18 Mar 2026 Julie Anne Pytches · Prevention of Future Deaths report Essex
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Concerns raised 1
Insufficient staff understanding of emergency protocols View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Nuffield Health
Maintain recurring major-haemorrhage and emergency scenario training, including escalation, blood-supply, role-clarity, documentation and transfer exercises.
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Nuffield Health
Further develop the major-haemorrhage training module to clarify end-to-end processes and differences from NHS pathways.
View source
Nuffield Health
Roll out mandatory emergency-protocol induction for site leaders, night coordinators and senior nursing staff, including role responsibilities.
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Nuffield Health
Monitor emergency training compliance, emergency-document availability, MyStaff policy access and scenario outcomes through audit and governance processes.
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Julie Anne Pytches · 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
Julie Anne Pytches died on 14 October 2023 during elective spinal surgery after suffering a covert probable arterial bleed, major haemorrhage and cardiac arrest while prone in the operating theatre. The report identifies concerns about emergency protocols, staff understanding and training, communication of clinicians’ practice limitations, and uncertainty about ambulance attendance and possible transfer to a tertiary centre.
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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 staff understanding of emergency protocols
Wider context from the report “(3) The site manager was new and although there had been some training for her role, there was a lack of understanding of the emergency protocols and this was also the case with nurses at the hospital for this event. A very senior member of the ambulance crew was attempting to assist the site co-ordinator as to locate the most relevant documents. Training needs to be embedded and protocols readily available.
” Source location Julie Anne Pytches · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain recurring major-haemorrhage and emergency scenario training, including escalation, blood-supply, role-clarity, documentation and transfer exercises.
Verbatim wording from the response “• Emergency reference guides are consistently available across all departments and include guidance for cardiac arrest and major haemorrhage in line with Nuffield Health Policy CL71 Medical Emergencies and Resuscitation Council guidelines. The availability, accessibility and use of these guides are routinely reviewed and reinforced through regular emergency scenario training and simulations to ensure staff familiarity and effective application in practice. Laminated emergency algorithms, including adult major haemorrhage pathways, are located on resuscitation trolleys and in key clinical areas.” Source location Response from Nuffield Health
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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 Further develop the major-haemorrhage training module to clarify end-to-end processes and differences from NHS pathways.
Verbatim wording from the response “Further actions across Nuffield Health:” Source location Response from Nuffield Health
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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 Roll out mandatory emergency-protocol induction for site leaders, night coordinators and senior nursing staff, including role responsibilities.
Verbatim wording from the response “Further actions across Nuffield Health:” Source location Response from Nuffield Health
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 Monitor emergency training compliance, emergency-document availability, MyStaff policy access and scenario outcomes through audit and governance processes.
Verbatim wording from the response “• Ongoing monitoring will be undertaken through existing audit and assurance processes, including Interim Quality Assurance Report requirements, scenario dashboards, and governance reviews.” Source location Response from Nuffield Health
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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 All staff, including the site manager, had received training on the transfusion and major haemorrhage policies in force at the time.
Verbatim wording from the response “• The site manager was new to the role but previously held a Senior clinical role as head of department in the Hospital for 9 years prior.” Source location Response from Nuffield Health
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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 Regulation 28 concerns did not contribute to the patient’s death.
Verbatim wording from the response “HM Coroner specifically noted that the Regulation 28 concerns did not contribute to this patient death.” Source location Response from Nuffield Health
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31 Oct 2025 Gloria SIMON · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 1
Insufficient training of non-clinical staff in responding to urgent health concerns View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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Gloria SIMON · 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
Gloria Simon moved into a care home for respite care and died there from natural causes on 20 September 2025 after her health deteriorated. Concerns included missed opportunities for timely clinical assistance, a GP misunderstanding the care home setting and oxygen saturation reading, and possible insufficient training of non-clinical staff in seeking help and taking and responding to basic observations.
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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 training of non-clinical staff in responding to urgent health concerns
Wider context from the report “2. On 17 September 2025 the staff at the care home were sufficiently concerned about the Gloria Simon’s health that they sought assistance from her registered GP, who declined to visit because she was no longer within their area. Whilst efforts were made to register her with a practice local to the care home, staff did not make any alternative arrangements for obtaining clinical input in the meantime. The court heard that staff should have called 111. Depending upon the seriousness of their concerns, another possibility would have been to call 999. In fact, no further attempt was made to seek help until 14:52 on 19 September 2025.
The court is concerned that the training of non-clinical staff was insufficient to equip them with knowledge about how to manage a situation such as this effectively and would like to know what measures are being taken to address this.
