub-optimal’, and numerous concerns were set out including:
o Chronic staff shortages in respect of doctors, nurses and administrative staff within the neurology department
o Substantial and unsafe backlogs for first and follow up appointments
o Inability to answer, in a timely manner, the volume of phone calls, phone messages and emails from patients/carers raising queries.
o The delays / ways in which investigations are carried out and reported, and the way in which clinical staff can access results.
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to establish medication doses and apply appropriate conversion factors
Wider context from the report “An overworked consultant under considerable pressure, did not have time before or during the consultation to establish the dose that Chloe was taking and/or apply the appropriate conversion factor , for medications that can interact negatively at higher doses .
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unsafe backlogs for neurology first and follow-up appointments
Wider context from the report “The consultant in question gave evidence of a very bleak picture of ongoing practice in the neurology department; a letter from all four consultants in that department had been sent to the Trust in July 2023, where patient care was described as ‘sub-optimal’, and numerous concerns were set out including:
o Chronic staff shortages in respect of doctors, nurses and administrative staff within the neurology department
o Substantial and unsafe backlogs for first and follow up appointments
o Inability to answer, in a timely manner, the volume of phone calls, phone messages and emails from patients/carers raising queries.
o The delays / ways in which investigations are carried out and reported, and the way in which clinical staff can access results.
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to deliver medication tapering information through a valid and timely communication channel
Wider context from the report “The same regime was repeated in a letter to the Epilepsy Nurses, but this letter was not received until October 2021 (in paper form) as the initial email was sent to an address that no longer existed .
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to make timely referrals to adult neurology services
Wider context from the report “Neurology departments are so overwhelmed and/or understaffed that a vulnerable young girl (particularly so during the Covid-19 pandemic), was not referred in a timely manner to adult neurology services and in fact, it transpired a referral had not been made at all . This appears to have been done for the first time in August 2021.
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Worsening unsafe condition of the neurology department
Wider context from the report “The state of the department , compared to when Chloe died was described as ‘worse’ .
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide visual assessment when clinically required
Wider context from the report “An initial consultation with a complex non-verbal patient was arranged over the telephone , notwithstanding the concerns about a tremor which would have required visual assessment .
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to respond to patient communications requiring medication clarification
Wider context from the report “Phone calls and messages left with the neurology department went unanswered , at a time when clarity over the tapering regime was needed .
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient national neurologist capacity relative to demand
Wider context from the report “The independent consultant neurologist in giving evidence expressed that this was not an unfamiliar picture across a number of different Trusts and that there was a recognised shortage of neurologists and increase in demand for that speciality nationally .
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to answer patient and carer communications in a timely manner
Wider context from the report “The consultant in question gave evidence of a very bleak picture of ongoing practice in the neurology department; a letter from all four consultants in that department had been sent to the Trust in July 2023, where patient care was described as ‘sub-optimal’, and numerous concerns were set out including:
o Chronic staff shortages in respect of doctors, nurses and administrative staff within the neurology department
o Substantial and unsafe backlogs for first and follow up appointments
o Inability to answer, in a timely manner, the volume of phone calls, phone messages and emails from patients/carers raising queries.
o The delays / ways in which investigations are carried out and reported, and the way in which clinical staff can access results.
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to record medication tapering regimes in clinical notes
Wider context from the report “No note was made of the tapering regime for the medication change in Chloe’s notes.
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unsafe practice in the neurology department
Wider context from the report “A further letter was sent by Chloe’s consultant in January 2024 in lieu of her attending a meeting where progress was to be discussed. That letter highlighted that, not only did the concerns remain live , she believed that the department had now reached levels of ‘unsafe practice’ .
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue implementing and monitoring actions from the Serious Incident investigation and neurology improvement action plan.
Verbatim wording from the response “The matters raised in the Consultant’s letter in July 2023 were of great concern. I am aware my colleague Dr David Walker, Chief Medical Officer, wrote to you at the time to confirm the work we were taking to ensure the service was safe, a copy of his letter is attached. Our Serious Incident investigation went on to investigate these concerns, and those findings have informed the detailed action plan attached.” Source location Response from Mid and South Essex NHS
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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 Conduct a GIRFT review visit to Mid and South Essex NHS Foundation Trust’s neurology department.
Verbatim wording from the response “Having considered your Report and the concerns raised, a GIRFT visit to Mid and South Essex NHS Foundation Trust has been arranged to review the specific situation within their Neurology department.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Appoint two nursing posts within the neurology team.
Verbatim wording from the response “We now have two nursing posts within the team, both roles have recently been appointed to. Our overall administrative support has also increased and additional funding for administrative staff has been obtained for our Multiple Sclerosis service that sits under the Neurology umbrella.” Source location Response from Mid and South Essex NHS
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase neurology administrative support and obtain additional funding for administrative staff in the Multiple Sclerosis service.
Verbatim wording from the response “We now have two nursing posts within the team, both roles have recently been appointed to. Our overall administrative support has also increased and additional funding for administrative staff has been obtained for our Multiple Sclerosis service that sits under the Neurology umbrella.” Source location Response from Mid and South Essex NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish neurology medical staffing with four consultants and three specialty doctors, with annual staffing-needs review.
Verbatim wording from the response “In addition to this, we have invested in staffing within the neurology service. Our medical staffing is now fully established which includes four consultants and three specialty doctors. Our medical staffing is reviewed annually to check the needs of the service are properly met.” Source location Response from Mid and South Essex NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the Long Term Workforce Plan, expanding domestic education, training and recruitment while improving culture, leadership and staff wellbeing.
Verbatim wording from the response “NHS England is also working at a national level to deliver the Long Term Workforce Plan which was published in June 2023. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years.” Source location Response from NHS England
Open published response
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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 neurology clinic records for record-keeping compliance and conduct quarterly reviews for divisional governance assurance.
Verbatim wording from the response “To ensure adherence to the expected standards we have completed an audit of neurology clinic records during February and March 2024.The results of this audit showed overall good compliance with dictation, headers, footers, and onward referrals. Small deviations that were picked up were fed back to the team and actioned. Audit reviews will continue quarterly to provide assurance to the divisional governance meeting. These are in addition to the Trust wide record keeping audits.” Source location Response from Mid and South Essex NHS
Open published response
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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 national neurology guidance and specifications supporting integrated care, including epilepsy services.
