Recurring concern

Unsafe management of refusal of necessary care or protective action

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First reported 16 Dec 2013•Latest report 21 Aug 2025

Definition

What this concern includes

Includes capacity-sensitive assessment, persuasion, escalation and protective decision-making when refusal of necessary treatment, care or disclosure creates a serious safety risk.

Not included

  • Advance decisions or lawful treatment choices with no identified process failure
  • General mental-capacity assessment unrelated to a refusal
  • Non-clinical consent disputes
Reports
13

Distinct published reports

Individual concerns
16

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
25

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England3
North East London NHS Foundation Trust2
Care Quality Commission1
Central and North West London NHS Foundation Trust1
Cornwall Partnership NHS Foundation Trust1
Daughter of the deceased1
Department of Health and Social Care1
General Medical Council1
General Pharmaceutical Council1
Hama Medical Centre1
King's College Hospital1
Mersey Care NHS Foundation Trust1
Ministry of Justice1
NHS Cornwall and the Isles of Scilly Integrated Care Board1
North London Mental Health Partnership1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Nicholas Paul MURPHY · 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

    Nicholas Paul MURPHY reported taking an overdose on 29 December 2023, declined further assessment and hospital transfer, and was later found deceased at home on 9 January 2024 after a further welfare concern. The principal concerns were that ambulance outcome codes did not record refusal of treatment or transfer, and that recording the outcome as “Advice only” or “advice given” could mislead staff and result in critical safeguarding information being 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

    Outcome codes failing to record patient refusal of treatment

    Wider context from the report

    “From the evidence I heard I am concerned that information critical to safeguarding and proper decision making may be missed, as it was in this case, given that the outcome codes do not include one that reveals the patient refused treatment. I am also concerned that the outcome of ‘advice given’ can give a very misleading impression of events when used in these type of circumstances. ”

    Source location

    Nicholas Paul MURPHY · 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

    Implement a CAD closure code for patients refusing treatment or conveyance, making it immediately available for crews to use.

    Verbatim wording from the response

    “████████ informed you in her letter that she had asked our Head of Clinical Communications and Telemetry to urgently review whether it was possible to add a closure code indicating that a patient has refused treatment or conveyance to hospital to our CAD system. I am pleased to advise that we have now implemented this coding within our system, and it is available for our crews to use immediately.”

    Source location

    Response from South Central Ambulance Service
    Page 1 · response
    Published 2 September 2025

    Open published response

  2. Cornwall and Isles of Scilly

    AI-generated summary

    Callum James Hargreaves · 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

    Callum James Hargreaves, who had a history of substance misuse and housing instability, was found dead in the sea on 20 January 2024 after being removed from a cliff edge and assessed under the Mental Health Act the previous day. The principal concerns were that the rationale for not pursuing a short-term admission was not recorded, and that clinicians did not further explore or test Callum’s refusal to allow his mother to be informed of his discharge. The report also noted that the Nearest Relative’s details appeared not to have been completed on the MH 1.

    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 explore or test a capacitated patient's refusal to disclose information to a potentially protective relative

    Wider context from the report

    “I accepted independent expert evidence that the mental health act assessment had been thorough and appropriately concluded there were no grounds in law for detaining Callum. Additionally, I accepted evidence given by the clinicians that while NICE guidance did allow for short-term admissions to manage a period of crisis in a patient presenting with complex PTSD/EUPD, that was not indicated here. It was identified that the rationale for reaching that decision was not recorded in the notes. This is a matter I have taken up separately with those responsible for the AMHP. 1) It was accepted in evidence that, owing to the decisions made by Callum, there were only limited options available to the clinicians. Of note, an offer to have personal follow-up by one of the clinicians involved in the assessment through the HTT was rejected. Additionally, the possibility of prescribing additional Diazepam was correctly discounted once it became evident Callum was already sourcing illicitly more than could be prescribed safely. 2) Callum refused permission for his mother (described as his rock) to be informed of his imminent discharge. On her evidence, she had been (wrongly) advised by police that her son would be detained and was safe. There was no evidence that this decision by Callum was explored or tested by the clinicians – instead it simply appeared to have been accepted by the clinicians without further enquiry. The independent expert was of the view that in a situation like this, where the assessing team had very few ‘levers’ available to it, Callum’s mother was potentially one that could and should have been explored further. It was noted that GMC guidance allows for further enquiry, specifically that 58. If an adult patient who has capacity to make the decision refuses to consent to information being disclosed that you consider necessary for their protection, you should explore their reasons for this. It may be appropriate to encourage the patient to consent to the disclosure and to warn them of the risks of refusing to consent. It was noted that the Nearest Relative’s details appeared not to have been completed on the MH 1. Again, this is a matter that has been brought to the attention of those responsible for the AMHP. ”

    Source location

    Callum James Hargreaves · 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

    Confidentiality duties and case-by-case clinical risk assessment determine whether refusal to share information should be explored or overridden.

