Recurring concern

Unsafe clinical decisions by non-medically qualified personnel

First to latest report 18 Mar 2014 — 2 Feb 2026

Reports that mention this concern
9
Times this concern has been raised
9
Stated actions linked to this concern
1

What this concern includes

Includes failures where non-medically qualified staff make, direct or materially determine clinical or medication-related decisions that require appropriate medical expertise, including the anchor’s unauthorised medication or prescription of remedies by non-medically qualified care staff and the Practice Manager’s clinical decision-making without medical qualification.

What is not included
  • Excludes failures involving qualified clinicians who make poor decisions where lack of medical qualification is not the unsafe condition.
  • Excludes generic staffing, training, supervision or competence deficiencies unless they directly result in clinical decisions being made by personnel without the required medical qualification.
  • Excludes administrative, governance or operational decisions that do not determine clinical care, treatment or medication.
  • Excludes cases where non-medically qualified staff provide information or administrative support under appropriate clinical direction without making or determining the clinical decision.

Reports and published responses 9 reports

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

  1. Kent and Medway

    AI-generated summary

    David ROOMES · 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 ROOMES, who had bipolar affective disorder and a relapse in depressive symptoms, was found deceased in the garage of his address on 14 April 2025, having suspended himself by ligature. The concerns included delays and shortcomings in referral triage, the absence of assessment by a qualified clinician, delays and missed opportunities for clinical review, and potential wider training issues for non-clinical decision makers.

    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

    Inadequate training and understanding among non-clinical decision makers

    Wider context from the report

    “(2) David's Dialog+ assessment (an assessment tool, which includes questions to assess risk) was not undertaken by a clinician. I was told in evidence that, given the complexities of David's case, his Dialog+ assessment 'would have benefitted' from assessment by a clinician and that he should have been seen by a qualified clinician at that appointment. I heard evidence that the Band 4 member of staff who undertook the assessment was content with their assessment and the plan that was formulated as a result of it. However, that plan did not include referral to be seen and assessed by a qualified clinician, whereas the evidence I heard was that there was an expectation that David should have been referred to a qualified clinician. While I heard and accepted the evidence that a patient in a similar situation to David would now be able to access the MHT+ team directly, the issue here is one of potential training concerns where non-clinical decision makers are potentially over-confident or may not fully understand the nature and effect of the decisions they are required to make. I was not reassured that this matter has been addressed. ”

    Source location

    David ROOMES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Essex

    AI-generated summary

    Jan Goodliffe · 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

    Jan Goodliffe died on 15 June 2021 several days after taking his own life, following a recent suicide attempt and a history of mental health problems. The report raises concerns that social workers, rather than medically qualified clinicians, assessed him despite information about his suicide risk and recent restart of medication, and that opportunities to obtain qualified medical advice may have been missed.

    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 use medically qualified clinicians in home assessments

    Wider context from the report

    “That the Clinicians who attended to assess Mr Goodliffe where not medically qualified, they were social workers. They were presented with evidence around a serious attempt by Mr Goodliffe to take his own life that he had been doing by a family member. ████████ gave all this information at the assessment along with the recent reintroduction of the Bi Polar medication, and the facts of the previous reintroduction when starting this medication and the time taken for this medication to start to work. As they were unqualified medical practitioners, there were missed opportunities to seek qualified medical advice around the interactions of the medication and whether as a result of this contributed to his death. I am concerned that suitably medically qualified clinicians are not being used in the home assessments and decisions are being made around issues that require medical expertise. ”

    Source location

    Jan Goodliffe · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. West London

    AI-generated summary

    Sophie 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

    Sophie Elizabeth Alice Bennett died at Kingston Hospital from injuries caused by applying a ligature at Lancaster Lodge, a care home operated by RPFI. The Jury identified concerns about inadequate governance, staffing, training, documentation, leadership and oversight, and found contributory errors or omissions in risk management, including failure to follow advice to take Sophie to A&E, inadequate observation and poor control of access to ligature items.