Verbatim wording from the response “NHS England’s Neurology Programme is in the process of developing guidance and specifications to support Systems and NHS Trusts to develop integrated care for neurology services, including epilepsy. However, this cannot directly impact issues arising from funding shortfalls in individual services or challenges with recruitment and retention of appropriately qualified medical and nursing staff in some parts of the country, as raised in your Report.” Source location Response from NHS England
Open published response
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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 and disseminate a national bundle of care for children and young people with epilepsy, including transition recommendations.
Verbatim wording from the response “Transition pathways from paediatric to adult services are a particular point of risk with variable processes across the country, with both paediatric and adult neurology services stretched. This is particularly a recognised issue for epilepsy. NHS England’s Paediatrics Programme recently published the national bundle of care for children and young people with epilepsy. Published in October 2023, and builds on existing guidance from the National Institute for Health and Care Excellence (NICE), it is aimed at clinicians by outlining specific recommendations for integrated care systems on the provision of care for children and young people with epilepsy particularly around transition.” Source location Response from NHS England
Open published response
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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 Operate specialist neurology consultations in person rather than routinely by telephone for clinically vulnerable, complex patients.
Verbatim wording from the response “We agree that a telephone appointment was not appropriate to fully assess Chloe’s clinical presentation on this occasion. However, at that time we were operating clinics differently to manage the significant risks presented by the COVID-19 pandemic.” Source location Response from Mid and South Essex NHS
Open published response
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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 Communicate and reinforce the requirement that medication tapering regimes are recorded in notes and scanned into electronic patient records.
Verbatim wording from the response “It is our usual practice to record tapering regimes in patient notes, and this is the expected standard as set out in our clinical record keeping standards policy. The regime was recorded in the letter to Chloe’s GP dated 8 September 2021, however the related table drawn up by the Consultant should have been included in Chloe’s notes.” Source location Response from Mid and South Essex NHS
Open published response
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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 Many concerns about Chloe’s care fall within the NHS Foundation Trust’s remit rather than NHS England’s national programme or policy remit.
Verbatim wording from the response “In your Report you raise concerns over pressures being placed on neurology departments and that there was a recognised shortage of neurologists amid an increase in demand. This response focuses on the concerns raised relevant to NHS England national programme or policy. Many of your concerns around the quality of care delivered to Chloe sit within the remit of Mid and South Essex NHS Foundation Trust, and I note that you have also addressed your Report to them.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The consultant had time to establish Chloe’s dose because it was documented and clinic capacity was available before the appointment.
Verbatim wording from the response “Chloe’s then current dose was readily available to the Consultant prior to her appointment, it was listed on the second page of the GP letter 10 August 2021. We have reviewed the clinic that took place on 3 September 2021 and can confirm that prior to Chloe’s appointment there was one unfilled clinical slot. This is a slot we plan to keep free for urgent/ unexpected cases; and there was one further patient who did not attend. We therefore consider the consultant had time to establish Chloe’s current dose prior to the consultation.” Source location Response from Mid and South Essex NHS
Open published response
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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 guidance cannot directly address funding shortfalls or recruitment and retention challenges in individual neurology services.
Verbatim wording from the response “NHS England’s Neurology Programme is in the process of developing guidance and specifications to support Systems and NHS Trusts to develop integrated care for neurology services, including epilepsy. However, this cannot directly impact issues arising from funding shortfalls in individual services or challenges with recruitment and retention of appropriately qualified medical and nursing staff in some parts of the country, as raised in your Report.” Source location Response from NHS England
Open published response
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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 Trusts are responsible for ensuring safe staffing levels during the day-to-day operation of their hospitals.
Verbatim wording from the response “These actions will aim to close anticipated staffing shortfalls in the NHS in the long term, however Trusts have a responsibility to ensure safe staffing levels in the current day to day operation of their hospitals. This is in line with Care Quality Commission (CQC) Regulation 18 which states that providers must deploy enough suitably qualified, competent, and experienced staff to enable them to meet all other regulatory requirements.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust considers its neurology staffing establishment appropriate to meet service needs after staffing increases and annual review arrangements.
Verbatim wording from the response “In addition to this, we have invested in staffing within the neurology service. Our medical staffing is now fully established which includes four consultants and three specialty doctors. Our medical staffing is reviewed annually to check the needs of the service are properly met.” Source location Response from Mid and South Essex NHS
Open published response
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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 Consultants already had 24/7 pharmacy support and online resources for dosage-conversion queries, although the available support was not accessed.
Verbatim wording from the response “Our consultants are also supported by the pharmacy team who are available 24/7 to assist with dosage conversion queries and ad hoc queries. They also have access to online support and resources. Unfortunately, the consultant did not access this support.” Source location Response from Mid and South Essex NHS
Open published response
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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 referral was not attributable to the Trust, which disputes responsibility for the alleged failure to refer Chloe to adult neurology.
Verbatim wording from the response “We acknowledge your concern that there was a delay in Chloe’s referral to adult neurology services, however this delay was not attributable to Mid and South Essex Hospital NHS Foundation Trust.
Chloe was known to our paediatric services however, once she reached 16 years of age her epilepsy was managed by the Royal London Hospital in conjunction with her GP; we did not receive any communication from them relating to her transitional care.” Source location Response from Mid and South Essex NHS
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation After age 16, Chloe’s epilepsy was managed by the Royal London Hospital and her GP, who were responsible for transitional communication.
Verbatim wording from the response “We acknowledge your concern that there was a delay in Chloe’s referral to adult neurology services, however this delay was not attributable to Mid and South Essex Hospital NHS Foundation Trust.
Chloe was known to our paediatric services however, once she reached 16 years of age her epilepsy was managed by the Royal London Hospital in conjunction with her GP; we did not receive any communication from them relating to her transitional care.” Source location Response from Mid and South Essex NHS
Open published response
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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 Telephone assessment was selected as safer during the COVID-19 pandemic because Chloe was clinically vulnerable to potentially life-threatening infection.
