13 Jan 2025 Aarav Pal CHOPRA · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 6 Lack of a mechanism to evidence trainees' experience and competence across hospital trusts View source Lack of a mechanism to identify and communicate individual patient risk factors View source Lack of access to all clinical records when planning treatment View source Lack of a way to obtain consent when a trainee performs a procedure View source Failure to learn from deaths at the earliest opportunity View source Lack of guidance for prophylactic antibiotics in severely immunocompromised patients View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Aarav Pal CHOPRA · 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
Aarav Pal CHOPRA died on 22 November 2023 after an intercostal artery was damaged during a liver biopsy, causing a haemothorax, cardiac arrest and hypoxic brain injury. The report identified concerns about inadequate planning and communication, delayed recognition and treatment of the haemothorax, unclear decision-making, trainee competence, consent, patient risk factors, prophylactic antibiotics, learning from deaths and access to complete electronic records.
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. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism to evidence trainees' experience and competence across hospital trusts
Wider context from the report “2. Experience and competence of trainees: The inquest heard evidence that there was confusion around the experience and level of the trainee involved. He was thought to be an ST6 when he was an ST4. My concern is that there is no mechanism to evidence trainees experience and competence when they travel to various different hospital trusts as part of their training .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism to identify and communicate individual patient risk factors
Wider context from the report “4. Individual patient risk factors: Aarav had a complex medical background and several risk factors for any procedure. My concern is that there is currently no mechanism to identify individual patient’s risk factors so that all clinicians involved in their care are aware .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of access to all clinical records when planning treatment
Wider context from the report “6. Electronic patient records: I heard evidence that the lack of electric medical records meant clinicians found it difficult to see all of the patient’s medication details . My concern is that critical information can be missed if clinicians do not have access to all the clinical records when planning treatment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a way to obtain consent when a trainee performs a procedure
Wider context from the report “3. Consent forms: The parents of Aarav were unaware that a trainee would be doing the liver biopsy. My concern is that there is currently no way to obtain consent when a trainee will be doing the procedure .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to learn from deaths at the earliest opportunity
Wider context from the report “5. Learning from deaths: The initial M&M meeting after Aarav's death was described as inadequate. My concern is that there was no immediate learning from this tragedy and further consideration is needed to ensure a safe and effective mechanism to properly learn from deaths at the earliest opportunity .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for prophylactic antibiotics in severely immunocompromised patients
Wider context from the report “1. Prophylactic antibiotics for severely immunocompromised patients: The inquest heard evidence that patients like Aarav who are immunocompromised require additional prophylactic antibiotics for procedures. This is not covered in the current NICE guidelines. My concern is that there is currently no guidance for the use of prophylactic antibiotics in severely immunocompromised patients .
” 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 an electronic patient record providing staff with accessible medication details and individual patient risk factors.
Verbatim wording from the response “The importance of effective communication between colleagues will be reiterated across the workforce. In addition to this, the roll out of the Electronic Patient Record (EPR), which is due to go live in May 2025 will provide the ability to see at a glance individual patient risk factors.” Source location Response from Birmingham Women's and Children's NHS Foundation Trust
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 Reinforce consent guidance requiring families to be informed when clinicians in training may perform procedures.
Verbatim wording from the response “GMC consent guidance states that patients and families should be given the right not to be involved where teaching, training or research is taking place. Therefore, families should be advised at the time of the procedure if a clinician in training may be performing the procedure. BWC will reinforce this GMC guidance to its consultant body in order to ensure the correct conversations are had between colleagues and importantly with our families. This information was shared in the recent Senior Medical and Dental Staff Committee meeting and has been followed up with an email to the consultant body.” Source location Response from Birmingham Women's and Children's NHS Foundation Trust
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 Require trainers to discuss trainee competence and support with the named educational or clinical supervisor before procedures or treatment.