    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

    Inadequate control of treatment and safety decisions

    Wider context from the report

    “The governance of Lancaster Lodge, and of the staff, and others, working there during the material period, was inadequate in the following respects: 1. There was no “registered manager” who met the statutory criteria. 2. The staff were (despite RPFI’s assertions to the contrary), generally, untrained, unqualified and too few in number. 3. There were no, or no adequate, checks and controls by the staff, or by the acting manager, on the keeping of essential documents, including risk assessments and progress notes, which were, in consequence, themselves inadequate, unreliable and misleading - with corresponding risk to the safety of the residents. 4. The changes to which the determined circumstances refer were made following an audit by ████████ out: • ████████ was not qualified clinically, or in the field of mental health, to conduct that audit; • the audit conducted by him (which led to the proposals for change) took only a single day, which was grossly inadequate; • there was no, or no adequate, consultation with the staff, or by the staff with the residents, regarding the substantial changes introduced, and to be made; and • the changes were introduced at a “launch”, with no, or no adequate regard to the negative impact of their sudden introduction on the mental stability of the residents. 5. Leadership and oversight by the Board of RPFI was grossly inadequate, in relation to: • the need to have in place robust employment procedures; • the matters listed under paragraphs 1 to 4 above; • the appointments of the clinically unqualified ████████ and, later, the clinically unqualified art therapist as Clinical Lead, of a statutorily-approved registered manager, and of an adequate number of trained and qualified staff; • supervision and control of the changes introduced at ████████ instigation; • decisions made by the (unqualified) acting manager and staff in relation to the treatment to be given to the residents, and other steps required to meet their needs, and safety; • communication with other agencies involved in the care of the residents; • the keeping and production (including to the Court, for the purpose of the inquest) of the Board’s own records, communications and contracts; and • knowledge and performance of the Board’s fundamental obligations, including their duty of candour (not least in the Board having failed to fulfil its mandatory obligation to report to the CQC five instances of admission of Lancaster Lodge residents to hospital). 6. Advice to the acting manager was provided by ████████ - the founder of RPFI - and significant decisions regarding Lancaster Lodge and the residents, were made by her (in each case as a “consultant” to the Board, rather than by the Board of RPFI), and were followed by RPFI staff, when: • ████████ was neither a director, nor a Trustee, of RPFI (one Board member describing her role as “somewhat ambiguous”, and the evidence suggesting that she was a “shadow director”); and • ████████ had never visited Lancaster Lodge, and had never met (or had any knowledge, firsthand, knowledge of the residents). 7. The possibility of there being: • a conflict between the interests of ████████ (who, it appears, may have had a personal or family connection with the ownership of Lancaster Lodge) and those of RPFI itself; and • financial impropriety, in relation to the lease under which Lancaster Lodge was (it seems) held. 8. The post-death investigations carried out on behalf of RPFI: • were inadequate, verging on self-serving, and not objective; and • give rise to concerns as to their veracity and accuracy (the authorship of certain supposedly contemporaneous statements being denied by the staff member whose name appears on them as their maker). 9. The facts that: • a director and trustee of RPFI is also the Chairman of RCI; and • ████████ appears to have some family connection with the owner of RCI’s premises give rise to concerns in relation to RCI corresponding to those itemised under paragraphs 5 to 7 above. ”

    Source location

    Sophie Bennett · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Norfolk

    AI-generated summary

    JAKUB DAWID MOCZYK · 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

    JAKUB DAWID MOCZYK was taking part in a boxing match when he received a blow to the head, became unresponsive and died from his injuries on 21 November 2016. Concerns included incomplete pre-fight medical checks, medics not notifying the referee or promoter, and medics not assessing the opponent after he gagged or vomited before continuing the fight.