Verbatim wording from the response “We agree that a telephone appointment was not appropriate to fully assess Chloe’s clinical presentation on this occasion. However, at that time we were operating clinics differently to manage the significant risks presented by the COVID-19 pandemic.” Source location Response from Mid and South Essex NHS
Open published response
Concerns raised 4
Failure to refer dosage-clarification correspondence to a clinician View source Failure to refer medication-change correspondence to a clinician for consideration View source Failure to give the prescribing GP express instructions to amend Brivaracetam prescriptions after dosage changes View source
Failure to maintain a reliable written basis for Brivaracetam dosage administration View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Joshua Ethan BURGESS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joshua Ethan Burgess, who had epilepsy and Lennox-Gastaut syndrome, died at home on 19 November 2022 after vomiting and aspirating during an epileptic seizure. The report identifies concerns about communication and prescribing processes for Brivaracetam, including failures to update the prescription, medication being withheld for several days, and a subsequent increase to 10ml twice daily despite information that 4ml twice daily was appropriate.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to refer dosage-clarification correspondence to a clinician
Wider context from the report “1. The Neurology department of the Royal Stoke University Hospital operated a system whereby it did not instruct the prescribing GP to amend the prescription of Brivaracetam when changes to dosage had been agreed with Mr Burgess’ mother. The evidence from the Consultant Neurologist was that an assumption was made that when changes to medication had been discussed and agreed that Mr Burgess’ mother would attend the GP surgery to discuss the changes in medication. The same witness gave evidence that it was assumed a pharmacist within the GP surgery would read the correspondence from the neurology department and make the necessary changes to prescriptions without express instructions to do so.
2. The “workflow” within the Brook Medical Centre was such that letters sent from the Neurology department discussing changes in medication (albeit not containing a request to amend the prescription) were processed by support staff and not referred to a clinician to consider and so no changes were made to the prescription.
3. The letter of 27 July 2022 from the Neurology department to Brook Medical Centre seeking clarification as to the correct dosage of Brivaracetam was processed by support staff and a summary medications sent without referral to a clinician .
4. Godfrey Care were informed by Mr Burgess’ mother and the Neurology department of Royal Stoke University that the appropriate dose of Brivaracetam was 4ml twice daily. Medication was withheld between 22-26 July 2022 due to the information not being in writing from the prescriber, however the evidence at inquest was that 10ml twice daily was commenced on 26 July 2022 following a call to the 111 service.
” Source location Joshua Ethan BURGESS · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to refer medication-change correspondence to a clinician for consideration
Wider context from the report “1. The Neurology department of the Royal Stoke University Hospital operated a system whereby it did not instruct the prescribing GP to amend the prescription of Brivaracetam when changes to dosage had been agreed with Mr Burgess’ mother. The evidence from the Consultant Neurologist was that an assumption was made that when changes to medication had been discussed and agreed that Mr Burgess’ mother would attend the GP surgery to discuss the changes in medication. The same witness gave evidence that it was assumed a pharmacist within the GP surgery would read the correspondence from the neurology department and make the necessary changes to prescriptions without express instructions to do so.
2. The “workflow” within the Brook Medical Centre was such that letters sent from the Neurology department discussing changes in medication (albeit not containing a request to amend the prescription) were processed by support staff and not referred to a clinician to consider and so no changes were made to the prescription .
3. The letter of 27 July 2022 from the Neurology department to Brook Medical Centre seeking clarification as to the correct dosage of Brivaracetam was processed by support staff and a summary medications sent without referral to a clinician.
4. Godfrey Care were informed by Mr Burgess’ mother and the Neurology department of Royal Stoke University that the appropriate dose of Brivaracetam was 4ml twice daily. Medication was withheld between 22-26 July 2022 due to the information not being in writing from the prescriber, however the evidence at inquest was that 10ml twice daily was commenced on 26 July 2022 following a call to the 111 service.
” Source location Joshua Ethan BURGESS · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to give the prescribing GP express instructions to amend Brivaracetam prescriptions after dosage changes
Wider context from the report “1. The Neurology department of the Royal Stoke University Hospital operated a system whereby it did not instruct the prescribing GP to amend the prescription of Brivaracetam when changes to dosage had been agreed with Mr Burgess’ mother . The evidence from the Consultant Neurologist was that an assumption was made that when changes to medication had been discussed and agreed that Mr Burgess’ mother would attend the GP surgery to discuss the changes in medication. The same witness gave evidence that it was assumed a pharmacist within the GP surgery would read the correspondence from the neurology department and make the necessary changes to prescriptions without express instructions to do so .
2. The “workflow” within the Brook Medical Centre was such that letters sent from the Neurology department discussing changes in medication (albeit not containing a request to amend the prescription) were processed by support staff and not referred to a clinician to consider and so no changes were made to the prescription.
3. The letter of 27 July 2022 from the Neurology department to Brook Medical Centre seeking clarification as to the correct dosage of Brivaracetam was processed by support staff and a summary medications sent without referral to a clinician.
4. Godfrey Care were informed by Mr Burgess’ mother and the Neurology department of Royal Stoke University that the appropriate dose of Brivaracetam was 4ml twice daily. Medication was withheld between 22-26 July 2022 due to the information not being in writing from the prescriber, however the evidence at inquest was that 10ml twice daily was commenced on 26 July 2022 following a call to the 111 service.
” Source location Joshua Ethan BURGESS · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain a reliable written basis for Brivaracetam dosage administration
Wider context from the report “1. The Neurology department of the Royal Stoke University Hospital operated a system whereby it did not instruct the prescribing GP to amend the prescription of Brivaracetam when changes to dosage had been agreed with Mr Burgess’ mother. The evidence from the Consultant Neurologist was that an assumption was made that when changes to medication had been discussed and agreed that Mr Burgess’ mother would attend the GP surgery to discuss the changes in medication. The same witness gave evidence that it was assumed a pharmacist within the GP surgery would read the correspondence from the neurology department and make the necessary changes to prescriptions without express instructions to do so.
2. The “workflow” within the Brook Medical Centre was such that letters sent from the Neurology department discussing changes in medication (albeit not containing a request to amend the prescription) were processed by support staff and not referred to a clinician to consider and so no changes were made to the prescription.
3. The letter of 27 July 2022 from the Neurology department to Brook Medical Centre seeking clarification as to the correct dosage of Brivaracetam was processed by support staff and a summary medications sent without referral to a clinician.