    Verbatim wording from the response

    “It is important that contact with family is balanced against the wishes of the patient in cases where their level of risk is not such that there are grounds to override confidentiality, or them expressly declining consent to share information. Where a patient is detained under the Mental Health Act, and therefore there is a compulsory admission to hospital, there is an obligation upon the Approved Mental Health Practitioner to contact their next of kin to inform them of this fact. In cases where a patient does not meet the criteria for detention, and they are not admitted to a ward, a clinical judgement needs to be applied to determine whether their level of risk justifies going against any wishes regarding information sharing. In most patients who would not be deemed detainable under the Mental Health Act, it is unlikely that there would be such grounds to breach confidentiality.”

    Source location

    Response from Cornwall Partnership NHS Foundation Trust
    Page 3 · response
    Published 9 June 2025

    Open published response

  3. Lancashire and Blackburn with Darwen

    AI-generated summary

    Kevin Anthony Ince · 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

    Kevin Anthony Ince was detained under the Mental Health Act 1983 and became unwell at Kem Ple View Hospital on 24 October 2023. He was taken to hospital, where his condition deteriorated, and he died on 25 October 2023 from right ventricular failure caused by acute interstitial pneumonitis associated with vaping-related lung injury. The concerns included insufficient consideration of responses when detained patients refused necessary medical treatment and insufficient action when a detained patient routinely declined food over a prolonged period.

    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 take sufficient steps to persuade patients detained under the Mental Health Act who refuse necessary and appropriate medical treatment

    Wider context from the report

    “(1) The inquest heard clear evidence of lower refusals of necessary and appropriate medical treatment by patient detained under the Mental Health Act 1983, over several years with insufficient consideration of steps that were then appropriate including a lack of steps to persuade the patient, insufficient consideration of the powers under the Mental Capacity Act 2005 and insufficient consideration of utilising s.63 of the Mental Health Act 1983 (2) Insufficient action was taken when patient detained under the Mental Health Act 1983 routinely declined food over a prolonged period. ”

    Source location

    Kevin Anthony Ince · Prevention of Future Deaths report
    Page 1 · 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

    Insufficient action in response to routine food refusal by patients detained under the Mental Health Act 1983

    Wider context from the report

    “(1) The inquest heard clear evidence of lower refusals of necessary and appropriate medical treatment by patient detained under the Mental Health Act 1983, over several years with insufficient consideration of steps that were then appropriate including a lack of steps to persuade the patient, insufficient consideration of the powers under the Mental Capacity Act 2005 and insufficient consideration of utilising s.63 of the Mental Health Act 1983 (2) Insufficient action was taken when patient detained under the Mental Health Act 1983 routinely declined food over a prolonged period. ”

    Source location

    Kevin Anthony Ince · Prevention of Future Deaths report
    Page 1 · 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 sufficiently consider using section 63 of the Mental Health Act 1983 when patients detained under the Mental Health Act refuse necessary and appropriate medical treatment

    Wider context from the report

    “(1) The inquest heard clear evidence of lower refusals of necessary and appropriate medical treatment by patient detained under the Mental Health Act 1983, over several years with insufficient consideration of steps that were then appropriate including a lack of steps to persuade the patient, insufficient consideration of the powers under the Mental Capacity Act 2005 and insufficient consideration of utilising s.63 of the Mental Health Act 1983 (2) Insufficient action was taken when patient detained under the Mental Health Act 1983 routinely declined food over a prolonged period. ”

    Source location

    Kevin Anthony Ince · Prevention of Future Deaths report
    Page 1 · 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 sufficiently consider powers under the Mental Capacity Act 2005 when patients detained under the Mental Health Act refuse necessary and appropriate medical treatment

    Wider context from the report

    “(1) The inquest heard clear evidence of lower refusals of necessary and appropriate medical treatment by patient detained under the Mental Health Act 1983, over several years with insufficient consideration of steps that were then appropriate including a lack of steps to persuade the patient, insufficient consideration of the powers under the Mental Capacity Act 2005 and insufficient consideration of utilising s.63 of the Mental Health Act 1983 (2) Insufficient action was taken when patient detained under the Mental Health Act 1983 routinely declined food over a prolonged period. ”

    Source location

    Kevin Anthony Ince · 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

    Review the poor-diet-and-fluid-intake flowchart to include capacity, best interests, family involvement and section 63 considerations.