” Source location Gloria SIMON · 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 Supervise senior care assistants on obtaining clinical support, including contacting 111 or 999 when residents are unwell and a GP is unavailable.
Verbatim wording from the response “Supervision of all senior care assistants has been completed by the Registered Manager which includes instruction that when a resident is unwell and a GP cannot be accessed every attempt to obtain clinical support will be made. This would include contacting 111 or in fact 999 following observations.” Source location Response from Riversdale Care Home
Open published response
Concerns raised 1
Lack of training on rapid escalation of emergency events View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Daisy May McCoy · 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
Daisy May McCoy was born by Caesarean section on 9 February 2022 after reduced and unusual foetal movement was reported, and died in a children’s hospice on 22 February 2022 following a brain injury and peri-natal asphyxia. The report identified concerns about recognising foetal compromise, communication and escalation between staff, staffing and consultant attendance, professional challenge, and the adequacy and implementation of relevant policies and training.
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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 training on rapid escalation of emergency events
Wider context from the report “3. A lack of training and policies on rapid escalation of emergency events
” Source location Daisy May McCoy · 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 Embed the Escalating Clinical Concerns Charter through staff engagement, training amendments and bi-monthly safety walkabouts.
Verbatim wording from the response “To support embedding of the charter, a launch month was held where senior staff attended handovers and team meetings to support full understanding and operationalisation of the tools and to share further information, to take real time feedback and develop training and information sharing amendments in response. To monitor the impact and ensure these are embedded, the senior team and board level safety champions conduct bi-monthly safety walkabouts where the impact of the charter is discussed with frontline staff and any escalation of concern can be made.” Source location Response from Somerset NHS Foundation Trust
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9 Apr 2025 Ivy May DIXON · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Lack of healthcare assistant and nursing staff training and clinical skills or knowledge for emergency care View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
Acorn Lodge Care Centre
Continue providing nursing and care staff with up-to-date CPR and emergency-situation training.
View source
Acorn Lodge Care Centre
Purchase Lifevac devices and train relevant staff in their use, alongside providing choking-response sessions.
View source
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AI-generated summary
Ivy May DIXON · 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
Ivy Dixon choked on food while being fed by staff at Acorn Lodge Care Home on 6 October 2024, causing cardiac arrest. Staff did not perform CPR, and concerns were raised about inaccurate communication to paramedics, staff integrity, and possible training or clinical skills gaps in emergency care.
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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 healthcare assistant and nursing staff training and clinical skills or knowledge for emergency care
Wider context from the report “2. While the patient was breathing and conscious at the time of the 999 call, when LAS staff attended six minutes later, the patient was not conscious, not breathing, had no palpable pulse, and was critically unwell in confirmed cardiac arrest. However, despite this, staff from the Care Home were not undertaking CPR. The DNACPR would not have applied in this case, because choking is a potentially reversible cause of cardiac arrest, which the Care Home’s manager confirmed in her evidence.
This raises the concern that staff (healthcare assistants and nursing staff) at the Care Home may have previously unidentified training needs and/or lacked the clinical skills/knowledge to provide emergency care .
” Source location Ivy May DIXON · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue providing nursing and care staff with up-to-date CPR and emergency-situation training.
Verbatim wording from the response “With regards to the training, skills and competence of our staff, our nurses undertake CPR training every 12 months and the staff on duty on that day were up to date with their training. However, given the tight time line of events, there had only been 6 minutes between the 999 call being made and the attendance of the LAS. As previously mentioned, our staff are of the belief that at the time of arrival of LAS, Mrs Dixon was still alive but deteriorating and care was taken over by the LAS at 18.21 hrs, only 6 minutes after the 999 call being made.” Source location Response from Lukka Care Homes Limited
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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 Purchase Lifevac devices and train relevant staff in their use, alongside providing choking-response sessions.
Verbatim wording from the response “improving training with our staff and providing the tools to do so.” Source location Response from Lukka Care Homes Limited
Open published response
7 Jan 2025 Sheila Ann Nicholls · Prevention of Future Deaths report Buckinghamshire
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Concerns raised 2
Failure to provide and embed effective life-support training for emergency response View source Failure to maintain emergency-response training through drills and expiry awareness View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Chiltern Care Services
Deliver emergency-response training through eLearning, recorded face-to-face sessions, expiry reminders, a maintained training matrix and weekly compliance review.
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Chiltern Care Services
Engage four additional trainers to maintain consistency and capacity in face-to-face training.
View source
Chiltern Care Services
Finalise the process document governing emergency CPR drills.
