Recurring concern

Failure to escalate significant clinical concerns to appropriately senior clinicians

First to latest report 23 Aug 2013 — 27 May 2026

Reports that mention this concern
72
Times this concern has been raised
81
Stated actions linked to this concern
103

What this concern includes

Includes failures of clinical escalation for significant patient concerns, abnormal findings, changing clinical conditions or treatment problems where escalation to an appropriately senior clinician is required, including obstetric escalation and escalation by junior staff during busy shifts.

What is not included
  • Excludes generic organisational governance failures where no clinical concern requiring senior clinical review is identified.
  • Excludes failures of escalation in non-clinical operational, safeguarding, complaints or emergency-control-room processes.
  • Excludes delays in senior review where the failure is solely lack of consultant availability and no escalation deficiency is identified.
  • Excludes failures limited to documentation, communication or training unless they directly constitute or undermine escalation of a significant clinical concern.

Reports and published responses 72 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Essex

    AI-generated summary

    Abbigail Louise SMITH · 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

    Abbigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 and was pronounced deceased shortly after midnight on 16 February 2022 from compression of the neck by ligature. The report describes concerns about failures in mental-health care, communication, staff training, risk assessment and discharge planning, including her discharge to supported living without an adequate plan to mitigate a known risk of self-harm.

    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 maintain significant clinical information and escalate deterioration to the Consultant Psychiatrist

    Wider context from the report

    “3. In October 2021 Abbi suffered a deterioration in her mental health with reported non-compliance of Clozapine medication. The Consultant Psychiatrist emergency plan was not followed: a. Short-term prescription of Diazepam to assist with an exacerbation of distressing symptoms to permit Abbi’s Clozapine to be re-titrated was incorrectly continued as a permanent prescription in the absence of a medical review and this was not compliant with the NICE Guidelines. b. urgent follow-up required for a predicted and inevitable deterioration in the event of continued non-compliance did not take place. c. Abbi’s medical records were not updated as required; there were omissions in the significant information about Abbi’s clinical condition and Abbi was not escalated back to the Consultant Psychiatrist. These matters were then not understood by the mental health professionals as Abbi continued to deteriorate and increase in Abbi Diazepam was prescribed. ”

    Source location

    Abbigail Louise SMITH · Prevention of Future Deaths report
    Page 3 · concerns

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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

    Save care-related emails to patient records and deliver Trust-wide training on timely records storage.

    Verbatim wording from the response

    “• The Care Coordinator who was involved in Abbi’s care now ensures that all email documentation is saved on the patient’s records. In addition, Trust wide training has been delivered on the importance of ensuring full records are stored / saved in a timely manner into patient records.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 3 · response
    Published 13 August 2026

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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

    Escalate medication non-adherence to the responsible Consultant Psychiatrist, discuss it in MDT and zoning meetings, assess risk, and document an agreed action plan.

    Verbatim wording from the response

    “• Upon staff becoming aware that a patient is not taking their medication as prescribed, immediate escalation is made to the responsible Consultant Psychiatrist, the case is discussed at the multidisciplinary team (MDT) meeting, risk is formally assessed and RAG-rated within the zoning meeting, and an agreed action plan is documented; a copy of the MDT minutes is uploaded to the patient’s electronic record (PARIS) and circulated to all relevant professionals.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 4 · response
    Published 13 August 2026

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct every-shift record-keeping audits at the Linden Centre and cascade identified corrective actions.

    Verbatim wording from the response

    “To ensure that risk assessments are up to standard, a record keeping audit is undertaken at every shift at the Linden Centre to monitor details, accuracy and that information is up to date particularly with recent incidents. This is undertaken by the allocated qualified staff member and any identified actions are cascaded at the end of every shift. Should any staff have an identified training need this will be addressed in supervision to ensure performance management.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 9 · response
    Published 13 August 2026

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Use ward-specific electronic dashboards and daily printed information to identify and address gaps in records, risk assessments, and care plans.

    Verbatim wording from the response

    “Management Teams and staff also have access to an electronic Trust dashboard which is specific to each ward and provides a full oversight of relevant ward information about their current patients (including records, risk assessments and care plans), this supported the identification of any record gaps that can then be promptly addressed. These are printed on a daily basis for staff.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 9 · response
    Published 13 August 2026

    Open published response

  2. Blackpool and the Fylde

    AI-generated summary

    Mark Simpson · 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

    Mark Simpson died on 22 October 2025 after being found unresponsive and not breathing at home; the medical cause of death was acute heart failure due to ischaemic heart disease and coronary artery atheroma, with renal cell carcinoma also recorded. The report raises concerns that information about his NHS 111 consultation for prolonged chest pain was assessed by non-medically qualified staff, was not relayed to a clinician, and was not added to his medical record.