    Verbatim wording from the response

    “Following Mr Ince’s death, a ‘Management of Poor Diet and Fluid Intake’ flowchart was also introduced at Kemple View. I understand this was also explained by the Hospital Director during the inquest. This flowchart shows the process to follow when a patient has inadequate diet and fluid intake, to include escalation to the Responsible Clinician for discussion and referral to the Dietician for advice. The patient’s capacity to refuse an adequate nutritional diet is to be assessed and where the patient is deemed to be without capacity, a best interest meeting is to be arranged. All decision making is to be documented.”

    Source location

    Response from The Priory
    Page 2 · response
    Published 26 November 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

    Operate and review a database weekly to monitor food and fluid intake, with documented actions when patients refuse adequate nutrition.

    Verbatim wording from the response

    “A database has also been created at Kemple View to capture data about patients who are monitored using food and fluid intake charts: this will facilitate a more thorough review as to whether adequate nutrition is being accepted by the patient. This database is now reviewed weekly during an extended hospital handover meeting, with actions documented in accordance with the flowchart where a nutritional diet is refused.”

    Source location

    Response from The Priory
    Page 2 · response
    Published 26 November 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

    Deliver a staff briefing on good nutrition and fluid intake at Priory Hospital Kemple View.

    Verbatim wording from the response

    “A Priory dietician is scheduled to complete a briefing to Priory Hospital Kemple View staff in January 2025 on the topic of good nutrition and fluid intake.”

    Source location

    Response from The Priory
    Page 2 · response
    Published 26 November 2024

    Open published response

  4. Inner North London

    AI-generated summary

    Yemisi Cielto-Opaleye · 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

    Yemisi Cielto-Opaleye, a psychiatric inpatient at St Pancras Hospital, died on 13 December 2023 after receiving an Olanzapine depot injection and developing Olanzapine toxicity. The report identified concerns about inadequate pre- and post-injection vital-sign monitoring, unclear staff responsibilities, insufficient escalation and contingency planning, and failures to obtain required approval and provide adequate information about risks.

    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 assess the suitability of Olanzapine depot injections for in-patients who refuse vital signs checks

    Wider context from the report

    “(d) In cases where psychiatric in-patients are known to have a history of refusing vital signs checks, careful consideration and scrutiny should be given as to whether an Olanzapine depot injection is a suitable medication for such patients, especially in view of the crucial post-injection monitoring requirements. ”

    Source location

    Yemisi Cielto-Opaleye · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

  5. North Yorkshire and York

    AI-generated summary

    Stephen Frederick DULLING · 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

    Stephen Frederick Dulling, who had Parkinson’s disease, symptoms of dementia and swallowing problems, was admitted to York District Hospital and choked while eating toast, subsequently dying from aspiration pneumonia. Concerns included the response to reported risks before admission and multiple nursing-care lapses during his hospital admission, including the appropriateness of his diet, nutritional monitoring, response to choking and incident investigation.

    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 assess and escalate refusal of intravenous fluids

    Wider context from the report

    “4. I heard evidence of a number of omissions and lapses in the care afforded Mr Dulling by registered nurses during his admission to York District Hospital. My concerns relate to the following findings – a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs, despite Mr Dulling being deemed to lack capacity; b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, despite a) above; c) No food chart being implemented and maintained despite the outcome of Mr Dulling’s malnutrition risk assessment; d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids; e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking; f) The absence of a de-brief of staff involved in the choking incident by a nurse of the requisite level within the period of 72 hours after the event. This, together with the subsequent delay in undertaking and completing the patient safety investigation review, resulted in important gaps in the evidence supplied both to the review and the inquest. 5. My concern is that the above reflects a series of lapses in basic nursing care identified in respect of a single patient, a repetition of any of which could present a risk of future deaths to others. ”

    Source location

    Stephen Frederick DULLING · 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

    Introduce a Nucleus fluid assessment for all patients that prompts hydration monitoring according to clinical need.

    Verbatim wording from the response

    “Since this incident occurred there is a new fluid assessment, as part of the Nucleus digital patient record, which is completed for all patients. This then prompts appropriate hydration monitoring dependant on the level of clinical need. The Food, Nutrition and Hydration Policy clearly states that when a patient lacks capacity a best interest’s decision should be made about ongoing fluid management, in consultation with family or carers.”