View source
Chiltern Care Services
Assess the competency of staff who will deliver emergency CPR training within one month.
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Chiltern Care Services
Obtain a PractiMan adult/child CPR training manikin for the home.
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Sheila Ann Nicholls · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sheila Ann Nicholls died after choking on food during respite care at Mandeville Grange Nursing Home on 19 November 2023. Her family had warned the nursing home about her swallowing difficulties, but important information was not recorded or shared, and she was given food that was unsuitable or insufficiently prepared. The report raised concerns about policy management, emergency response training, and the investigation and learning from adverse incidents.
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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 provide and embed effective life-support training for emergency response
Wider context from the report “2. At the time of Sheila’s death, of the several staff members that responded to her choking emergency, only one staff member (nurse GC) had currently valid training in life support , but still undertook CPR ineffectively without being corrected by other staff .
Evidence was also given that no simulated emergency drills were ever performed, and some staff were never aware their training had expired.
Whilst nurse GC still works for Grange Mandeville Nursing Home, it is unclear how that nurse will be supported in their ability to provide an adequate emergency response, bearing in mind their existing training appears to have been insufficient.
The deficiency in training and embedding that training, both generally for all staff, and for that specific nurse , creates a risk of death to residents should future emergencies arise.
” Source location Sheila Ann Nicholls · 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 emergency-response training through drills and expiry awareness
Wider context from the report “2. At the time of Sheila’s death, of the several staff members that responded to her choking emergency, only one staff member (nurse GC) had currently valid training in life support, but still undertook CPR ineffectively without being corrected by other staff.
Evidence was also given that no simulated emergency drills were ever performed , and some staff were never aware their training had expired .
Whilst nurse GC still works for Grange Mandeville Nursing Home, it is unclear how that nurse will be supported in their ability to provide an adequate emergency response, bearing in mind their existing training appears to have been insufficient.
The deficiency in training and embedding that training, both generally for all staff, and for that specific nurse, creates a risk of death to residents should future emergencies arise.
” Source location Sheila Ann Nicholls · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver emergency-response training through eLearning, recorded face-to-face sessions, expiry reminders, a maintained training matrix and weekly compliance review.
Verbatim wording from the response “Effective from 14 October 2024, we transitioned the majority of our training to an eLearning format provided by The Access Group (Access Learning for Care). This platform automatically generates a training matrix for Mandeville Grange and also records any face-to-face sessions, ensuring the matrix remains accurate and up to date.” Source location Response from Mandeville Grange Nursing Home
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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 Engage four additional trainers to maintain consistency and capacity in face-to-face training.
Verbatim wording from the response “To maintain consistency in our face-to-face training, we have recently engaged four additional trainers.” Source location Response from Mandeville Grange Nursing Home
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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 Finalise the process document governing emergency CPR drills.
Verbatim wording from the response “We have not carried out any emergency CPR drills to date as we have been trying to work through a process document to ensure that what we put in place is fit for purpose. The document is now finalised however the starting of drills is awaiting assessment of staff competency who will deliver the training. This will happen within 1 month.” Source location Response from Mandeville Grange Nursing Home
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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 Assess the competency of staff who will deliver emergency CPR training within one month.
Verbatim wording from the response “We have not carried out any emergency CPR drills to date as we have been trying to work through a process document to ensure that what we put in place is fit for purpose. The document is now finalised however the starting of drills is awaiting assessment of staff competency who will deliver the training. This will happen within 1 month.” Source location Response from Mandeville Grange Nursing Home
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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 Obtain a PractiMan adult/child CPR training manikin for the home.
Verbatim wording from the response “We have ordered a PractiMan Advanced CPR Adult/Child Manikin, 2-in-1 Life-like CPR Training Manikin for Adult/Child CPR Training for the home.” Source location Response from Mandeville Grange Nursing Home
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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 Emergency CPR drills have not started because trainer competency assessment is pending; drills are expected to begin within one month.
Verbatim wording from the response “We have not carried out any emergency CPR drills to date as we have been trying to work through a process document to ensure that what we put in place is fit for purpose. The document is now finalised however the starting of drills is awaiting assessment of staff competency who will deliver the training. This will happen within 1 month.” Source location Response from Mandeville Grange Nursing Home
Open published response
11 Jun 2024 Yuri Hatton · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Lack of official training for Operational Support Grades View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Yuri Hatton · 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
Yuri Hatton, who was detained at HMP Wandsworth, died in hospital on 9 November 2018 after being found unresponsive following a suspected opiate overdose and later showing features of brain stem death. The jury identified four failures that cumulatively possibly contributed to his death, including failures involving emergency response, clinical observations and communications. The report also raised concerns about limited OSG training, the frequency and monitoring of first aid training, and the lack of prison-specific training on recognising unconsciousness.