    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 ensure medically informed review and escalation of potentially significant NHS 111 information

    Wider context from the report

    “If a patient contacts the NHS 11 service it is necessary and appropriate for that patient’s GP Practice to be informed. Mark Simpson contacted the NHS 111 service reporting chest pain for approximately seven hours before being advised to call 999 should the pain become dramatically worse or he feel breathless. His GP Practice was provided with a record of that consultation, but this information was not relayed to a clinician nor was it added to Mark's medical record at the surgery. Concern 1 The information forwarded to the GP Practice was considered by a member of staff who was not medically qualified, and yet in deciding the consultation did not need to be brought to the attention of a medical professional was making an important decision with potentially significant ramifications for that patient. Notwithstanding that a GP Practice may receive numerous reports about patients of this type, if such potentially significant information is not considered by a member of staff with medical knowledge, important information may be missed and to the later detriment of the patient. ”

    Source location

    Mark Simpson · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Worcestershire

    AI-generated summary

    Surendrakumar Patel · 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

    Surendrakumar Patel died at Alexandra Hospital, Redditch, on 31 October 2024 after collapsing with a lower respiratory tract infection, with self-neglect through malnutrition contributing to his death. While on remand at HMP Hewell, he stopped eating, expressed that he no longer wished to live, lost weight, and developed acute kidney injury. The report identified concerns about healthcare staff’s failure to recognise the need for a timely mental capacity assessment, consider hospital transfer and expedited senior medical and psychiatric assessment, and consider family contact; prison staff also lacked awareness of procedures for informing or consulting next of kin about food refusal.

    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

    Delays in full medical assessment by a senior healthcare professional

    Wider context from the report

    “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy: a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began b. Failure to consider hospital transfer for prisoners severely weakened by weight loss c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival d. Failure to consider and advocate for family contact 2. Prison staff lacked awareness of HMP Hewell food refusal policy, including: • Not informing Next of Kin of the prisoner’s decision to refuse food/fluids • Not asking the prisoner whether such information should be shared ”

    Source location

    Surendrakumar Patel · Prevention of Future Deaths report
    Page 2 · concerns

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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 is responsible for responding to concerns about healthcare delivery at HMP Hewell.

    Verbatim wording from the response

    “Following evidence heard at the inquest you raised concerns directed to both HMPPS and Practice Plus Group (PPG). I understand PPG will respond to those issues relating to the delivery of healthcare at HMP Hewell, for which they are responsible. I am therefore responding to the issue relating to HMPPS.”

    Source location

    Response from HM Prison & Probation Service
    Page 1 · response
    Published 12 March 2026

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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 clinical presentation did not indicate a need for more urgent psychiatric assessment.

    Verbatim wording from the response

    “At the time of assessment, his presentation was not indicative of a clear acute mental illness requiring urgent psychiatric intervention. In addition, records indicate that from 24 October onwards he was taking fluids and intermittently consuming food.”

    Source location

    Response from Midlands Partnership NHS Foundation Trust
    Page 2 · response
    Published 12 March 2026

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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

    Active clinical observation through ACCT and food refusal processes was sufficient before psychiatric assessment.

    Verbatim wording from the response

    “It is also relevant that the period between the reported onset of food refusal (21 October 2024) and multidisciplinary review (24 October 2024) was brief, and during this time Mr Patel remained under active clinical observation, including management through ACCT and food refusal processes.”

    Source location

    Response from Midlands Partnership NHS Foundation Trust
    Page 2 · response
    Published 12 March 2026

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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 food and fluid refusal pathway is considered robust and fit for purpose regardless of the reason for refusal.

    Verbatim wording from the response

    “This does not mean that Practice Plus Group has not reflected on this case. The outcome of the Inquest follows a period whereupon the food and fluid refusal pathway has robustly been tested and, as a result, Practice Plus Group considers it to be robust and fit for purpose regardless of the”

    Source location

    Response from Practice Plus Group
    Page 3 · response
    Published 12 March 2026

    Open published response

  4. Essex

    AI-generated summary

    Paolino AMICO · 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

    Paolino Amico, who had metastatic bladder cancer and advanced clinical frailty, was admitted with severe bilateral pneumonia and died in hospital on 12 June 2024. He received multiple overdoses of slow-release morphine following a prescription error, with concerns also raised about medication administration, delayed emergency escalation, oxygen provision after discharge, and the management of morphine reversal and pain relief.

