Recurring concern

Unsafe implementation and oversight of service changes

First to latest report 31 Oct 2014 — 14 Oct 2025

Reports that mention this concern
10
Times this concern has been raised
12
Stated actions linked to this concern
12

What this concern includes

Includes failures in the dedicated governance and implementation of material service or practice changes, including inadequate supervision or control, insufficient consultation where safety is affected, unclear responsibility, delayed completion and failure to demonstrate that changes have been implemented.

What is not included
  • Excludes routine operational changes with no identified safety consequence or deficient safety control.
  • Excludes failures limited to implementing a separately identified safety action, clinical policy, operational protocol or named pathway where that more specific concern is the supported boundary.
  • Excludes generic organisational leadership, staffing, audit or governance deficiencies unless they directly impair the safe implementation or oversight of a service change.
  • Excludes failures limited to verifying the effectiveness of an already implemented change when no broader service-change implementation or oversight failure is identified.

Reports and published responses 10 reports

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

  1. Inner South London

    AI-generated summary

    Paula Doreen Hughes · 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

    Paula Doreen Hughes was admitted to hospital after a fall and received paracetamol in excess of the recommended dose because paracetamol was prescribed alongside co-codamol. The overdose was not recognised until she had developed fulminant acute liver failure, and timely treatment was not provided. The principal concerns included preventing duplicate paracetamol prescriptions and administration, recognising and managing therapeutic excess, accurately assessing confusion, recording over-the-counter medicines, mitigating confirmation bias, and providing guidance for virtual patient reviews.

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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

    Risk of loss or dilution of prescribing safety nets during electronic system changes

    Wider context from the report

    “1. In respect of preventing concurrent prescriptions of paracetamol containing drugs and otherwise preventing prescribing errors resulting in therapeutic excess of paracetamol (NHSE, RPS, Cerner, MHRA, LGT) (1) NHSE, RPS, Cerner, MHRA I consider that the risk of concurrent prescriptions of paracetamol containing drugs is of wider national concern. The Cerner prescribing system offers a duplicate checking functionality that is not a standard feature. It is hard stop and can be overridden and was not adopted by the LGT when the system was introduced. All the healthcare professionals were aware that co-codamol contained paracetamol and should not be prescribed with paracetamol. However, the 2 prescribing doctors failed to recognise that Mrs Hughes was already prescribed a paracetamol containing drug. 2 nurses failed to recognise they were administering 2 paracetamol containing drugs. A pharmacist failed to identify the concurrent prescriptions during reconciliation. (2) LGT LGT’s response to the incident was swift and commendable. A hard stop was introduced to the electronic prescribing system which eliminated concurrent prescriptions of paracetamol containing drugs. Further refinements of the system significantly reduced therapeutic excesses of paracetamol based on weight, which had been identified as an issue when investigating Mrs Hughes’ death. However, it is my understanding that consideration is being given to changing the electronic record and prescribing system. My concern is that during any move to a new system, the safety nets introduced by the Trust will be diluted or lost. ”

    Source location

    Paula Doreen Hughes · 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

    Liaise with NHS England about preventing prescribing systems from dispensing two concurrent medicines containing paracetamol.

    Verbatim wording from the response

    “We have liaised with NHSE with regard to the ability of the prescribing system to dispense two concurrent medicines containing paracetamol and we understand they will incorporate learning from this incident into the commissioning of the ePRaSE tool.”

    Source location

    Response from Medicines & Healthcare Products Regulatory Agency
    Page 2 · response
    Published 19 December 2025

    Open published response

    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

    Seek assurance that Epic will implement iCare paracetamol safety features when introduced across the three Trusts.

    Verbatim wording from the response

    “In May 2027, the Trust will be joining Epic, an electronic records and prescribing system shared by our neighbouring Trusts, Guy’s and St Thomas’ NHS Foundation Trust (GSTT) and King’s College Hospital NHS Foundation Trust (KCH).”

    Source location

    Response from Lewisham and Greenwich NHS Trust
    Page 2 · response
    Published 19 December 2025

    Open published response

  2. Rutland and North Leicestershire

    AI-generated summary

    Christopher Henrik LARSEN · 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

    Christopher Henrik Larsen, a 52-year-old man, was found hanging at his home in Leicestershire on 6 January 2023 and died before a planned mental health triage call. Concerns included inadequate documentation and decision-making in multidisciplinary team meetings, inaccurate interpretation of risk information, insufficient risk assessment and discharge planning, and weaknesses in the serious incident investigation and learning process.