4. Godfrey Care were informed by Mr Burgess’ mother and the Neurology department of Royal Stoke University that the appropriate dose of Brivaracetam was 4ml twice daily. Medication was withheld between 22-26 July 2022 due to the information not being in writing from the prescriber , however the evidence at inquest was that 10ml twice daily was commenced on 26 July 2022 following a call to the 111 service .
” Source location Joshua Ethan BURGESS · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a local medication policy covering medication receipt, transcription, altered labels, missed doses, written prescribing confirmation and triangulation between prescribers.
Verbatim wording from the response “Reviewed Policies and Procedures
The following actions will be implemented by 1st April 2024.” Source location Response from Godfrey Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review internal policies and procedures against the coroner’s concerns and identify necessary changes.
Verbatim wording from the response “Godfrey Care Response
We intend to review our internal policies and procedures considering the coroners concerns and identify where changes need to be made. Below, we respond to the coroner’s areas of concern, setting out what we have already done, what we are doing now, and what we intend to do in the future.” Source location Response from Godfrey Care
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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 Update staff medication competency assessments to test clarification of unclear directions, MAR-label discrepancies and verbal medication changes.
Verbatim wording from the response “3 The Staff Medication Competency Assessment has been reviewed and now includes the following questions.” Source location Response from Godfrey Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Have a GP review and triage all neurology correspondence and clinic letters received by Brook Medical Centre.
Verbatim wording from the response “2. We have discussed the above process with nominated individuals from the ICS. Due to the timeframes that would be required for the creation of standardised template for clinic letters within the ‘Medisec’ system across the Trust, we are reiterating the Trust standards and ████████ has agreed, with immediate effect, that all clinic letters received from neurology will be reviewed by a GP at Brook Medical Centre. This has been implemented due to the acknowledgement that neurological conditions are often complex, and it is more likely that they will require frequent medication changes, titration and/or closer monitoring.” Source location Response from University Hospitals of North Midlands
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require GP review and triage of all neurology correspondence received by Brook Medical Centre.
Verbatim wording from the response “2. We have discussed the above process with nominated individuals from the ICS. Due to the timeframes that would be required for the creation of standardised template for clinic letters within the ‘Medisec’ system across the Trust, we are reiterating the Trust standards and ████████ has agreed, with immediate effect, that all clinic letters received from neurology will be reviewed by a GP at Brook Medical Centre. This has been implemented due to the acknowledgement that neurological conditions are often complex, and it is more likely that they will require frequent medication changes, titration and/or closer monitoring.” Source location Response from University Hospitals of North Midlands
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a standardised Medisec clinic-letter template specifying medication changes and clear prescribing actions for primary care.
Verbatim wording from the response “1. The Trust’s outpatient clinic letter standards describe the structure of clinic letters based on standard headings. You will recall that ████████ (GP) gave evidence at the inquest to the effect that there were areas in the acute Trust setting which already provided discharge information which he considered to be of a ‘gold standard.’ The Trust is committed to working towards improving compliance with these standards. To support this, we are working towards creation of a standardised template in our ‘Medisec’ system (system where letters are created). This will include a section for changes to medications and clear actions for those in the primary care setting, for example, instructions for the prescribing GP to amend prescriptions.” Source location Response from University Hospitals of North Midlands
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update weekly and monthly managers’ medication audits to verify written authorisation, dosage changes and timely receipt of replacement prescriptions.
Verbatim wording from the response “• Run through the reviewed managers monthly medication audit to ensure expectations are clear.” Source location Response from Godfrey Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a standardised clinic-letter template specifying medication changes and clear actions for prescribing GPs.
Verbatim wording from the response “1. The Trust’s outpatient clinic letter standards describe the structure of clinic letters based on standard headings. You will recall that ████████ (GP) gave evidence at the inquest to the effect that there were areas in the acute Trust settings which already provided discharge information which he considered to be of a ‘gold standard.’ The Trust is committed to working towards improving compliance with these standards. To support this, we are working towards creation of a standardised template in our ‘Medisec’ system (system where letters are created). This will include a section for changes to medications and clear actions for those in the primary care setting, for example, instructions for the prescribing GP to amend prescriptions.” Source location Response from University Hospitals of North Midlands
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A standardised clinic-letter template cannot be created immediately because implementation across the Trust requires substantial timeframes.
Verbatim wording from the response “2. We have discussed the above process with nominated individuals from the ICS. Due to the timeframes that would be required for the creation of standardised template for clinic letters within the ‘Medisec’ system across the Trust, we are reiterating the Trust standards and ████████ has agreed, with immediate effect, that all clinic letters received from neurology will be reviewed by a GP at Brook Medical Centre. This has been implemented due to the acknowledgement that neurological conditions are often complex, and it is more likely that they will require frequent medication changes, titration and/or closer monitoring.” Source location Response from University Hospitals of North Midlands
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 administering medication did not contribute to the death.
Verbatim wording from the response “4. Whilst this concern is not directly addressed to the acute Trust (UHNM) or Brook medical Centre, it has been considered as part of the wider learning following Joshua’s death. Medications for epilepsy is considered across the healthcare economy to be ‘critical’. The National Patient Safety Agency (2010) defined critical medicines as ‘medicines which can result in patient death or serious harm if there are delays in their administration’. Whist the Coroner found that the delay in administering medications on this occasion did not contribute to Joshua’s death, we believe that further education within the care home setting is required. With this in mind, we will work together with the local authority to ensure that up to date communications are shared across the Stoke on Trent and North Staffordshire health and social care economy to reiterate this message.” Source location Response from University Hospitals of North Midlands
Open published response
16 Jan 2024 Trevor Alan MONERVILLE · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 6
Lack of a mechanism to report medication non-compliance to Security View source Lack of prison staff training in managing long-term health conditions on the wings View source Failure of the CSRA policy to protect prisoners with relevant medical conditions View source
Lack of individualized seizure care planning and monitoring View source Inadequate communication about prisoners’ health conditions View source Deficit in national policy for managing and supporting prisoners with epilepsy and seizures View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Trevor Alan MONERVILLE · 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
Trevor Alan Monerville, who had been detained at HMP Lewes, was found unresponsive in his cell on 18 April 2021 and died after suffering from epilepsy and non-epileptic attack disorder. The principal concerns were inadequate monitoring and management of his epilepsy after the ACCT closed, poor communication and information-sharing between healthcare, prison staff and family, and insufficient staff training in managing epilepsy and seizures.