    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 escalate medication concerns to appropriately senior clinicians

    Wider context from the report

    “(2) Mr Amico did not receive his prescribed medications during his second admissions when he was readmitted to hospital on 9 June. a. On 9 June a doctor in Accident & Emergency had reviewed Mr Amico’s prescribed medications and increased liquid oral morphine sulphate 10 mg in 5mL Solution 4 hourly as required with 2.5 -5 mg max 6 doses at 22:57 hours with slow released morphine sulphate (MST) continued 2 times daily. Trust staff did not administer any morphine to Mr Amico although he and his family were raising concerns about his high level of pain. b. The family was informed incorrectly that medications had not been prescribed. On the morning of 10 June, the family were given permission by a nurse to dispense from Mr Amico’s own supply of medications that he had brought to the hospital due to his level of pain. This was not accurately recorded in Mr Amico’s record. Mr Amico took his prescribed morning dose of MST. c. On 10 June the nurse in Accident & Emergency did not escalate to the nurse in charge or a senior doctor that she could not locate the doctor allocated to Mr Amico and instead approached a foundation year 1 doctor to prescribe pain relief for Mr Amico. The nurse informed the doctor who was junior and very busy that the frequency of the morphine needed to be increased for Mr Amico. The doctor did not escalate the matter and did not review Mr Amico before prescribing a controlled drug. d. Neither the nurse nor the doctor sufficiently scrutinised the medication prescribed on 9 June or on the Trust system that would have shown the correct medications. This led to a prescription error being made with MST being increased from 2 times daily to 4 times daily. Mr Amico was not referred for pain management. e. Mr Amico then moved to a ward. Multiple nurses were involved in checking and administering a controlled drug morphine sulphate slow release (MST) on 5 separate occasions between 10 and 11 June 2024 and did not raise concerns about the potential for a prescription error or note that Mr Amico had already received 1 dose of MST that morning. ”

    Source location

    Paolino AMICO · Prevention of Future Deaths report
    Page 3 · concerns

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    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delay and inappropriate escalation of a high NEWS score

    Wider context from the report

    “(4) The on-call doctor was called approximately one hour after Mr Amico’s NEWS score was found to be 10 and arrived at 07:50, this was not an emergency call. The on-call doctor had not been informed of: a. the deterioration in Mr Amico’s presentation during the night b. that the family had informed nursing staff of their concerns Mr Amico had been given the wrong medication when he was noted to be unresponsive at approximately 03:00 hours, that should have immediately raised concerns about an overdose of MST. ”

    Source location

    Paolino AMICO · Prevention of Future Deaths report
    Page 3 · concerns

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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 restorative clinical supervision and professional nurse advocate learning on controlled drugs, communication, challenge and escalation.

    Verbatim wording from the response

    “Restorative clinical supervision took place in June 2024, which was a reflective discussion with special emphasis on how to manage challenging prescribers and how to have an effective professional discussion when in doubt of management plan, and how to escalate higher if still in doubt.”

    Source location

    Response from Princess Alexandra Hospital
    Page 5 · response
    Published 19 November 2025

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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

    Include the emergency department escalation process in area-specific orientation for nurses redeployed from their base wards.

    Verbatim wording from the response

    “A Multi-Disciplinary After-Action Review meeting was held, including staff involved in the incident. This identified learnings and actions to be taken. It established that the ED nurses looking after Mr Amico had been redeployed from another ward so were not fully aware of the ED escalation process that occurs in the emergency department.”

    Source location

    Response from Princess Alexandra Hospital
    Page 4 · response
    Published 19 November 2025

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    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.

    Verbatim wording from the response

    “The Princess Alexandra Hospital NHS Trust will be providing their own response to this Report, however, the Hertfordshire & West Essex ICB have advised NHS England of the Trust’s governance arrangements and actions being taken to address the concerns raised. It is understood that the Trust’s Patient Safety Group (PSG) has active oversight of several of the areas highlighted in the Report, particularly medicines safety, recognition of deterioration, and incident learning.”