    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 embed serious incident learning and changes in frontline practice

    Wider context from the report

    “4. The Serious Investigation and Reporting Process at LPT I remain concerned about inadequacies in the Serious Incident Investigation and Reporting processes at Leicestershire Partnership NHS Trust. The Serious Incident Investigation into Mr Larsen’s death did uncover and accepted some failings in relation to the care provided to Mr Larsen. However, it failed to uncover all the matters arising at inquest and, some of the matters that it did uncover do not have correlating items of work listed in the action plan. There was no exploration of the MDT meeting’s functionality or documentation as part of the SI investigation. Further, I have concerns about the implementation and embedding of the lessons learned which are identified by the SI Report. In this case the live witnesses who gave evidence during the course of the inquest did not demonstrate that learning had filtered down to the front-line staff. I am therefore concerned that the SI process at LPT does not support a robust and critical analysis and investigation of the care provided to patients, further, I have concerns about the ability of the Trust to embed changes and learning. This failure to properly explore matters and learn where possible inevitably leads to a delay, or failure altogether, to learn lessons which are vital to patient safety across the whole Trust. ”

    Source location

    Christopher Henrik LARSEN · 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

    Deliver additional training and reflection sessions for the nurse and her line manager regarding the case context.

    Verbatim wording from the response

    “Regular training, clinical supervision and reflection sessions take place routinely for clinical staff, however following this feedback, additional training and reflection sessions were undertaken with the nurse, and the line manager of the nurse to fully understand the context in this case. A full investigation into the nurses’ practice is underway internally; this will include consideration of the appropriateness of an NMC referral in line with Trust processes. In the meantime, the nurse is restricted from undertaking any nursing shifts within community services within the Trust or as a practicing lone qualified member of staff in an inpatient setting until the investigation concludes.”

    Source location

    Response from Leicestershire Partnership NHS (1)
    Page 2 · response
    Published 14 June 2024

    Open published response

    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 causal factors and deliver additional training to the team on reading clinical records before Safe and Well calls and clinical decisions.

    Verbatim wording from the response

    “We understand and recognise that this has occurred previously and as part of our ongoing learning we are reviewing all causal factors whilst reminding clinicians of the importance of reviewing medical records before taking any clinical decisions. Additional training has been delivered to this team regarding professional responsibility for reading a clinical record before making calls and taking clinical decisions.”

    Source location

    Response from Leicestershire Partnership NHS (1)
    Page 2 · response
    Published 14 June 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Update the Central Access Point Standard Operating Procedure to require clinicians to review records, assess referrals and prioritise triage calls by risk, urgency and availability.

    Verbatim wording from the response

    “Training and team meetings are important vehicles for us in reminding people of the importance of this, and we are also formalising this by updating the Central Access Point Standard Operating Procedure (SOP) to be explicit that it is the clinician’s responsibility to manage their own allocated work for the shift, look through the referrals having considered the patient record and prioritise the triage calls on risk, urgency and patient availability.”

    Source location

    Response from Leicestershire Partnership NHS (1)
    Page 2 · response
    Published 14 June 2024

    Open published response

    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

    Redesign the Safe and Well template with staff input, obtain clinical safety sign-off and make it available within the electronic patient record.

    Verbatim wording from the response

    “As a learning point from the feedback provided, we are reviewing the layout of the safe and well template to ensure that this is in a format which makes this as easy as possible for call takers to review the information and assess risk and capture information from the call. The new template will be co-produced with staff and will be signed off by the Information Management and Technology (IM&T) Clinical Safety and Improvement Group.”

    Source location

    Response from Leicestershire Partnership NHS (1)
    Page 2 · response
    Published 14 June 2024

    Open published response

  3. Cornwall and Isles of Scilly

    AI-generated summary

    Michael Pender and 2 others · Prevention of Future Deaths report

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

    Report summary

    Michael Pender, Jan Klempar and Paul Mullen drowned at beaches in Cornwall during summer 2020 after entering difficulty in the sea; the beaches would ordinarily have had lifeguards, but none were present at the relevant times following the easing of COVID-19 lockdown restrictions. The principal concerns were difficulties in recruiting and preparing seasonal lifeguards, lack of advance notice to the RNLI about the relaxation of lockdown, difficulties sourcing PPE, and wider uncertainty about responsibility for beach-safety policy and the provision of lifeguards.