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 a mechanism to report medication non-compliance to Security
Wider context from the report “b. Communication between healthcare and prison staff especially when Trevor was returned to the wing, between the prison staff and family, briefing by prison managers to officers on the wing about Trevor’s condition were all inadequate.
Evidence was heard about the lack of integration of various IT systems which contributed to poor communication. In spite of the evidence from PPG regarding the sensitivity of medical records which should not be disclosed to the prison staff, I remain concerned that there was no effective monitoring and management of Trevor on the wing once the ACCT was closed. There was no mechanism in place for prison and healthcare staff to report their concerns about Trevor’s non compliance with taking his medication to Security , thus preventing the cell from being searched for retained medication.
” Source location Trevor Alan MONERVILLE · 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 prison staff training in managing long-term health conditions on the wings
Wider context from the report “c. There was a lack of training of prison staff in dealing with long term health conditions such as epilepsy on the wings. I understand there is a deficit in national policy within the prison service to manage and support prisoners with epilepsy and seizures.
” Source location Trevor Alan MONERVILLE · 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 the CSRA policy to protect prisoners with relevant medical conditions
Wider context from the report “a. Consideration should be given to the review of the treatment, monitoring and management of patients with a history of epilepsy or seizures by both the prison staff and healthcare staff. In particular, there was no seizure care plan, no seizure diary and once the ACCT had closed on 10th March 2021, there was no formal mechanism of monitoring Trevor’s condition. Further, the ACCT is not a suitable mechanism for such monitoring. The CSRA policy is designed to protect other prisoners, but not those who suffer from medical conditions as Trevor suffered. PPG in their evidence to be considered relating to PFD matters state that a care plan dashboard is now in place at HMP Lewes but this does not appear to be individualized or tailored to the prisoner’s clinical requirements.
” Source location Trevor Alan MONERVILLE · 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 individualized seizure care planning and monitoring
Wider context from the report “a. Consideration should be given to the review of the treatment, monitoring and management of patients with a history of epilepsy or seizures by both the prison staff and healthcare staff. In particular, there was no seizure care plan, no seizure diary and once the ACCT had closed on 10th March 2021, there was no formal mechanism of monitoring Trevor’s condition . Further, the ACCT is not a suitable mechanism for such monitoring. The CSRA policy is designed to protect other prisoners, but not those who suffer from medical conditions as Trevor suffered. PPG in their evidence to be considered relating to PFD matters state that a care plan dashboard is now in place at HMP Lewes but this does not appear to be individualized or tailored to the prisoner’s clinical requirements .
” Source location Trevor Alan MONERVILLE · 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 Inadequate communication about prisoners’ health conditions
Wider context from the report “b. Communication between healthcare and prison staff especially when Trevor was returned to the wing , between the prison staff and family , briefing by prison managers to officers on the wing about Trevor’s condition were all inadequate.
Evidence was heard about the lack of integration of various IT systems which contributed to poor communication. In spite of the evidence from PPG regarding the sensitivity of medical records which should not be disclosed to the prison staff, I remain concerned that there was no effective monitoring and management of Trevor on the wing once the ACCT was closed. There was no mechanism in place for prison and healthcare staff to report their concerns about Trevor’s non compliance with taking his medication to Security, thus preventing the cell from being searched for retained medication.
” Source location Trevor Alan MONERVILLE · 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 Deficit in national policy for managing and supporting prisoners with epilepsy and seizures
Wider context from the report “c. There was a lack of training of prison staff in dealing with long term health conditions such as epilepsy on the wings. I understand there is a deficit in national policy within the prison service to manage and support prisoners with epilepsy and seizures.
” Source location Trevor Alan MONERVILLE · 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 Use confidential intelligence reports to notify Security when patients may be stockpiling medication.
Verbatim wording from the response “Pharmacy technicians manage medication compliance. They have now been given wings to lead on so that they have full oversight of patients on their own wing. SystmOne assists with supporting the identity of patients who have missed doses. In addition, the IR process is in place if it is believed or suspected that a patient might be stockpiling. An IR is an intelligence report that will be received confidentially by the security department.” Source location Response from Practice Plus Group
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 First Aid at Work and Emergency First Aid training to identified prison staff, including responses to seizures.
Verbatim wording from the response “HMPPS undertake First Aid needs assessments to ensure that sufficient emergency aid response is available on each site. First Aid at Work and Emergency First Aid training courses are delivered to identified prison staff, which includes emergency response to both minor and major seizures.” Source location Response from HM Prison and Probation Service
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 Create and maintain a SystmOne care plan hub with epilepsy templates and review-template links.
Verbatim wording from the response “Practice Plus Group made it an organisational priority for 2023 to ensure that the use of personalised care plans is embedded throughout sites at which Practice Plus Group is the healthcare provider. Using the limited capacity in which Practice Plus Group can make changes to SystmOne, the electronic medical records system, a care plan hub has been created to support clinical staff in accessing appropriate templates. This includes a specific care plan to support management of epilepsy and a direct link to the epilepsy care plan has been added within the review template for epilepsy annual reviews. Staff received training on the use of the care planning hub on SystmOne via workshops, regular updates and in June 2023 staff received a care plan guide.” Source location Response from Practice Plus Group
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 Use SystmOne recalls to schedule, monitor and allocate long-term-condition reviews.
Verbatim wording from the response “Care planning workshops for the healthcare teams at HMP Lewes were facilitated by the national and regional primary care leads. The SystmOne recall functionality is being utilised to ensure a systematic approach is adopted for long term condition reviews and that these are monitored and staff allocated to book patients into clinics when required. Healthcare staff working at HMP Lewes have also been provided with access to a training module ‘Epilepsy training for primary care nurses’. This training is there to provide support on identifying different types of seizures, treatment review etc.” Source location Response from Practice Plus Group
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 samples of epilepsy care plans for quality improvement and alignment with national guidelines.