    Source location

    Response from NHS England
    Page 4 · response
    Published 19 November 2025

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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

    An emergency call was not required because appropriate care was initiated promptly after the raised NEWS score.

    Verbatim wording from the response

    “5. The on-call doctor escalated concerns immediately but no emergency call was put out.”

    Source location

    Response from Princess Alexandra Hospital
    Page 7 · response
    Published 19 November 2025

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  5. City of London

    AI-generated summary

    Tony Montana Duncan · 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

    Tony Montana Duncan had a long-term mental health condition and, during an acute deterioration, told healthcare services that he had suicidal thoughts and planned to jump from a bridge. He was assessed by a psychiatric liaison team and discharged without medication review, admission, documented risk assessment, or follow-up safeguarding, despite information about his suicide plan. On 4 July 2024, he jumped into the River Thames and likely died shortly afterwards; the report identified concerns about the response of mental health services to the risks he presented.

    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 review medication, consider admission, or escalate care for an acutely deteriorating patient

    Wider context from the report

    “2. When the Deceased attended the hospital, the Accident and Emergency team’s triage notes included express reference to his specific suicide plan and attached the GP’s letter of referral. The Deceased was then assessed by a psychiatric liaison nurse who concluded that his presentation was as a result of psycho-social stressors rather than mental illness; she was not concerned about the risk of suicide because he had no plan or intent; and she referred the Deceased to the homelessness team and discharged him back to the care of his GP. The nurse did not take any steps to review the Deceased’s medication or consider admission, or escalate these matters to a doctor, nor did she involve the Crisis or Home Treatment teams for follow up / immediate safeguarding. Despite there being a recognised risk to self and to others, both of which the Deceased himself said he could not control, there is no evidence of any risk assessment documentation being completed. ”

    Source location

    Tony Montana Duncan · Prevention of Future Deaths report
    Page 4 · concerns

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct multiple daily multidisciplinary clinical safety huddles in the emergency department to review risks and coordinate care.

    Verbatim wording from the response

    “Since Mr Duncan’s death the Trust has introduced several new systems to address the challenges raised by patients presenting to ED. The Liaison Psychiatry team carries out multiple clinical safety huddles in ED each day. These are brief, daily, multi-disciplinary team meetings to quickly review patient safety, share urgent information, identify risks (like high-risk behaviour or medication issues), plan care, improve teamwork, and resolve problems. This follows the team handover which facilitates rapid risk review and shared decision making between ED and Liaison Psychiatry teams.”

    Source location

    Response from South London and Maudsley NHS Foundation Trust
    Page 7 · response
    Published 20 October 2025

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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

    Operate a 24/7 Emergency Department Low Intensity Area at King’s College Hospital with capacity for six patients.

    Verbatim wording from the response

    “KCH has also launched a new ED Low Intensity Area (LIA) in partnership with SLAM. The LIA space offers a calm and supportive environment for suitable patients who would otherwise wait in the busy environment of the main ED. Operating 24/7, it currently has capacity for six patients. The LIA is a continuum of the ED, but patients are kept in a less stimulating environment. Patients who are moved into LIA have already been assessed and have a plan in place, but they need to wait to have it enacted. These plans may include referral for a psychiatric admission, referral to an associated team such as the homeless team or addictions care team, with ongoing care planning following the assessment, or referral to Recovery House in Lewisham, where they can be offered a maximum of 7 nights stay, as an alternative to admission for people who feel unable to return home.”

    Source location

    Response from South London and Maudsley NHS Foundation Trust
    Page 7 · response
    Published 20 October 2025

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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

    Medication discontinuation was not clearly the main cause of relapse, and the presentation did not indicate medication review by liaison psychiatry.

    Verbatim wording from the response

    “It is not clear discontinuation of medication was the main causative factor in Mr Duncan’s relapse as one might suspect in a psychotic illness. During the Psychiatric Liaison Nurse’s (PLN) assessment in KCH Emergency Department (ED), Mr Duncan did not present with signs or symptoms of psychotic or mood disorder, or with agitation or sleep disturbance which might indicate the need for medication. We acknowledge the GP requested a medication review in the referral letter and that the PLN did not address this. Medication review is often more usefully carried out with a full treatment history, and this is more suitable for the Community Mental”

    Source location

    Response from South London and Maudsley NHS Foundation Trust
    Page 3 · response
    Published 20 October 2025

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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

    Admission was not clearly beneficial for this condition, so community treatment was considered an appropriate alternative when the patient initially engaged.