    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 provide advance notice of changes requiring beach safety mobilisation

    Wider context from the report

    “ii) The lack of advance notice given to the RNLI of government’s intention to relax lockdown and allow people to travel to the beach again. The RNLI anticipated the difficulties developing. It wrote to the Department of Transport and the Prime Minister to make sure the relevant people were aware of the problems. By letter of 24 April 2020, Kelly Tolhurst MP, Minister for Aviation, Maritime & Security informed the RNLI Chief Executive that: ‘Officials will ensure RNLI is notified as far in advance as possible to enable you to mobilise your assets as appropriate.’ That did not happen. The RNLI learned of the decision to relax lockdown at the same time as the general public and was put in an impossible situation of needing to provide lifeguards on beaches the next day. Mr Pender drowned before there were any lifeguards on any beaches. ”

    Source location

    Michael Pender and 2 others · Prevention of Future Deaths report
    Page 3 · 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

    Existing regular communication between DfT, MCA and RNLI addresses advance notice for lifeguard recruitment and training.

    Verbatim wording from the response

    “○ On the RNLI receiving advance notice to allow them to recruit and train lifeguards, the Department for Transport and the Maritime and Coastguard Agency have advised they maintain a strong working relationship with the RNLI with regular communication with the organisation. Government communication is also a subject that was covered in Module 2 of the UK Covid-19 Inquiry so we await their recommendations in relation to this;”

    Source location

    Response from Cabinet Office
    Page 2 · response
    Published 12 February 2024

    Open published response

  4. Birmingham and Solihull

    AI-generated summary

    Sinon MASHA · 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

    Sinon Masha was born at home on 17 December 2021 following a breech presentation that was not identified until labour. After a 27-minute delay before delivery of his head, he suffered a catastrophic hypoxic brain injury and died on 21 December 2021. The principal concern was that the Trust’s process for managing home births against medical advice was not operating as set out in its guidance, was fragmented, and might result in insufficiently informed birth choices that put lives at risk.

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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

    Failure to formally plan and consider amendments to birth-choice guidance

    Wider context from the report

    “2. Specifically, Section 5 of the Birth Choices Guidance include: “5.1 All women requesting birth outside of guidance must be referred for discussion to the consultant midwife via BadgerNet for decision-making regarding their birth choices. ... 5.7. Where there are complexities that require the input of other professionals and if the woman remains undecided or voices a decisive choice to pursue a plan outside of Trust guidance a joint multiprofessional appointment must be arranged. 5.8. This appointment should include the consultant midwife; the woman’s named obstetric consultant and other relevant professionals/clinicians as needed. The consultant midwife will convene the multiprofessional team meeting with the purpose of ensuring that a comprehensive multiprofessional pregnancy and birth plan is formulated. 5.9. There may be occasions when the multiprofessional team cannot meet. In these circumstances it is acceptable for the multiprofessional team to see the woman separately. However, the team members must still agree a plan together and document this on the woman’s records.” 3. Evidence given at the inquest pertaining to the current situation was that the system outlined in section 5.8 of the Birth Choices Guidance is not in operation at all. Evidence was given by UHB’s Community Matron that without the input of a Consultant Obstetrician at the multiprofessional appointment, things might be missed in the birth plan, and the information given by the Consultant Midwife and Community Midwives may not carry the same weight with the patient as hearing the opinion of the Consultant Obstetrician. It was stated in evidence by the Community Matron that this could put the lives of Mums and babies at risk. 4. Evidence was given by the Director of Midwifery that although patient’s named Consultants are not involved in multiprofessional appointments with the patient there is a bi-weekly meeting of the other professionals who discuss all high risk patients and then the Consultant midwife meets with the patient’s named Consultant (who will have reviewed the patient in clinic) and discusses the individual cases and the birth plans. This system is felt to be working satisfactorily by the Consultant midwife. 5. I remain concerned that the current approach has evolved from necessity rather than being a carefully considered and planned amendment to the Trust’s guidance. Furthermore, the approach appears fragmented increasing the risk of mis-communication or mis-understanding. This system also deprives the patient of the benefit of hearing the perspectives of all the relevant professionals together in a setting where they, the patient, can witness the discussion and be satisfied that everyone has considered all the relevant factors and answered any queries or concerns they may have relevant to their decision. Consequently, I am concerned that patients may not be making fully informed decisions resulting in birth choices that put lives at risk. ”

    Source location

    Sinon MASHA · 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 and align the Birth Choices and home birth guidelines to clarify referral pathways, team responsibilities, and inclusion in birth-planning discussions.