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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 official training for Operational Support Grades
Wider context from the report “(1) Operational Support Grade (OSG) training. Following the Inquest, I sought further evidence regarding several matters, including OSG training. A statement provided by HMP Wandsworth confirms that of 83 OGSs, only 5 had received HMPPS official training . This is against the background of OSG’s only being present on the wings at night, and therefore often the first to respond to any emergency.
” Source location Yuri Hatton · Prevention of Future Deaths report
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21 May 2024 Christine MCDONALD · Prevention of Future Deaths report Cheshire
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Concerns raised 1
Inability of training to fully prepare first-on-scene staff for emergencies View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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Christine MCDONALD · 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
Christine McDonald died in hospital on 3 March 2019 after being found unresponsive in her prison cell with a ligature. The report identified concerns about failures in communication and information sharing, failure to assess and respond to her healthcare needs, and failures relating to treatment of her drug dependency. The emergency response code was not used, causing delays in providing emergency equipment and medical treatment, although this was not found to have contributed to her death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inability of training to fully prepare first-on-scene staff for emergencies
Wider context from the report “I heard evidence during the course of this Inquest in respect of the process for using the emergency response codes, this is something which arises in many cases of this type. I heard evidence in this case that the emergency response code was not used and as a consequence, those responding to the call were not prepared in the sense of emergency equipment, nor were they prepared mentally for the situation they had been asked to attend.
I heard evidence in respect of the training and integrity testing that is now conducted to try to simulate the unexpected nature of an emergency, the evidence being that it is very difficult and that no training can fully prepare those staff who are first on scene for what they may find .
I also heard evidence relating to measures within the control room, which might assist those first on scene in terms of the use of emergency codes and provide additional safeguards for those whose lives are at risk.
” Source location Christine MCDONALD · 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 Launch and disseminate a medical-emergency response video through HMPPS, including delivery to new officers and sharing with Governing Governors.
Verbatim wording from the response “Nationally, a video was launched in January 2024 that demonstrates how staff should respond to a medical emergency. This includes instructions on when to enter a cell in an emergency and the appropriate use of Code Blue and Code Red communications. This video has been made available to all HMPPS staff, including Officer Support Grades (OSGs) and staff completing night duties who may need to respond to a medical emergency. Since January 2024, the video has been delivered to all new officers via foundation training and has been shared locally with Governing Governors.” Source location Response from HMPPS
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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 Show the medical-emergency response video to all current operational staff at HMP Styal by November 2024.
Verbatim wording from the response “HMP Styal are committed to showing the video to all current operational members of staff by November 2024, which will aid in preparing staff for being first on scene at an unexpected or traumatic medical emergency. In the interim, staff are regularly issued Emergency Response Information Cards, which provide convenient and accessible information on when it is necessary to call an emergency code and are also regularly briefed on the importance of utilising the code system in the event of a medical emergency. Additionally, communication room staff have been issued a notice to staff that reinforces their duties in a medical emergency.” Source location Response from HMPPS
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11 Mar 2024 Ronald James JEPSON · Prevention of Future Deaths report Coventry
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Concerns raised 1
Failure to provide sufficiently frequent and effective emergency response training for care home staff View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
J&K Partnership
Provide face-to-face basic life-support and Level 1 first-aid training covering choking recognition, immediate response and escalation; training has reached 82% of staff.
View source
J&K Partnership
Give the two staff members without face-to-face training choking-response guidance and e-learning training.
View source
J&K Partnership
Deliver a face-to-face three-day Level 3 first-aid qualification to all service shift leaders.
View source
J&K Partnership
Introduce tabletop emergency exercises alongside face-to-face training and continuing e-learning.
View source See 1 more action
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AI-generated summary
Ronald James JEPSON · 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
Ronald James Jepson, who resided at a mental healthcare facility and had a known risk of choking, suffered an unwitnessed choking episode after being provided with supper and died in hospital on 15 March 2023. Concerns included delayed and suboptimal CPR, staff calling 111 rather than 999, and infrequent and ineffectual emergency training for care home staff.