Verbatim wording from the response “Practice Plus Group amended the process for reporting on care plans approximately 18 months ago and have seen positive progress in the quantitative data. Over the last 3-4 months a process to review a small sample of these plans to support quality improvement and align with national guidelines has been started. As HMP Lewes is a remand site, the completion rate will always be variable whilst new patients await their initial long term condition review. On review for December 2023, 83% of patients with epilepsy at HMP Lewes now have a documented care plan. The team are striving to achieve 100%, however the data taken at the end of the month is reflective of the prison’s population at that point in time and new arrivals in the last few days/week who have not yet received a long term conditions review would affect this figure.” Source location Response from Practice Plus Group
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 epilepsy reviews and agree individualized care plans with patients.
Verbatim wording from the response “Response: Oversight of patients with long term conditions is currently being carried out by the long term conditions nurse and primary care nurses, supported by the regional primary care lead and inclusive of prescribers where applicable. In order to ensure that patients with epilepsy are monitored and supported through a patient-centred approach, the long term conditions nurse has been completing reviews and agreeing a personal care plan with the patient that is specific to their individual needs. This is aligned with the wider work that has taken place on long term conditions management pathways.” Source location Response from Practice Plus Group
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 and monitor long-term-condition care plans to maintain progress.
Verbatim wording from the response “The most recent inspection report from HMIP/CQC dated 23 February 2023 states “Patients with long-term conditions had timely reviews, and a new care plan hub made sure clinicians and patients jointly managed care, which was safe and well-coordinated”. We will continue to regularly audit and monitor the long term conditions care plans of patients at HMP Lewes to ensure progress is maintained.” Source location Response from Practice Plus Group
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 Train healthcare staff to use the care planning hub through workshops, updates and guidance.
Verbatim wording from the response “Practice Plus Group made it an organisational priority for 2023 to ensure that the use of personalised care plans is embedded throughout sites at which Practice Plus Group is the healthcare provider. Using the limited capacity in which Practice Plus Group can make changes to SystmOne, the electronic medical records system, a care plan hub has been created to support clinical staff in accessing appropriate templates. This includes a specific care plan to support management of epilepsy and a direct link to the epilepsy care plan has been added within the review template for epilepsy annual reviews. Staff received training on the use of the care planning hub on SystmOne via workshops, regular updates and in June 2023 staff received a care plan guide.” Source location Response from Practice Plus Group
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 NHS England to clarify routine health-information sharing and processes for risk or safeguarding concerns.
Verbatim wording from the response “HMPPS recognises that, information sharing is vital to effective health management of people in prison and is working closely with NHSE to increase staff confidence and support effective information sharing by offering clarity about the general and routine sharing of health information and where risk/safeguarding concerns have been raised.” Source location Response from HM Prison and Probation Service
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 Regional Multi Professional Complex Case Clinic escalation for the most complex patients.
Verbatim wording from the response “Practice Plus Group operates an integrated healthcare model. Any patients pending transfer back to the main wing with ongoing needs are to be discussed at the Multi Professional Complex Case Clinic (MPCCC) prior to transfer. This allows oversight of all departments within the integrated team and a holistic complex care plan to be created. The MPCCC is led by the GP, attended by all clinical leads, and any relevant staff involved in patient care. For individual cases prison partners may be invited to attend and a care plan created with a named coordinator allocated. Practice Plus Group has now implemented a further point of escalation to Regional MPCCC. For the most complex of patients, attendees will include healthcare, prison staff and, on occasion, representatives from NHS England.” Source location Response from Practice Plus Group
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 information-sharing protocols and weekly meetings are considered appropriate for communication and management of complex safety concerns.
Verbatim wording from the response “There are Information Sharing protocols in place, as directed by national policy, which underpin the exchange of information between healthcare and prison staff. There are several regular meetings involving healthcare and prison staff where individual issues are raised and addressed, including the Safety Intervention Meeting and Multi-Disciplinary Complex Case Clinic, both of which are held weekly.” Source location Response from HM Prison and Probation Service
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 Training prison staff to manage epilepsy and seizures is a matter for His Majesty’s Prison and Probation Service.
Verbatim wording from the response “Response: This concern is for His Majesty’s Prison and Probation Service to address. However, as always Practice Plus Group are committed to working collaboratively with our prison colleagues to support the safety and wellbeing of our patients and would fully support any prison led epilepsy awareness campaign for officers and wing staff.” Source location Response from Practice Plus Group
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 PPG decides whether prisoners with epilepsy require standard or inpatient placement; HMPPS facilitates any required move.
Verbatim wording from the response “As was heard at the inquest, the creation of a seizure care plan and seizure diary, a clinical matter, falls within the responsibility of the healthcare provider at HMP Lewes, Practice Plus Group (PPG). It is within PPG’s remit to decide which prisoners are fit to be managed on a standard wing and, where a health condition such as epilepsy is identified, whether the severity of this means they should be located on the inpatient wing. HMPPS will facilitate a move to the inpatient unit where this is required.” Source location Response from HM Prison and Probation Service
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 Healthcare provider PPG is responsible for seizure care plans, diaries and long-term health management; prison staff facilitate its instructions.
Verbatim wording from the response “As was heard at the inquest, the creation of a seizure care plan and seizure diary, a clinical matter, falls within the responsibility of the healthcare provider at HMP Lewes, Practice Plus Group (PPG). It is within PPG’s remit to decide which prisoners are fit to be managed on a standard wing and, where a health condition such as epilepsy is identified, whether the severity of this means they should be located on the inpatient wing. HMPPS will facilitate a move to the inpatient unit where this is required.” Source location Response from HM Prison and Probation Service
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 Practice Plus Group cannot resolve integration of healthcare and prison IT systems because SystmOne is commissioned by NHS England and medical records are confidential.