    Verbatim wording from the response

    “• A review of the Birth Choices Guidelines (CG1200) and the home birth guidance (CG1143) is being undertaken and will be completed by 31 October 2023. Currently there are discrepancies in relation to the referral pathway, roles and responsibilities of members of the multi-professional team (including Consultant Midwife), and inclusion of the woman in birth planning discussions. Alignment of these guidelines will provide a clear and standardised pathway for referral and management for women/birthing people requesting birth outside of guidance including homebirth, and clarity of Roles and responsibilities of each member for the Multi professional team.”

    Source location

    Response from University Hospitals Birmingham NHS Foundation Trust
    Page 2 · response
    Published 7 July 2023

    Open published response

  5. North Wales (East and Central)

    AI-generated summary

    Kyle Nicholas James Hurst · 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

    Kyle Nicholas James Hurst was admitted to Glan Clwyd Hospital on 24 January 2021 after taking an undisclosed quantity of a substance and died there later the same day despite treatment. Concerns included the lack of an adopted protocol for accelerated administration of N-Acetylcysteine and delays in implementing procedures intended to mitigate risks from failures to act on diagnostic results.

    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 achieving safety changes within self-set timeframes

    Wider context from the report

    “3. I am concerned that the Health Board continue to fail to achieve changes in a timely manner, even in circumstances where they have set their own timeframe and that as a result of this lives are being put at risk. ”

    Source location

    Kyle Nicholas James Hurst · 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

    Track serious incident investigation actions in the Datix patient safety system and audit completion timeframes and supporting evidence.

    Verbatim wording from the response

    “In April 2021 we changed our serious incident process and this included all investigation reports going for scrutiny and approval at an Incident Learning Panel. This new step in the process adds an organisational level of scrutiny on all investigations completed by our clinical divisions and we have seen an improvement in the quality of reports and action plans as a result. We are also now tracking actions from these investigation reports through our Datix patient safety system and auditing compliance with action completion timeframes and evidence.”

    Source location

    2021-0359-Response-from-BCUHB_Published
    Page 2 · response
    Published 2 November 2021

    Open published response

    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 historic serious incident action plans and verify evidence for each action through an appointed clinician.

    Verbatim wording from the response

    “This process covers incidents from April 2021 onwards, and so for incidents prior to this we have appointed a clinician to undertake a review of historic action plans to ensure evidence is available against each action. This person commenced in post in November, however they have been redeployed to front line services as a result of the current COVID wave, and we hope they will be available to return back to this important work during January 2022.”

    Source location

    2021-0359-Response-from-BCUHB_Published
    Page 2 · response
    Published 2 November 2021

    Open published response

  6. Norfolk

    AI-generated summary

    Ben Buster KING · 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

    Ben Buster KING was detained under the Mental Health Act at Jeesal Cawston Park and died in hospital on 29 July 2020 after becoming unwell following respiratory problems and receiving sedative medication. The inquest identified concerns including failure to diagnose obesity hypoventilation syndrome, inadequate consideration of promethazine, failure to recognise the seriousness of a life-threatening situation, and wider care, observation, record-keeping and hospital communication issues.

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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

    Failure to implement substantive safety changes in residential care homes

    Wider context from the report

    “9. The internal investigation carried out following Mr Ben King’s death did not capture the concerns raised at inquest 10. Evidence was heard that no substantive changes have been made at the residential homes owned by JHL and JRCSL following the death of Ben King and the closure of JCP to deal with these concerns ”

    Source location

    Ben Buster KING · 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

    Hospital systems and processes are not considered generally relevant to residential services, so sweeping changes are not necessarily warranted.

    Verbatim wording from the response

    “While lessons can be learned from any enquiry, it does not necessarily follow that sweeping changes should be made in residential services unless those changes emanated from a review of residential services elsewhere. In which case there would undoubtedly be valuable lessons to learn, the people that are supported, the staff the management and the collaborative working in our services demonstrate that we are well ahead of the workings of a hospital setting. Hospital systems and processes are often not relevant to the way services are delivered for our residents.”