    Verbatim wording from the response

    “Mr Duncan had last been admitted to hospital in 2016; this was initially a voluntary admission, subsequently an emergency Section 5(2) was used to detain him until a full Mental Health Act assessment could be organised. He was found not to be detainable and self-discharged against medical advice. Shortly after this he requested to be readmitted and when this could not be accommodated, he caused damage to Trust property by smashing the windows of the ward. When in the community, he was less agitated than on the ward and was subsequently managed by a CMHT and then primary care without further intervention from acute services. It is therefore not clear admission had been helpful, and this is not uncommon in patients with personality disorder and one of the reasons why the benefits of admission should be weighed against potential harms of admission to hospital.”

    Source location

    Response from South London and Maudsley NHS Foundation Trust
    Page 4 · response
    Published 20 October 2025

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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

    Doctor referral was not initially indicated because the established pathway covered admission, medication changes and other clinical complexities, with senior psychiatric doctors available continuously.

    Verbatim wording from the response

    “Referral by the PLN to a doctor was not clearly indicated, as this pathway is for those who may require admission under the Mental Health Act, or changes to their medication, or for other complexities as deemed by the assessing clinician. The AAR explored onward referral to doctors by PLNs and this was thought to be working well, with senior psychiatric doctors available 24 hours a day. Mr Duncan initially presented as calm and without signs or symptoms of affective disorder or psychosis. Later, when Mr Duncan became agitated, referral to a doctor to consider next steps (including potential referral to a crisis team) may have been indicated, and his self-discharge without further review or discussion was a lost opportunity to review the assessment and offer further support.”

    Source location

    Response from South London and Maudsley NHS Foundation Trust
    Page 5 · response
    Published 20 October 2025

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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

    Recovery House was unsuitable for homeless patients and therefore unavailable as an alternative to admission in this case.

    Verbatim wording from the response

    “KCH has also launched a new ED Low Intensity Area (LIA) in partnership with SLAM. The LIA space offers a calm and supportive environment for suitable patients who would otherwise wait in the busy environment of the main ED. Operating 24/7, it currently has capacity for six patients. The LIA is a continuum of the ED, but patients are kept in a less stimulating environment. Patients who are moved into LIA have already been assessed and have a plan in place, but they need to wait to have it enacted. These plans may include referral for a psychiatric admission, referral to an associated team such as the homeless team or addictions care team, with ongoing care planning following the assessment, or referral to Recovery House in Lewisham, where they can be offered a maximum of 7 nights stay, as an alternative to admission for people who feel unable to return home.”

    Source location

    Response from South London and Maudsley NHS Foundation Trust
    Page 7 · response
    Published 20 October 2025

    Open published response

  6. Nottinghamshire

    AI-generated summary

    David Charles Noel Jones · Prevention of Future Deaths report

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

    Report summary

    David Charles Noel Jones attended hospital after dizziness and was found to have low blood pressure and a low pulse rate. After developing chest pain and sweatiness while mobilising, he was discharged the following day and died later that day from the effects of an aortic dissection. Concerns included the failure to escalate his changing clinical condition to a senior doctor and possible gaps in learning, training and review processes relating to atypical aortic dissections.

    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 escalate significant clinical changes for review by appropriately senior clinicians

    Wider context from the report

    “2. Despite Mr Jones’ clinical picture changing whilst in the emergency department, the middle grade doctor reviewing Mr Jones did not alert a senior doctor of the change. I am concerned that training in relation to atypical aortic dissections brought to my attention in evidence at this and a previous inquest, and to my coroner colleague’s attention in inquests they conducted, may not have been ineffective. I am concerned about recurrence for other patients who present atypically, and that the patients who experience similar significant developments whilst in hospital may remain unreviewed by those with the appropriate skill and seniority, and a risk of death from undiagnosed aortic dissections may follow. ”

    Source location

    David Charles Noel Jones · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Essex

    AI-generated summary

    Resmije Ahmetaj · 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

    Resmije Ahmetaj, also known as Merita Brahimi, died on 30 June 2024 from a traumatic head injury after falling from a height at a multi-storey car park while suffering an exacerbation of psychosis. The report identifies concerns about subtherapeutic antipsychotic medication levels not being acted on, communication and escalation within the mental health team, incomplete record-keeping, medication prescribing confusion, and safety mitigation on the car park’s penultimate floor.