Verbatim wording from the response “As to lack of integration of various systems, this is not an issue that Practice Plus Group can resolve. SystmOne is commissioned by NHS England and Practice Plus Group is commissioned to use SystmOne. As with patients in the community, medical records are highly sensitive and personal to the individual. They are not shared with prison staff for reasons of medical confidentiality.” Source location Response from Practice Plus Group
Open published response
18 Dec 2023 Nuel-Junior DZERNJO · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1
Lack of clear guidance on the appropriate route of Acyclovir treatment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Nuel-Junior DZERNJO · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Nuel-Junior Dzernjo, who was receiving high-dose steroids and was immunosuppressed, developed chicken pox and deteriorated after being assessed at hospital on 21 February 2023. He was discharged despite ongoing abnormal observations, inability to mobilise and confusion, then deteriorated at home and died after collapsing the following day. The investigation identified unclear guidance on treatment, including whether intravenous rather than oral Acyclovir was indicated.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clear guidance on the appropriate route of Acyclovir treatment
Wider context from the report “During the course of my investigation into the death of Nuel-Junior I instructed an independent paediatric expert to review his management and opine on causation. During the course of hearing the evidence from the expert and all of the treating clinicians it became clear that there was some potentially relevant guidance available but it lacked clarity . Here intravenous Acyclovir, if prescribed, may have prevented Nuel-Junior's death but he was instead prescribed oral Acyclovir which was unlikely to have made a difference . Had clear guidance been available then Nuel-Junior's death may have been prevented.
” Source location Nuel-Junior DZERNJO · Prevention of Future Deaths report
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 Share report-derived information and local improvement suggestions with paediatric members through the patient safety portal, including promoting BNFC guidance.
Verbatim wording from the response “The College will be sharing information and suggestions for local improvement from your report with our paediatric members via its patient safety portal, including the promotion of the BNFC guidance to improve awareness across the profession. The information within your report will also be shared for discussion with the RCPCH Clinical Quality in Practice group in early Spring, where further actions may be identified.” Source location Response from Royal College of Paediatrics and Child health
Open published response
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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 Developing guidance on chickenpox and covering every clinical circumstance falls outside NICE’s requested scope and recommendations.
Verbatim wording from the response “NICE have not published a guideline on managing chickenpox. We are not asked to develop guidance on all conditions and our recommendations do not cover all clinical circumstances.” Source location Response from National Institure for Health and Care Excellence
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 existing Clinical Knowledge Summary recommendation is considered clear about seeking specialist advice and determining intravenous aciclovir admission.
Verbatim wording from the response “There is a Clinical Knowledge Summary (CKS) published on our website on chickenpox, including a section on the management of chickenpox in people who are immunocompromised. The CKS are developed by an external company called Agilio Software and are designed to summarise the evidence on the treatment of specific health conditions. They use a variety of sources and may include NICE guidance, if there is any that is relevant, but they use many other sources too. We publish them on our website as a source of advice and information for health professionals working in primary care, but they do not constitute NICE guidance.” Source location Response from National Institure for Health and Care Excellence
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 Agilio Software is responsible for providing further clarification about the Clinical Knowledge Summary topic’s content.
Verbatim wording from the response “As part of this process, we have shared this report with Agilio Software for their awareness, however, if further clarification is required on the content of the CKS topic, Agilio software can be contacted directly.” Source location Response from National Institure for Health and Care Excellence
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 BNFC guidance for intravenous treatment of varicella in immunocompromised children is clear, contrary to the concern that guidance was unclear.
Verbatim wording from the response “Thank you for sharing your report with us regarding the tragic and untimely passing of Nuel-Junior. We were saddened to read the circumstances surrounding Nuel-Junior’s death and have discussed with senior colleagues within the RCPCH and the British Paediatric Allergy, Immunity and Infection Group (BPAIIG). Thank you for confirming in a separate correspondence that the doctors knew that Nuel-Junior was immunocompromised, and that he was initially not particularly "unwell" and presented with typical signs of chickenpox (including a temperature and spots/lesions). You described further that Dr Louis Grandjean, an independent paediatric expert instructed by the court, was of the view that the guidance was unclear.” Source location Response from Royal College of Paediatrics and Child health
Open published response
Concerns raised 1
Failure to measure the incision from the insular to the Temporal Horn at appropriate intra-operative times View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Tracy Gambrill · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Tracy Gambrill underwent neurosurgery on 7 November 2016 and sustained serious brain injury after excessively deep incisions were made while locating the temporal horn. She died in hospital on 19 November 2016. The principal concern was that it was not current and expected practice to measure the incision from the insular to the temporal horn at appropriate times during the operation.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to measure the incision from the insular to the Temporal Horn at appropriate intra-operative times
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
Each of the three surgical incisions were far too deep considering the average distance between the insular and the Temporal Horn. Only the second incision was measured intra operatively using a cannula and this was after the completion of the incision. From the evidence it is apparent that this operation is undertaken with surgeons relying on anatomical landmarks and head position to perform the procedure safely. The inquest did hear from an expert neurosurgical witness whose practice it was to measure the length of his incisions intra-operatively at appropriate times. This practice resulted in him having aborted an operation after failing to find the Temporal Horn within expected limits. Post-operatively he discovered that the patient’s head had moved from the correct position.
I am concerned that it remains the position that it is not current and expected practice to measure the incision from the insular to the Temporal Horn at appropriate times during the operation.
” Source location Tracy Gambrill · Prevention of Future Deaths report
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 Disseminate the case précis and surgical safety advice to members performing amygdalohippocampectomy.
Verbatim wording from the response “On considering the coroner’s report, I consider that sharing a précis of the case, as presented to me, is appropriate so that points raised by the coroner can be considered by members performing amygdalohippocampectomy.” Source location Response from Society of British Neurological Surgeons
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 Clinical procedure guidance falls outside the respondent’s role, which provides only high-level professional standards.
Verbatim wording from the response “You raise the concern in your report that it is not current and expected practice for surgeons to measure the incision from the insula to the temporal horn at appropriate times during a transsylvian amygdalohippocampectomy. We do not provide guidance on clinical procedures, and other organisations who hold the expert clinical knowledge will be better placed to address your concern more directly, but I will explain where our standards and guidance will support actions taken to address your concern.” Source location Response from General Medical Council
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 Queries about specific procedure details should be directed to NICE, medical royal colleges, or specialty bodies.