    Source location

    Response from York and Scarborough Teaching Hospitals NHS Foundation Trust
    Page 2 · response
    Published 15 October 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 Food, Nutrition and Hydration Policy to require best-interest decisions on fluid management for patients lacking capacity, in consultation with family or carers.

    Verbatim wording from the response

    “It is accepted that the assessment of Mr Dulling’s nutritional needs on admission was not detailed enough and that a food chart was not instigated/completed when it should have been. The Trust’s Food, Nutrition and Hydration Policy (available if required) was updated in November 2024. There are currently several assessments, relating to eating and drinking and nutrition, that nursing staff undertake when a patient is admitted. These assessments are not all located in the same place and not as intuitive as they could be. We recognise that this is”

    Source location

    Response from York and Scarborough Teaching Hospitals NHS Foundation Trust
    Page 1 · response
    Published 15 October 2024

    Open published response

  6. East London

    AI-generated summary

    Mary Ebere Nwanyonyiri · 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

    Mary Ebere Nwanyonyiri was admitted to Goodmayes Hospital after deterioration in her mental state and was found unresponsive on 19 April 2021; post-mortem investigations found that she died from Covid-19 infection. The report raised concerns about the absence of a written care plan and completed risk assessment, the lack of clear assessment of her capacity to refuse physical observations, and failures to recognise and respond urgently to the severity of her condition.

    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 assessment of patients’ capacity to refuse physical observations

    Wider context from the report

    “1. Senior nursing staff who gave evidence at the Inquest did not appear to appreciate the importance of an agreed comprehensive care plan in which the multi-disciplinary ward team, patient and relatives are involved. The nursing staff did not acknowledge the value of a holistic care plan which incorporates the consideration of the many ways in which patients can be supported to engage in their recovery. Such a care plan could also incorporate assessments of capacity to refuse physical observations. There was no clear evidence of assessment of Mary’s capacity to refuse physical observations. ”

    Source location

    Mary Ebere Nwanyonyiri · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Inner South London

    AI-generated summary

    Mr Locksley Burton · Prevention of Future Deaths report

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

    Report summary

    Mr Locksley Burton, an 80-year-old disabled right leg amputee with dementia and other conditions, died in hospital on 24 April 2020 from mixed natural causes including systemic sepsis, Covid-19 pneumonia and osteomyelitis of the left heel. Concerns included inadequate wound inspections and dressing changes after diabetic foot clinic attendance was reduced, insufficient communication and care planning, and no demonstrated process for managing refusal of potentially life-threatening care where capacity was probably lacking.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of a process for managing patients who decline necessary potentially life-threatening care and may lack capacity

    Wider context from the report

    “Mr Burton did not receive adequate inspections of his wound and changes of dressings when the attendance at the diabetic foot clinic ceased to be weekly or fortnightly. The pandemic was a likely reason for this, but there might be other reasons in future for such changes. There was no evidence at inquest that alternative arrangements and revised care plan was made. The GP did not know of the reduction in clinic attendance or reduction in changes of dressing and assumed others were inspecting the wound and prescribed antibiotics without an examination being done. No witness was able to demonstrate any process of managing a patient who declined necessary potentially life threatening care and probably lacked capacity to make the decision. ”

    Source location

    Mr Locksley Burton · 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

    Expand consent and Mental Capacity Act learning and training for clinicians, including three completed consent seminars.

    Verbatim wording from the response

    “In the last three months, we have increased the range of learning and training available for our clinicians in relation to consent and the MCA through our internal and external legal partners. The Trust has already held three consent seminars with clinicians.”

    Source location

    Response from Kings College Hospital
    Page 2 · response
    Published 29 September 2022

    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

    Establish a working group to improve consent and Mental Capacity Act assessments.

    Verbatim wording from the response

    “In conjunction with the Corporate Medical Director for Quality and Governance, we have established a working group for improving consent and MCA assessments. We are working alongside the Director of Nursing for Vulnerable People and the Associate Director of Nursing for Mental Health to establish an improvement plan. This will include evaluation of the consent and MCA training programmes to ensure that these are effectively supporting staff in delivering best practice.”

    Source location

    Response from Kings College Hospital
    Page 3 · response
    Published 29 September 2022

    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

    Develop an improvement plan with nursing leads and evaluate consent and Mental Capacity Act training programmes.