    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 escalate and act on markedly subtherapeutic clozapine levels

    Wider context from the report

    “(3) There were issues around communication and escalation within the Trust mental health team. A routine 6-month blood anti-psychotic to check clozapine levels assay was taken on 3 June and the results reported on 7 June were sent to the psychiatrist and showed markedly subtherapeutic blood levels of antipsychotic medication. This subtherapeutic level was not acted upon and was contrary to: a. Ms Ahmetaj insisting she was compliant with her medication b. Ms Ahmetaj did not have any noted risks that would cause interference with her medication. c. Ms Ahmetaj informed EPUT clinicians that: i. On 24 June she thought her medication Clozapine was not working ii. On 27 June she no longer wished to take her prescribed antipsychotic medication , and iii. Did not agree she had Schizophrenia, and iv. wanted to revert to a previous medication Quetiapine. These matters were not escalated to the psychiatrist and Ms Ahmetaj was informed to continue her clozapine and wait for her appointment on 1 July and there was no consideration of the risk of relapse of psychosis. ”

    Source location

    Resmije Ahmetaj · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Take forward MDT learning on documenting and escalating inconsistencies between clozapine assays, adherence reports and clinical stability.

    Verbatim wording from the response

    “On reflection, while the management of this case was consistent with current guidance, there are learning points regarding communication and escalation. Specifically, inconsistencies between assay findings, patient-reported adherence, and clinical stability should have been explicitly documented and escalated to the consultant psychiatrist at an earlier stage. Doing so would have provided additional assurance around risk management and strengthened the therapeutic dialogue with the patient. This learning is being taken forward by the MDT.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 4 · response
    Published 14 August 2025

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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 clozapine assay showed low plasma levels, not sub-therapeutic prescribing, because the prescribed dose remained unchanged.

    Verbatim wording from the response

    “The plasma Clozapine assay undertaken on 3rd June 2024 and reported on 7th June demonstrated a markedly low levels of clozapine in the plasma. The result was reviewed by the clinical team. It is important to emphasise that this did not reflect sub-therapeutic prescribing, as the patient’s Clozapine dose had remained unchanged since discharge. A previous Clozapine assay undertaken in 2023, at the same dosage, confirmed a therapeutic plasma level of 0.53.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 3 · response
    Published 14 August 2025

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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 assessment and the already scheduled psychiatric review were considered sufficient; no earlier appointment was indicated without evidence of deterioration.

    Verbatim wording from the response

    “National and local guidelines emphasise that Clozapine plasma levels are an adjunct to clinical decision-making and should not be used in isolation to guide practice. Clinical assessment of the patient remains the primary determinant of treatment intervention.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 3 · response
    Published 14 August 2025

    Open published response

  8. Milton Keynes

    AI-generated summary

    Jordan Michael BABB · 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

    Jordan Michael BABB had chest pain and attended an urgent care centre on 13 September 2024, where he was assessed and discharged without investigation for a possible pulmonary embolism. He collapsed on 16 September 2024 and died of a pulmonary embolism. Concerns included failure to escalate abnormal observations, lack of a structured pulmonary embolism risk assessment, unclear use of clinical decision tools, and a risk of similar failings recurring.

    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 formal thresholds or protocols for urgent escalation of abnormal observations

    Wider context from the report

    “1. Failure to Escalate Abnormal Observations Despite the patient presenting with a significantly elevated heart rate, high respiratory rate, and reduced oxygen saturations — all indicative of physiological instability — there was no escalation to secondary care or referral to the emergency department. There appears to have been no formal threshold or protocol in place to ensure that abnormal observations of this nature trigger an urgent clinical response. ”

    Source location

    Jordan Michael BABB · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Operate standardised NEWS2 and POPS assessment within 15 minutes, with senior triage review and immediate escalation to the Emergency Department when indicated.

    Verbatim wording from the response

    “Robust systems currently in operation. All patients presenting at MKUTC undergo a standardised early warning assessment within 15 minutes of arrival:”

    Source location

    Milton Keynes Urgent Care Services
    Page 2 · response
    Published 28 July 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Standardised NEWS2/POPS assessment, senior triage review and established escalation pathways are considered sufficient to address abnormal observations.