    Source location

    2021-0250-Response-from-Jeesal-Residential-Care-Services_Published
    Page 5 · response
    Published 23 July 2021

    Open published response

  7. 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

    Failure to consult staff and residents about substantial changes

    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

    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 manage the mental-health impact of sudden service changes

    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

    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 supervision and control of service changes

    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

  8. Manchester City

    AI-generated summary

    Veronica Gregory · 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

    Veronica Gregory, who was 83 and living in a nursing and care home, suffered an unwitnessed incident followed by a delayed recognition of pain and a fractured neck of femur. She underwent surgery, developed pneumonia and died on 23 November 2017. The principal concerns included inadequate falls-risk care planning and review, incomplete observation and clinical records, insufficient staffing and supervision, and failures to seek medical assistance promptly.

    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 demonstrate changes in practice and procedure

    Wider context from the report

    “7. A failure to be able to demonstrate, even at the time of the inquest hearing, specifically what changes in practice and procedure had been made, and how the governance of the Home was being managed and regular checking of the quality of all records now being kept. ”

    Source location

    Veronica Gregory · Prevention of Future Deaths report
    Page 4 · 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

    Introduce management and governance controls including daily checks, incident reviews, walkarounds, resident-of-the-day reviews, online documentation, and wider audits.

    Verbatim wording from the response

    “There has been change in management. A new Manager who is also a qualified nurse has been employed since February 2018. Changes to practice and procedures have been made: Manager’s daily walk around, accident and incidents reviews, daily checks, Resident of the day implementation, training of relevant staff is undertaken regularly and as when needed, internal documentation changed to online based, wider range of audits are now carried out.”

    Source location

    2018-0377-Response-by-Zinnia-Healthcare
    Page 3 · response
    Published 12 May 2019

    Open published response

  9. Coventry

    AI-generated summary

    Vanessa Ferkova and Sylvia Daniel · 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

    Vanessa Ferkova, aged 2, died after presenting to a walk-in centre with fever and vomiting, developing a rash, and later suffering cardiac arrest; the report states she died from meningococcus septicaemia. Sylvia Daniel, aged 73, presented with symptoms including neck pain, was diagnosed with an ear infection, and was found deceased the following morning; the report states she died from acute meningitis. Concerns included delays and deficiencies in initial assessment and registration, failure to transcribe or retain information provided by families, and an unsafe non-clinical triage and flagging process.

    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 change the service to address identified clinical risks

    Wider context from the report

    “1. I am concerned that this standard is being introduced to address clinical risks but Virgin Care do not intend to change their service to address this risk but are instead awaiting a change in their commissioning arrangements. I am concerned that future deaths could arise in this circumstance. ”

    Source location

    Vanessa Ferkova and Sylvia Daniel · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  10. Inner South London

    AI-generated summary

    CHRISTOPHER TOKE AJAYI · 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

    Christopher Toke Ajayi, who had schizo-affective disorder and insulin-dependent type II diabetes, was discharged into unsupported accommodation and was found decomposed there on 17 September 2012 after apparently receiving no professional or carer visits for about a month. The report identified concerns about discharge planning, lack of supported accommodation and GP care, failures to communicate his medical needs, and failure to follow up missed appointments, medication and insulin treatment. The inquest found the cause of death to be hyperosmolar non-ketotic coma associated with diabetes mellitus, with neglect contributing.

    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 audit and assurance of departmental safety changes