Verbatim wording from the response “As the standards we set for medical education and practice don’t describe the details of specific procedures, we would refer queries on these to the National Institute for Clinical Excellence (NICE), medical royal colleges or specialty bodies. I note that The Society of British Neurological Surgeons (SBNS) has already responded to your concern with immediate action, writing to all SBNS members, asking them to recognise the importance of measuring depth intraoperatively, and empowering them to abort surgery when findings are not consistent with expectations.” Source location Response from General Medical Council
Open published response
18 Sep 2023 Amarjit SINGH · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5
Careless completion of cell sharing risk assessments View source Lack of seizure-response training for prison staff View source Unavailability of guidance for prisoners responding to a cellmate’s fit View source
Lack of ongoing first aid training for prison officers View source Low first aid understanding among prison officers View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Amarjit SINGH · 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
Amarjit Singh, aged 41, was found dead in his cell at HMP Pentonville on the morning of 21 November 2021 after his cellmate reported that he had suffered a fit, but medical attention was not sought and the cell door remained locked. The inquest jury determined that he died from natural causes, contributed to by neglect. Outstanding concerns included a careless cell-sharing risk assessment and gaps in prison staff and prisoner guidance and first-aid understanding, including failures to recognise the need for CPR or distinguish unconsciousness from death.
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 Careless completion of cell sharing risk assessments
Wider context from the report “1. The completion of the cell sharing risk assessment was described by the extremely experienced nurse who completed it, as careless.
” Source location Amarjit SINGH · 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 seizure-response training for prison staff
Wider context from the report “2. Though I was told that training for prison staff in how to deal with fits is to be given at HMP Pentonville in October 2023 , I heard that there is only a hope that prisoners will also receive some guidance in what to do if their cellmate suffers a fit. Apparently, this has already been implemented in HMP Brixton.
” Source location Amarjit SINGH · 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 Unavailability of guidance for prisoners responding to a cellmate’s fit
Wider context from the report “2. Though I was told that training for prison staff in how to deal with fits is to be given at HMP Pentonville in October 2023, I heard that there is only a hope that prisoners will also receive some guidance in what to do if their cellmate suffers a fit . Apparently, this has already been implemented in HMP Brixton.
” Source location Amarjit SINGH · 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 ongoing first aid training for prison officers
Wider context from the report “3. Whilst the fact that not all prison officers receive ongoing first aid training is a national resourcing issue, the level of first aid understanding of some prison officers at HMP Pentonville seemed surprisingly low.
One officer told me that it did not cross his mind to start CPR in the three minutes it took nurses to arrive after Mr Singh was found not breathing. (Mr Singh had been assessed by a custodial manager as having died, but the other officer did not know this at the time.)
A different officer told me he did not know that there is a difference between a person who is unconscious and a person who is dead.
” Source location Amarjit SINGH · 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 Low first aid understanding among prison officers
Wider context from the report “3. Whilst the fact that not all prison officers receive ongoing first aid training is a national resourcing issue, the level of first aid understanding of some prison officers at HMP Pentonville seemed surprisingly low .
One officer told me that it did not cross his mind to start CPR in the three minutes it took nurses to arrive after Mr Singh was found not breathing. (Mr Singh had been assessed by a custodial manager as having died, but the other officer did not know this at the time.)
A different officer told me he did not know that there is a difference between a person who is unconscious and a person who is dead .
” Source location Amarjit SINGH · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Early Days quality-assurance process, including passport checks, multidisciplinary review, task tracking and completion sign-off before patients leave the system.
Verbatim wording from the response “Q: What strikes me is if that happened on that day, what is happening with all the other prisoners?
A: Since then [AS’s death] changes have been made to the reception process, on each side. There has been a big focus on early days in custody, recognising that the first 14 days and particularly the first couple of days are the most important period in someone’s stay in prison. One of things that would identify poor completion of cell sharing risk assessment is early day passport. This is overseen by custodial managers and nursing staff. There is a checklist to ensure that everything mandatory within the process has been completed and completed to a good standard. Definitely if not completed to good standard would expect that to be flagged to me.
Q: Who is doing this?
A: Custodial managers.” Source location Response from Practice Plus Group
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 Provide specialised reception-process training, induction explanation, shadowing and periodic refresher training for nurses completing cell-sharing risk assessments.
Verbatim wording from the response “designed training specifically just for the reception process, which is a two day training. Which Antonio has been on recently.” Source location Response from Practice Plus Group
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 Schedule training for prison staff at HMP Pentonville on responding to fits.
Verbatim wording from the response “Training for prison staff in how to deal with fits is scheduled to be given at HMP Pentonville in October, and prisoners are given instructions at their induction on how to report concerns regarding a cellmate and the need to ring the emergency cell bell in circumstances where their cellmate is unwell so that staff can ensure healthcare attend.” Source location Response from HM Prison and Probation Service
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, introduce and circulate the national First Aid and Emergency Aid Manual to prison staff at HMP Pentonville.
Verbatim wording from the response “The HMPPS National Health and Safety Arrangements for First Aid and Emergency Aid Manual was published and introduced in August 2023 and this was circulated to all prison staff at HMP Pentonville.” Source location Response from HM Prison and Probation Service
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 Distribute emergency response pocket cards to prisons and staff as reminders of how to respond to medical emergencies.
Verbatim wording from the response “should be called. In 2021, all Prisons were also issued with a supply of emergency response pocket cards which were shared with staff. The cards provided an instant reminder of how to respond to a medical emergency. In March 2022, a further supply of the emergency response pocket cards were issued to Regional Group Safety Leads for them to share with their prisons.” Source location Response from HM Prison and Probation Service
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 Issue emergency response guides to all prisons, covering required actions and circumstances for calling a medical emergency response code.
Verbatim wording from the response “At a national level, new emergency response guides were issued to all prisons which set out the actions required of staff in a medical emergency, including all the circumstances listed in the PSI 03/2013 Medical Emergency Response Codes under which a medical emergency response code” Source location Response from HM Prison and Probation Service
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 reception training, Early Days checks, clinical reviews and monitoring are considered sufficient to prevent inaccurate cell-sharing risk assessments.
Verbatim wording from the response “• Every patient has an Early Days passport as part of the Early Days process, which requires custodial managers and nurses to check off that items like the risk assessment form had been completed and completed to a sufficient standard. This requires a nurse to ensure that the risk assessment has been correctly completed, and sign off the passport.” Source location Response from Practice Plus Group
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 Prison authorities, rather than healthcare, are responsible for addressing staff training and prisoner guidance on managing seizures and first aid.
Verbatim wording from the response “Only number 1 above relates to healthcare, and therefore PPG, so we do not propose to respond to points 2 and 3, which no doubt will be addressed by the Prison.” Source location Response from Practice Plus Group
Open published response