    Verbatim wording from the response

    “In conjunction with the Corporate Medical Director for Quality and Governance, we have established a working group for improving consent and MCA assessments. We are working alongside the Director of Nursing for Vulnerable People and the Associate Director of Nursing for Mental Health to establish an improvement plan. This will include evaluation of the consent and MCA training programmes to ensure that these are effectively supporting staff in delivering best practice.”

    Source location

    Response from Kings College Hospital
    Page 3 · response
    Published 29 September 2022

    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 and update the Trust consent policy to make it easier for clinicians to follow and obtain additional support.

    Verbatim wording from the response

    “The Trust’s consent policy has been reviewed and updated to make it easier for clinicians to follow, and seek additional support as appropriate. In September 2022, we also initiated a Trust-wide consent audit through our Clinical Governance Leads forum; the results of which will be reviewed through the Patient Safety Committee which is chaired by the Chief Medical Officer.”

    Source location

    Response from Kings College Hospital
    Page 3 · response
    Published 29 September 2022

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The Home disputes that Mr Burton probably lacked capacity, stating he was assessed as having capacity throughout his residence.

    Verbatim wording from the response

    “It is important to note that Mr Burton was deemed to have capacity on admission and throughout his time at the Home. Mr Burton had been diagnosed with a personality disorder, but this did not affect any decision on his capacity. Mr Burton had no formal diagnosis of dementia and he was regularly reviewed by staff at the Home and external professionals. Mr Burton was also under the care of the South London and Maudsley Trust’s Care Home Intervention Team (CHIT). His presentations in relation to non-compliance with personal care and assessment of his cognition were assessed by the CHIT, initially in December 2019 and as relevant after this date. The CHIT consulted with staff at the Home and with Mr Burton’s daughter. Mr Burton’s daughter is recorded as advising that Mr Burton's significant behavioural issues were not reflective of a diagnosis of dementia.”

    Source location

    Response from The Kind Care Company
    Page 2 · response
    Published 29 September 2022

    Open published response

  8. Leicester City and South Leicestershire

    AI-generated summary

    Jamie Francis O'Connor · 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

    Jamie O’Connor was found deceased in the garden of his home in Leicester on 14 October 2018 after his mother became concerned that he was not responding to phone calls. The report identified concerns about online prescribing, including the lack of central tracking, limited information sharing with GPs, no required face-to-face consultation, limited questionnaires, patients requesting specific drugs, and limited regulation; the inquest concluded that this was a drug-related death and recorded the cause as ████████ toxicity.

    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 flag refusal to share prescribing information for further enquiry

    Wider context from the report

    “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs. 2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP. 3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed; 4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed; 5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber; 6. By virtue of where the company prescribing the drugs was registered there was limited regulation. ”

    Source location

    Jamie Francis O'Connor · 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

    Inspect online providers’ management of medicines, prescriptions, consent, identity checks, information sharing, governance and staff safety training.

    Verbatim wording from the response

    “For those providers who fall within the CQC’s scope of regulation we inspect against the regulations using an inspection framework. All providers must comply with the regulations as set out in The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (RAR 2014). The regulations that would be most relevant to any reviews around online providers, would include, but not be limited to, the following:”

    Source location

    2021-0363-Response-from-CQC_Published
    Page 2 · response
    Published 4 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

    Publish guidance requiring providers to inform patients’ GPs about prescribed medications and assess safety when patients decline information sharing.

    Verbatim wording from the response

    “CQC has published guidance for providers¹. The guidance describes the expectations of providers to ensure a patient’s GP is informed of prescribed medications from their service. We also expect that should the patient decline to consent for the sharing”

    Source location

    2021-0363-Response-from-CQC_Published
    Page 2 · response
    Published 4 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

    Publish updated prescribing guidance covering remote consultation suitability, information sharing, patient dialogue, and safeguards for controlled or potentially addictive medicines.

    Verbatim wording from the response

    “Following this exercise, we published updated guidance for doctors on prescribing in February 2021. This now places a greater emphasis on following the principles of good practice regardless of the medium through which a consultation is taking place, face to face or online.”