    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 retain independent medical decision-making on whether a boxer is fit to continue fighting

    Wider context from the report

    “(3) During the 2nd round the deceased’s opponent gagged/vomited on 2 occasions. The referee stopped the fight and counted to 8 on both occasions. The medics did not examine the boxer and advise as to his fitness to continue fighting, but relied on the referee to make the decision as to whether the fight should continue. It was known by the medics that the referee was not medically qualified. The medics were aware the referee was also the opponent’s own trainer. It was said in response to questioning in this respect, that the referee could be expected to know the boxer and whether he was fit to continue fighting. No account was taken that the referee/trainer may prefer the boxer to continue fighting rather than to stop the fight. ”

    Source location

    JAKUB DAWID MOCZYK · Prevention of Future Deaths report
    Page 1 · 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

    Referees and corner men are responsible for making decisions or seeking medical advice at boxing events.

    Verbatim wording from the response

    “3. Referees will have first aid training. It is up to the referee and the corner men to make decisions or ask for advice. This was not ask for. It is up to the referee in all boxing events including British Boxing Association.”

    Source location

    2017-0300-Response-by-Lifeshield-Medical-Services-Ltd
    Page 1 · response
    Published 27 November 2017

    Open published response

  5. Inner North London

    AI-generated summary

    Nuala Seddon · 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

    Nuala Seddon developed a hypoxic brain injury after a cardiac arrest on 27 November 2014, following her transfer from ITU to ward-based care, and died on 7 April 2016 after developing pneumonia. The report raised concern that a lack of available telemetry could expose patients discharged from ITU to significant risk of unrecognised deterioration.

    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 clinical staff make discharge decisions

    Wider context from the report

    “(1) It seems clear that a decision was made to transfer Mrs Seddon from ITU on 27 November 2014. There remains the potential that this decision was made by non-clinical staff. The lack of documentation regarding this significant decision is concerning and leaves open the possibility that future discharges could be based on non-clinical need or inappropriate decision-making which is not subsequently able to be scrutinised because of a lack of documentation. ”

    Source location

    Nuala Seddon · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. West Yorkshire (Western)

    AI-generated summary

    Kirsty Childs · 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

    Kirsty Childs, aged 20, developed severe abdominal symptoms and repeatedly sought advice from NHS Direct and other services between 31 December 2012 and 2 January 2013. She was not admitted to hospital and was later found dead at home; the inquest recorded septic shock caused by an undiagnosed and untreated mesenteric venous thrombosis. The principal concerns included incorrect telephone triage, failure to review earlier calls, medically unqualified staff selecting questionnaires, the ability to override recommended outcomes, and poor information-sharing between agencies.

    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

    Use of non-medically qualified personnel to select symptom questionnaires and care pathways

    Wider context from the report

    “2. Medical advisers in NHS Direct were not medically qualified, and emergency medical despatchers in West Yorkshire Ambulance service are not medically qualified. They were required to illicit details of the patient's symptoms, and proceed to identify the most significant symptom from the information gained to select the most appropriate questionnaire. I understand there are a significant number of questionnaires to select from. They repeatedly selected the incorrect questionnaire in Kirsty's case. This resulted in significantly different outcomes being followed. I am concerned that without medical training the likelihood of incorrect questionnaires being selected and as a consequence, incorrect pathways being followed will reoccur ”

    Source location

    Kirsty Childs · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

  7. Gateshead and South Tyneside

    AI-generated summary

    EDWIN THOMPSON · 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

    Edwin Thompson, a 77-year-old residential care home resident with dementia, was found dead in a bathroom on 8 October 2011. The post-mortem identified a previously undiagnosed cardiovascular disease as the natural cause of death. The report identified concerns about protective measures for a vulnerable resident, delayed medical assistance, loss of contact with a resident prone to wandering, response to a final medical crisis, staff training, and record keeping.