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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 provide sufficiently frequent and effective emergency response training for care home staff
Wider context from the report “i. Timely and commensurate interventions of care staff can have a significant positive bearing upon the outcome of a choking episode. Training on how to deal with emergency situations is not ingrained in care home staff.
ii. The circumstances of this inquest touching upon the death of Ronald JEPSON accentuated this point. The evidence was that Mr Jepson 'gargling' and becoming unresponsive was an emergency. 111 (a non-emergency number) was called by care home staff and not 999.
iii. A call handler recognising it was an emergency escalated matters and guidance was given to care staff as to CPR. First attempts as resuscitation by care staff were following an appreciable period of time (ascribed to inexperience and panic) and the cardiopulmonary resuscitation was sub optimal.
iv. The removal of the food occluding the airway of Mr Jepson and effective CPR was provided by paramedics immediately lead a reduced cyanosis.
v. A choking episode, of itself, is a time critical event.
vi. Such training at the time of the incident was ineffectual and infrequent (online) with the consequence being that when an emergency arose the actions of staff to aid a resident were cumulatively sub optimal.
vii. Following the incident there has been no significant increase in training frequency such as would better enable commensurate training to be ingrained in staff which may make significant difference in averting an adverse outcome for a resident in need of emergency care/ assistance.
” Source location Ronald James JEPSON · 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 face-to-face basic life-support and Level 1 first-aid training covering choking recognition, immediate response and escalation; training has reached 82% of staff.
Verbatim wording from the response “ii) At the time of Mr. Ronald James Jepson, staff at Meadow House had all completed e-learning 1st aid training. To ensure staff team are further prepared to deal with medical emergencies that might arise during support and care delivery, Provider sourced Face-to-Face Basic Life Support Training for staff, for which 82% of the staff attended. Since the incident, the Provider has sourced and supplied Level 1 1st Aid. The training encompassed a practical session for various emergencies that might arise in the service including recognizing when a resident is choking, immediate actions to take and escalation.” Source location Response from Meadow House
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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 Give the two staff members without face-to-face training choking-response guidance and e-learning training.
Verbatim wording from the response “iii) Remedial measures have been implemented for when the 2 members of staff are on duty that haven’t had their face-to-face training; they have received step by step guide for dealing with a choking service user from the registered manager as well as having completed their e-learning.” Source location Response from Meadow House
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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 a face-to-face three-day Level 3 first-aid qualification to all service shift leaders.
Verbatim wording from the response “iv) Advanced Life Support Training for all Senior Care and Support Workers in the Services. To ensure a high level of skill set in dealing with medical emergencies in the service, the Provider has taken further steps by sourcing face to face 3-day course, Level 3 Award in First Aid at Work (RQF). The training is aimed at all Shift Leaders in the Service and is due to be delivered from the 15th May 2024 to the 18th May 2024” Source location Response from Meadow House
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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 Introduce tabletop emergency exercises alongside face-to-face training and continuing e-learning.
Verbatim wording from the response “iii) From the face-to-face training provided and the desk top exercises now in place, the provider is assured that should a similar incident occur staff will act accordingly without panic and in a timely manner.” Source location Response from Meadow House
Open published response
7 Mar 2024 David Louis SIIRAK · Prevention of Future Deaths report West London
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Concerns raised 1
Failure to provide adequate unexpected simulation training for ward staff View source
Linked response
Central and North West London NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Central and North West London NHS Foundation Trust
Provide nationally accredited RCUK Level 3 Immediate Life Support training annually to substantive inpatient nurses and doctors, with compliance monitored through governance structures.
View source
Central and North West London NHS Foundation Trust
Deliver a Trust-wide in-situ simulation programme using standardised planning, facilitation, debriefing and recording processes for resuscitation and other emergencies.
View source
Central and North West London NHS Foundation Trust
Continue rolling in-situ simulation delivery across inpatient wards, adding sessions for areas identified as needing greater support.
View source
Central and North West London NHS Foundation Trust
Train staff who facilitate simulations and provide local facilitator update training.
View source
Central and North West London NHS Foundation Trust
Build a simulation room for staff identified as needing refresher training to attend planned sessions.
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AI-generated summary
David Louis SIIRAK · 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 Louis Siirak was a detained inpatient who suffered unsurvivable injuries after being seriously assaulted by another patient on 1 March 2020 and died on 4 March 2020. The principal concern was that ward staff response was described as chaotic and panicking, with evidence of inadequate training in unexpected simulation exercises to manage such emergencies.
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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 provide adequate unexpected simulation training for ward staff
Wider context from the report “Mr Siirak was discovered in his room, having been assaulted, at 1647 hours on 1 March 2020. The crash team, led by ████████, arrived at 1703 hours. The evidence was that between those times (until ████████ took charge at 1703) the response of ward staff to the incident was "chaotic" and "panicking" (as was acknowledged by the staff).