    Source location

    2021-0363-Response-from-GMC_Published
    Page 1 · response
    Published 4 November 2021

    Open published response

  9. Mid Kent and Medway

    AI-generated summary

    ELEANOR ROSE MURPHY-RICHARDS · 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

    Ellis died on 30 September 2020 after jumping from a footbridge onto a railway track in front of an oncoming train, intending to end his life. Concerns included gaps in the safety plan, a deviation from it without an updated risk assessment, incomplete sharing of information about a recent failed hanging attempt, and advice that did not account for the risk of Ellis leaving the centre.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of a protocol for Mental Health Act assessment of people who will not voluntarily attend hospital Accident & Emergency

    Wider context from the report

    “The Child & Adolescent Mental Health Centre provides services to children and young people, some of whom may require Mental Health Act assessment. There is no protocol or policy for those that require Mental Health Act assessment and will not voluntarily attend hospital Accident & Emergency. ”

    Source location

    ELEANOR ROSE MURPHY-RICHARDS · 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

    The Trust had no legal power to hold Ellis, and staff restraint or detention could constitute assault or unlawful imprisonment.

    Verbatim wording from the response

    “In the circumstances the Trust acted within their remit as prescribed by law. The Trust had no legal power to hold Ellis. Given this, the Trust considers that it did comply with its safety plan for Ellis. The Trust also consider that the contingency plan would have been, at the correct time, to have called the police, which did occur. However as a learning organisation the Trust fully accepts that there are always elements of cases that can be used for learning and it will continue to reflect on its practice and procedures for all cases going forward.”

    Source location

    2021-0237-Response-from-Trust-Head-Office_Published
    Page 3 · response
    Published 15 July 2021

    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

    Police Section 136 powers and attendance were contingent on statutory conditions and evidence of refusal to attend A&E.

    Verbatim wording from the response

    “The police have powers under Section 136 of the Mental Health Act to detain a person who is in a public place and appears in immediate need of care or control; the police would thereby take them to a place of safety for assessment.”

    Source location

    2021-0237-Response-from-Trust-Head-Office_Published
    Page 6 · response
    Published 15 July 2021

    Open published response

  10. Inner North London

    AI-generated summary

    John William Pearce · 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

    John William Pearce was a frail 90-year-old man who developed a worsening left knee wound after an injury in April 2018 and died in hospital on 21 September 2018. The report identified concerns about delayed hospital referral, insufficient district nursing attendances, reliance on his reluctance to attend hospital, and inadequate systems for recognising and sharing information about worsening wounds.

    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

    Overreliance on patient refusal of hospital care despite difficulty expressing himself

    Wider context from the report

    “I am concerned that: (a) There was no clear instruction, protocol or system which assists nursing staff in dealing with elderly patients who suffer from open wounds which worsen over time, as to when the emergency services should be contacted. It is clear that the staff were following a Tissue Viability Nurse care plan, but no-one appeared to recognise the severity of the injury and the fact that tendons and bone were exposed; (b) There were insufficient attendances on Mr Pearce by the District Nurse Team when it appeared to be decided that he would be visited at more frequent intervals; (c) Too much emphasis was placed on Mr Pearce’s own view that he did not like hospitals and did not want to go there, even though he was noted to be an individual who had difficulty expressing himself; (d) There was no clear evidence that photographs taken of the wound were shared with other agencies or the deceased’s GP, such that another view could be taken of those wounds so as to consider whether the emergency services should become involved as a matter of urgency. ”

    Source location

    John William Pearce · 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

    Consider adapting existing Mental Capacity Act training to support capacity and best-interests decisions when patients decline appropriate care.

    Verbatim wording from the response

    “This case has highlighted the difficulties of safely managing patients who decline care against clinical advice. In cases where health workers believe the patient is making unwise decisions against hospital admission and more frequent visits in his/her own home, we provide specific safeguarding advice and will now consider how best to adapt our existing Mental Capacity Act (MCA) training to support the application of the MCA, and best interests need to be made on each occasion when the patient is declining appropriate clinical care.”

    Source location

    2019-0068-Response-by-CNWL-NHS-Trust
    Page 3 · response
    Published 2 June 2019

    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

    Tighten formal, regular mental-capacity assessment and accurate recording when consequential treatment decisions are made.

    Verbatim wording from the response

    “We are tightening our process for ensuring that there is formal and regular mental capacity assessment at the point that treatment decisions of consequence are being made and recorded accurately in our clinical records.”

    Source location

    2019-0068-Response-by-CNWL-NHS-Trust
    Page 3 · response
    Published 2 June 2019

    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

    Provide bespoke community training on capacity, best interests, and supporting clinical documentation.

    Verbatim wording from the response

    “During May our Safeguarding Adults lead will also be providing additional bespoke training for capacity and best interest in community settings including supporting clinicians with necessary documentation.”

    Source location

    2019-0068-Response-by-CNWL-NHS-Trust
    Page 3 · response
    Published 2 June 2019

    Open published response
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Data last updated 7 September 2026