    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

    Unauthorised medication or prescription of ineffective remedies by non-medically qualified care staff

    Wider context from the report

    “There is a need to draft and disseminate to all care staff a clear, simple and concise directive to care home staff to seek medical advice or assistance in respect of residents presenting with pain, particularly of a cardiac nature without delay. Staff with no medical qualification must not seek to speculate as to possible causes of symptoms and should not seek to medicate ( unless otherwise previously prescribed by a Medical Practitioner) or prescribe “remedies” of no or no known worth to anyone in their care. ”

    Source location

    EDWIN THOMPSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Manchester (North)

    AI-generated summary

    Lucasz Lewandowski · 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

    Lucasz Lewandowski suffered catastrophic head injuries after jumping from the roof of his employer’s building on 16 July, and died two days later. The principal concerns included delays and communication failures in emergency and mental-health responses, failures in psychiatric information-sharing and continuity of care, and issues concerning clinical decision-making and responsibility for his safety.

    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

    Clinical decision-making by a non-medically qualified Practice Manager

    Wider context from the report

    “5. Clinical decision-making by a non-medically qualified Practice Manager. ”

    Source location

    Lucasz Lewandowski · Prevention of Future Deaths report
    Page 3 · 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

    Require referral notes to identify the referring clinician and clearly record any non-clinician’s administrative or logistical role.

    Verbatim wording from the response

    “All decisions to refer patients for clinical purposes to another health professional are taken by the medical practitioner under whose care the patient is. It will not be appropriate for the Practice Manager or any manager (unless clinically trained and significantly involved in the care of the patient in a clinical capacity) to form a view as to the appropriateness of a referral to another healthcare professional.”

    Source location

    2014-0445-Response-by-Green-Surgery-Medical-Dental-Care
    Page 2 · response
    Published 15 October 2014

    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

    Clinical referral decisions must remain with treating clinicians; practice managers may provide only administrative and logistical support.

    Verbatim wording from the response

    “All decisions to refer patients for clinical purposes to another health professional are taken by the medical practitioner under whose care the patient is. It will not be appropriate for the Practice Manager or any manager (unless clinically trained and significantly involved in the care of the patient in a clinical capacity) to form a view as to the appropriateness of a referral to another healthcare professional.”

    Source location

    2014-0445-Response-by-Green-Surgery-Medical-Dental-Care
    Page 2 · response
    Published 15 October 2014

    Open published response

  9. Manchester North

    AI-generated summary

    David Gary Chatburn · 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 Gary Chatburn had a significant history of mental health problems, including depression, probable bipolar disorder, alcohol misuse and fluctuating mood. He was found hanging from a tree on 18 October 2013, and the inquest concluded that he took his own life while the balance of his mind was disturbed. Concerns included the lack of referral to psychiatric services, the GP-led diagnosis and treatment, medication management, informal follow-up, record keeping and barriers in accessing mental health services.

    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 qualified practitioner management of single point of entry triage

    Wider context from the report

    “8. That the ‘triage’ process used by the single point of entry system is not always managed by a medically qualified practitioner – this being a vital stage in determining diversion/allocation. ”

    Source location

    David Gary Chatburn · 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

    Local mental-health access arrangements, including single-point entry, triage and bureaucracy, are for the relevant CCG and Pennine Care Foundation Trust.

    Verbatim wording from the response

    “Your remaining concerns relate to the current system for accessing mental health services in primary care. I am aware that a number of other inquests in the past have similarly focussed on the issue of a lack of clearly defined pathways for referral by GPs into mental health environments. The way in which these services are accessed is decided locally by the relevant NHS Trust. Thus your concerns surrounding the single point of entry, triage system and the evident bureaucracy are also more appropriately dealt with by the Clinical Commissioning Group (CCG) and Pennine Care Foundation Trust (FT). I am aware that the CCG is preparing its response in conjunction with both ████████ (Medical Director for the Greater Manchester Area Team) and Pennine Care.”

    Source location

    2014-0126-Response-by-Department-of-Health
    Page 3 · response
    Published 18 March 2014

    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