The evidence was that various members of your staff had never previously been involved in a real or simulated emergency. By "simulated emergency", I mean an unexpected dummy run on the ward, as opposed to training in the calm confines of a planned day.
One member of staff told the court that she had never been involved in an unexpected simulated emergency in the 14 years of working on the ward prior to 1 March 2020, nor in the 4 years since.
The jury found that "there was a clear failure to provide the adequate training in simulation exercises to effectively manage situations like the one that occurred on 1st March 2020. "
It was equally clear on the evidence that members of staff have still not undergone unexpected simulation training .
” Source location David Louis SIIRAK · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide nationally accredited RCUK Level 3 Immediate Life Support training annually to substantive inpatient nurses and doctors, with compliance monitored through governance structures.
Verbatim wording from the response “Resuscitation training: In November 2022, the Trust updated its resuscitation training to the Nationally accredited RCUK Level 3 Resuscitation training also known as Immediate Life Support (ILS). It is a course where to be successful the participants need to successfully demonstrate the skills required to resuscitate a patient. Providing assurance to both the individual and the Trust. All participants are involved in multiple resuscitation simulations, all of which have been developed from incidents that have occurred within the Trust. All registered substantive Nurses and Doctors who work on inpatient areas are required to attend this course annually. The Trust monitors ILS training compliance in a range of groups, Committees and also at Board level. Through this monitoring we obtain assurance that all relevant staff have undertaken ILS training and simulation exercises.” Source location Response from Central and North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a Trust-wide in-situ simulation programme using standardised planning, facilitation, debriefing and recording processes for resuscitation and other emergencies.
Verbatim wording from the response “Insitu simulation: This has been developed alongside a Trust-wide insitu Simulation education programme and complements the training programme outlined above. This programme was launched and led by the head of Adult Education at CNWL in 2022. The Trust-wide programme covers many areas, with resuscitation simulation being one of those areas. This uses a unified approach to planning, running, debriefing and recording each simulation. The Resuscitation team has a suite of simulation’s developed from previous incident that have occurred across the trust.” Source location Response from Central and North West London NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue rolling in-situ simulation delivery across inpatient wards, adding sessions for areas identified as needing greater support.
Verbatim wording from the response “Over the next 12 months, a rolling programme of insitu simulations is scheduled for every inpatient ward area, with additional sessions planned for areas identifying a greater need. Areas which may be considered as requiring additional input will include teams that have been involved in a recent resuscitation event and incident reviews.” Source location Response from Central and North West London NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train staff who facilitate simulations and provide local facilitator update training.
Verbatim wording from the response “Everyone involved in delivering and facilitating simulation has attended training provided by Milton Keynes University in 2022 and 2023, and local update training is planned for 2024. Since the launch of the programme over 100 insitu resuscitation simulations have been carried out across the trust, with 79 having occurred in the last year, one of these has occurred on Frays ward, including five members of staff.” Source location Response from Central and North West London NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Build a simulation room for staff identified as needing refresher training to attend planned sessions.
Verbatim wording from the response “The Trust is also currently building a simulation room, where staff identified as having a need to refresh can attend for planned sessions.” Source location Response from Central and North West London NHS Foundation Trust
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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 resuscitation and in-situ simulation arrangements provide sufficient assurance that the identified training concerns are being addressed.
Verbatim wording from the response “Resuscitation training: In November 2022, the Trust updated its resuscitation training to the Nationally accredited RCUK Level 3 Resuscitation training also known as Immediate Life Support (ILS). It is a course where to be successful the participants need to successfully demonstrate the skills required to resuscitate a patient. Providing assurance to both the individual and the Trust. All participants are involved in multiple resuscitation simulations, all of which have been developed from incidents that have occurred within the Trust. All registered substantive Nurses and Doctors who work on inpatient areas are required to attend this course annually. The Trust monitors ILS training compliance in a range of groups, Committees and also at Board level. Through this monitoring we obtain assurance that all relevant staff have undertaken ILS training and simulation exercises.” Source location Response from Central and North West London NHS Foundation Trust
Open published response
17 Sep 2019 Tyla Katherine Joan COOK · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1
Failure to organise a multi-disciplinary learning event on emergency non-technical skills View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS Norfolk and Suffolk Integrated Care Board Norfolk and Suffolk NHS Foundation Trust Norfolk County Council the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
Norfolk and Suffolk NHS Foundation Trust
Attend a fixed multi-agency meeting with partner organisations to plan the recommended non-technical-skills learning event.
View source
the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
Participate in the multidisciplinary meeting planning the learning event.
View source
the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
Support and contribute to the multidisciplinary learning event scheduled for February 2020.