    Wider context from the report

    “Mr Ajayi was aged 45 when he died. He had a long history of mental illness and a forensic history. He suffered with severe mental illness with a diagnosis of paranoid schizophrenia in 1989 which was amended to schizo-affective disorder in 2002. He was a wanderer and also not always compliant with medication. He was single and had little or no contact with his family in the time leading up to his death. In the last hospital admission before his death he was diagnosed with HONK – Hyperosmolar non-Ketotic coma. This means his blood sugar was high. He now required insulin to control his diabetes and he was, when discharged, to administer this to himself twice a day. On the 9th August 2012 there was a discharge planning meeting at the Maudsley (his last hospital admission). His Care Coordinator attended. It was known by then, because of his poor history of being non-compliant, that he would be being discharged with a Community Treatment Order in place. His named Care Coordinator does not seem to recall much about this meeting but has acknowledged that he would have been told that Mr Ajayi was now insulin dependent. From thereon, it appears that nothing of value was done in relation to Mr Ajayi's discharge planning. He was eventually discharged, wrongly, into unsupported accommodation with no care package, where no GP was caring for him and no Diabetic nurse aware of his discharge. Whilst his named Care Coordinator was on leave his colleague, another Care Coordinator, equally did not ensure everything was in place. Both argued that as Mr Ajayi was placed by Southwark Council, after discharge, into accommodation out of the borough, that militated, practically, in relation to them visiting post discharge. No one was to visit him. To use the words that Counsel for the family used, this group of staff (Care Coordinators) carry an enormous responsibility. The job must be carried out with great diligence and care. Staff must be of the right calibre, and have the right training, and support, to carry out their tasks well. The evidence revealed that these members of staff have a high degree of delegation imposed upon them. They are dealing with probably the most vulnerable people in society. It cannot be uncommon for a mentally unwell person to be discharged from hospital whilst suffering from a physical condition. One impinges on the other when that person is required to self-administer life-saving treatment to themselves. Therefore, they are particularly vulnerable. I acknowledge that patients such as Mr Ajayi, who frequently disengage with treatment, can only have their risk of harm/death reduced, not eliminated. However, this case highlighted so very many missed opportunities, mainly within the department of Care Coordinators. I have heard some evidence about resources impinging upon matters. Certainly, in this case, the accommodation which would be available for an individual such as Mr Ajayi (who was on the Sexual Offender's list as well as having the problems cited above), is, and was, limited. However, this report is not concerning that issue. It concerns the ability of this group of staff to carry out their jobs ensuring the lowest possible risk to their users as can be achieved. If necessary, Mr Ajayi should have (as would have been likely), stayed in hospital until the right discharge arrangement was in place (supported accommodation or unsupported with an intensive package of care). The caring element of the Care Coordinator role was missing. I am assured that the team that was responsible for Mr Ajayi's community care have developed a more structured multi-disciplinary approach including monitoring of 7 day follow up and I am told is robustly monitored in respect of compliance with the seven day follow up), and the identification of high risk patients such as Mr Ajayi. I am further assured that discharge planning is expected to be comprehensively and carefully planned before discharge. Sadly, I did not find this evidence reflected in the Care Coordinators' evidence. I have not been shown any audit figures to prove that changes have been checked as in action comprehensively, and the evidence was not impressive in relation to changes within this particular department. No re-training was evident. Both Care Coordinators were experienced and both also knew Mr Ajayi and his history, albeit not acting upon his new diagnosis. The evidence as a whole came across as still a service dealing with extremely vulnerable members of the public, where crucial decisions and follow up impinge directly on those individual's well-being, as well as others in the community. There appears to have been no root and branch overhaul of the department. Further, there was inconsistent evidence as to supervision, which in itself, would only account for supervisory control over some users of the service, at that particular time. I have concerns that the named Care Coordinator told me that his supervision was two weekly, where his manager told me it was monthly. Other than more supervision, I am struggling to find any other tangible changes that I am sure have been made, to prevent this group of staff from allowing the same circumstances to occur again. ”

    Source location

    CHRISTOPHER TOKE AJAYI · Prevention of Future Deaths report
    Page 4 · 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

    Audit seven-day follow-up and discharges involving patients with unstable diabetes to assess follow-up, communication and forward planning.

    Verbatim wording from the response

    “• The community team involved have undertaken two specific audits: (a) Team 7 day follow-up performance (Oct-Dec 2014) showed no missed reviews; (b) Discharge of two patients with unstable diabetes (Dec 2014) demonstrated extensive communication and forward planning prior to discharge, appropriately involving all partners.”

    Source location

    2014-0558-Response-by-South-London-and-Maudsley-NHS-Trust
    Page 4 · response
    Published 31 October 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Audit implementation of discharge planning, follow-up and care-coordinator support, then report and review results through safeguarding and Trust governance committees.

    Verbatim wording from the response

    “Robust discharge planning and follow up and support to care coordinators are supported by the actions outlined in this report. However, the Trust will undertake an audit in March 2015 to assure itself and partners that implementation has been effective.”

    Source location

    2014-0558-Response-by-South-London-and-Maudsley-NHS-Trust
    Page 8 · response
    Published 31 October 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