    Verbatim wording from the response

    “1. Failure to Escalate Abnormal Observations”

    Source location

    Milton Keynes Urgent Care Services
    Page 2 · response
    Published 28 July 2025

    Open published response

  9. Essex

    AI-generated summary

    DAVID WAYNE BENNETT · Prevention of Future Deaths report

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

    Report summary

    David Wayne Bennett died by hanging on 13 June 2023 after being found suspended by a ligature, with cocaine and alcohol ingestion. He had a history of drug-induced psychosis and had sought help for deteriorating mental health, psychosis and lack of sleep before his death. Concerns included inadequate sharing and recording of mental-health and primary-care information, unclear urgent-care pathways, failures to escalate requests for urgent medication review, and insufficient mental-health assessment and liaison at hospital.

    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 escalate urgent medication review requests to an appropriate clinician

    Wider context from the report

    “(4) Mr Bennett requested a GP appointment; a telephone appointment was made with the primary care mental health nurse. The primary care mental health nurse on 1ˢᵗ June did not escalate Mr Bennett to the GP or Community Psychiatrist when Mr Bennett was adamant he wanted to see a doctor and required an urgent medication review for his deteriorating mental health. ”

    Source location

    DAVID WAYNE BENNETT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Onward appointment processes are at each GP surgery’s discretion, rather than being determined by the Trust.

    Verbatim wording from the response

    “Response: The pathway is that the patient calls the GP, the GP care navigator makes the decision whether to book the appointment with a GP or directly books the patient in to see the Mental Health Practitioner (MHP) for a telephone consultation. If the MHP assesses there to be a need for psychiatric review they will take this to the First Response Team Multi-Disciplinary Team (MDT) and request their input (for example, if the Nurse Prescriber considers the patient’s medication need is out of his/her prescribing remit). If the need is physical the MHP will advise the patient to make an appointment with the GP. In this case the patient had wanted to see the GP and was duly advised to go back to the GP.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 2 · response
    Published 18 February 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Line Manager would not have prescribed medication because prescribing for this case was outside the manager’s remit.

    Verbatim wording from the response

    “As set out in evidence, the MHP ought to have discussed this case with a Nurse Prescriber or the Line Manager, the request for medication could have been looked into further. Whilst this would provide insight into medication history, the Line Manager has confirmed that he would not have prescribed any medication for Mr Bennett in light of the fact this is out of his remit. Mr Bennett’s case would have been presented at the First Response Team’s (FRT)”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 2 · response
    Published 18 February 2025

    Open published response

  10. Essex

    AI-generated summary

    Mr Warren James Green · Prevention of Future Deaths report

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

    Report summary

    Mr Warren James Green, who was receiving care in an acute hospital following a serious attempt on his life, died on 20 August 2024 after jumping through a gap in a four-storey stairwell and sustaining a skull fracture and traumatic subdural haemorrhage. The concerns identified included delays in securing a psychiatric bed, inadequate supervision and safeguarding for a patient at high risk of self-harm, patients being able to leave the acute ward without appropriate assessment or staff awareness, and unclear escalation to consultant psychiatric oversight.

    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 clear mechanisms and criteria for escalation to a Consultant Psychiatrist

    Wider context from the report

    “(1) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without appropriate risk assessment (2) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without the knowledge of the hospital staff The above shows a lacuna in terms of patients’ safety and safeguarding. (3) The evidence showed that the Mental Health Liaison Service relies on nurses to conduct initial assessments and follow up reviews of patients suffering with mental health issues and the mechanism by which escalation to a Consultants Psychiatric is decided and the factors to be taken into account for escalation are not at all clear. This leads to lack of Consultants oversight for these vulnerable patients. ”

    Source location

    Mr Warren James Green · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the Liaison Service Standard Operating Procedure to incorporate the described consultant-oversight provisions, completing the review by May 2026.

    Verbatim wording from the response

    “The Trust is currently reviewing its Standard Operating Procedure (SOP) in order to cover the above provisions. This will be completed by May 2026 we would be happy to share a copy of the same with the Court if required.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 4 · response
    Published 20 January 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing Core 24, multidisciplinary review, referral, escalation and on-call arrangements provide sufficient Consultant oversight for liaison patients.

    Verbatim wording from the response

    “Response: In line with the assurance evidence presented to Court, we confirm that the ‘Core 24’ model is a nationally endorsed NHS best-practice standard for 24/7 liaison mental health services in acute hospitals. This model was applied in respect of the care afforded to Mr Green.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 20 January 2026

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026