View source
NHS Norfolk and Suffolk Integrated Care Board
Arrange and chair a multidisciplinary task-and-finish group meeting to develop the learning event.
View source
NHS Norfolk and Suffolk Integrated Care Board
Request QEH’s Risk and Safety team to compile investigation learning for consideration by the task-and-finish group.
View source
NHS Norfolk and Suffolk Integrated Care Board
Arrange the multidisciplinary learning event for mid-February 2020.
View source
NHS Norfolk and Suffolk Integrated Care Board
Identify and secure an external facilitator for the proposed learning event.
View source
NHS Norfolk and Suffolk Integrated Care Board
Develop learning-event materials covering the incident, organisational changes, staff messages and relevant lessons learned.
View source
NHS Norfolk and Suffolk Integrated Care Board
Invite senior operational staff from NNUH and James Paget University Hospitals to disseminate incident and investigation learning.
View source See 6 more actions
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AI-generated summary
Tyla Katherine Joan COOK · 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
Tyla Cook had a complex mental health history and took 24 paracetamol tablets on 9 November 2017. After delayed treatment and subsequent deterioration, Tyla suffered a cardiac arrest and died at Queen Elizabeth Hospital on 15 November 2017. Concerns included delays in specialist assessment, the absence of an up-to-date written care and crisis plan, and the failure to organise a planned multi-disciplinary learning event addressing emergency response skills.
Read the report on judiciary.uk
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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 organise a multi-disciplinary learning event on emergency non-technical skills
Wider context from the report “3. The Review carried out by the West Norfolk Clinical Commissioning Group in May 2019 recommended a multi-disciplinary learning event involving participants from Norfolk and Suffolk Foundation Trust, Queen Elizabeth Hospital, Norfolk County Council and East of England Ambulance Service Trust be developed and implemented to train staff on how to apply good non-technical skills (teamwork, leadership, task prioritisation and communication) when responding to an emergency. At the inquest it became clear no steps have been taken to organise this event and there is confusion as to who is responsible for arranging this learning event . The Care providers indicated it was the West Norfolk Clinical Commissioning Group. The West Norfolk Clinical Commissioning Group do not appear to accept responsibility for organisation of the event. Tyla died on 15 November 2017. The West Norfolk Clinical Commissioning Group Review was published 8 May 2019. No steps have been taken with regard to this learning event , save East of England Ambulance Service Trust has been in contact with the West Norfolk Clinical Commissioning Group. There is concern that a multi-disciplinary learning event will not be organised and will not take place .
” Source location Tyla Katherine Joan COOK · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Attend a fixed multi-agency meeting with partner organisations to plan the recommended non-technical-skills learning event.
Verbatim wording from the response “Trust response to concern 3:
There is a multi-agency meeting fixed for the 4th November which our Head of Patient Safety, Saranna Burgess, will attend with representatives from all the other organisations involved to plan this.” Source location 2019-0299-Response-by-Norfolk-and-Suffolk-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate in the multidisciplinary meeting planning the learning event.
Verbatim wording from the response “I am pleased to be able to advise you that on 4th November a meeting was held at Chatterton House in King’s Lynn and present were senior staff from all of the key participants, namely the Director of Nursing and Quality Assurance - West Norfolk CCG (Chair), the Deputy Director for Patient Safety and Quality - Norfolk & Suffolk NHS Foundation Trust, the Interim General Manager - East of England Ambulance NHS Trust, the Approved Mental Health Professional (AMHP) Team Manager - Norfolk County Council, and the Deputy Director of Patient Safety from this Trust. Other support staff were in attendance. One of the main agenda items was for the learning event to be arranged and it was decided that a date would be selected in February 2020 and that the West Norfolk CCG would take the lead in organising the venue and facilitating the event with support and contribution from the other participants.” Source location 2019-0299-Response-by-The-Queen-Elizabeth-Hospital-Kings-Lynn-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support and contribute to the multidisciplinary learning event scheduled for February 2020.
Verbatim wording from the response “I am pleased to be able to advise you that on 4th November a meeting was held at Chatterton House in King’s Lynn and present were senior staff from all of the key participants, namely the Director of Nursing and Quality Assurance - West Norfolk CCG (Chair), the Deputy Director for Patient Safety and Quality - Norfolk & Suffolk NHS Foundation Trust, the Interim General Manager - East of England Ambulance NHS Trust, the Approved Mental Health Professional (AMHP) Team Manager - Norfolk County Council, and the Deputy Director of Patient Safety from this Trust. Other support staff were in attendance. One of the main agenda items was for the learning event to be arranged and it was decided that a date would be selected in February 2020 and that the West Norfolk CCG would take the lead in organising the venue and facilitating the event with support and contribution from the other participants.” Source location 2019-0299-Response-by-The-Queen-Elizabeth-Hospital-Kings-Lynn-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Arrange and chair a multidisciplinary task-and-finish group meeting to develop the learning event.
Verbatim wording from the response “• Arranged for the task and finish group (with attending representatives from NSFT, EEAST, QEH, NCC and West Norfolk CCG) to meet on 04 November 2019 to discuss the development of the learning event. Action completed 04 November 2019.” Source location 2019-0299-Response-by-West-Norfolk-CCG
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request QEH’s Risk and Safety team to compile investigation learning for consideration by the task-and-finish group.
Verbatim wording from the response “• Requested QEH (Risk and Safety team) to draw together the learning from the Investigation Report for consideration by the task and finish group (in line with Action 1 of Recommendation 2). Action completed 01 November 2019.” Source location 2019-0299-Response-by-West-Norfolk-CCG
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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 Arrange the multidisciplinary learning event for mid-February 2020.
Verbatim wording from the response “The actions (with provisional timescales to be confirmed by the group members) agreed at the task and finish group meeting are ongoing and include:” Source location 2019-0299-Response-by-West-Norfolk-CCG
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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 Identify and secure an external facilitator for the proposed learning event.
Verbatim wording from the response “• An External facilitator for the learning event has been identified by West Norfolk CCG and is available for the proposed date of the learning event.” Source location 2019-0299-Response-by-West-Norfolk-CCG
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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 learning-event materials covering the incident, organisational changes, staff messages and relevant lessons learned.
Verbatim wording from the response “• The materials to be developed for the learning event are to include a pen portrait of Tyla (his parents are to be invited to share their views on this), changes made by NSFT and QEH in light of the incident and key messages from the staff involved in the incident. Information regarding the relevant Lessons Learnt will also be included e.g. Lesson Learnt 12 - Monitoring of acute physical health deterioration.” Source location 2019-0299-Response-by-West-Norfolk-CCG
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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 Invite senior operational staff from NNUH and James Paget University Hospitals to disseminate incident and investigation learning.
Verbatim wording from the response “• As part of the sharing and dissemination of the outcomes of this incident and the Investigation report, the invitees to the learning event are to include senior operational staff from the Emergency Department at Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUH) and James Paget University Hospitals NHS Foundation Trust.” Source location 2019-0299-Response-by-West-Norfolk-CCG
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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 West Norfolk CCG will lead organising and facilitating the multi-disciplinary learning event, with other participants providing support and contributions.
Verbatim wording from the response “I am pleased to be able to advise you that on 4th November a meeting was held at Chatterton House in King’s Lynn and present were senior staff from all of the key participants, namely the Director of Nursing and Quality Assurance - West Norfolk CCG (Chair), the Deputy Director for Patient Safety and Quality - Norfolk & Suffolk NHS Foundation Trust, the Interim General Manager - East of England Ambulance NHS Trust, the Approved Mental Health Professional (AMHP) Team Manager - Norfolk County Council, and the Deputy Director of Patient Safety from this Trust. Other support staff were in attendance. One of the main agenda items was for the learning event to be arranged and it was decided that a date would be selected in February 2020 and that the West Norfolk CCG would take the lead in organising the venue and facilitating the event with support and contribution from the other participants.” Source location 2019-0299-Response-by-The-Queen-Elizabeth-Hospital-Kings-Lynn-NHS-Trust
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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 CCG did not agree to lead or take over responsibility for Recommendation 2 or the learning event.
Verbatim wording from the response “Accordingly there was no agreement by the CCG at that time or subsequently that the CCG would take the lead on any training event or Recommendation 2.” Source location 2019-0299-Response-by-West-Norfolk-CCG
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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 QEH and its Deputy Director of Patient Safety are the organisational and individual leads for Recommendation 2 and the learning event.
Verbatim wording from the response “Recommendation 2 clearly states that firstly, the task and finish group is responsible for the implementation of the recommendation (i.e. is the ‘action owner’). Secondly, that QEH and its Deputy Director of Patient Safety are the organisational and individual leads respectively for this recommendation.” Source location 2019-0299-Response-by-West-Norfolk-CCG
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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 review’s learning themes are already being addressed through existing work and approaches for working with children and families.
Verbatim wording from the response “Although these are recommendations from this particular review, they are all areas of work that are currently underway and being adopted in our approach to working with children and families.” Source location 2019-0299-Response-by-Norfolk-County-Council_Redacted
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.