Verbatim wording from the response “We will ensure that this process is strengthened further:” Source location Response from Birmingham Women's and Children's NHS Foundation Trust
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 liver biopsy guidance with microbiology input and relevant evidence to determine prophylactic antibiotic timing for severely immunocompromised patients.
Verbatim wording from the response “Prophylactic antibiotics for severely immunocompromised patients: The inquest heard evidence that patients like Aarav who are immunocompromised require additional prophylactic antibiotics for procedures. This is not covered in the current NICE guidelines. Your concern is that there is currently no guidance for the use of prophylactic antibiotics in severely immunocompromised patients.
The Hepatology Team are in the process of reviewing the Trust’s Liver Biopsy Guidance and are seeking the expert view of Microbiology colleagues to determine if any evidence which suggests that immunocompromised patients need prophylactic antibiotics at a different time.” Source location Response from Birmingham Women's and Children's NHS Foundation Trust
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 Share trainee competence and support information in local faculty group meetings.
Verbatim wording from the response “We will ensure that this process is strengthened further:” Source location Response from Birmingham Women's and Children's NHS Foundation Trust
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 Disseminate haemothorax management learning through trauma scenario training and a one-page incident summary.
Verbatim wording from the response “Recommendation 9 (LP8) - Disseminate learning about management of haemothorax from this case in trauma scenario training and by distribution of a 1-page summary of the incident and the learning points identified. In progress” Source location Response from Birmingham Women's and Children's NHS Foundation Trust
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 the Trust-wide M&M process, develop terms of reference, consult clinical leads and obtain external review support to identify improvements.
Verbatim wording from the response “The Trust’s entire M&M process is currently under review. Terms of reference are being developed, and support has been requested from the lead at GOSH to assist with the reviews. Meetings with the Clinical Service and Governance Leads are in place over the coming weeks with 4 main specialities at the Trust’s Children’s site to review the current practice and identify areas for development. We expect this work to be complete by May 2025.” Source location Response from Birmingham Women's and Children's NHS Foundation Trust
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 Communicate strengthened trainee oversight arrangements to consultants and monitor them through postgraduate education governance.
Verbatim wording from the response “4. The Chief Medical Officer has communicated with the consultant body in the recent Senior Medical and Dental Staff Committee meeting and has followed this up with an email.” Source location Response from Birmingham Women's and Children's NHS Foundation Trust
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 weekly PSIRF Decision Team meetings to select learning methodologies for relevant incidents and deaths.
Verbatim wording from the response “A weekly PSIRF Decision Team meeting was set up on 29 April 2024 and is chaired either by the Chief Medical Officer or Chief Nursing and Midwifery Officer. In attendance at these meetings are appropriate representatives from all Divisions within the Trust, who present specific incident categories and deaths where there might be questions raised about the care provided, identified through incident reporting structures and complaints.” Source location Response from Birmingham Women's and Children's NHS Foundation Trust
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 amend Interventional Radiology governance practice to achieve learning at the earliest opportunity.
Verbatim wording from the response “In addition, governance practice within the Interventional Radiology Department is under review and will be amended to ensure that learning is achieved at the earliest opportunity.” Source location Response from Birmingham Women's and Children's NHS Foundation Trust
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 Current guidance and practice do not indicate that prophylactic antibiotics should be administered earlier for severely immunocompromised patients.
Verbatim wording from the response “The Trust will respond to expert advice, literature and national guidance on this issue, noting that NICE and BNF guidance in context of certain types of surgery states that IV antibiotics should be given up to half an hour prior to any procedure even in immunosuppressed individuals. Currently,” Source location Response from Birmingham Women's and Children's NHS Foundation Trust
Open published response
3 Aug 2022 Kellum Paul Thomas · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Delays in sending outpatient letters containing important clinical information View source Failure to robustly manage the list of children waiting for replacement devices View source Delays in REVEAL device replacement View source Failure to clearly identify REVEAL device battery end of life View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Kellum Paul Thomas · 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
Kellum Paul Thomas, aged thirteen, collapsed at home on 9 June 2021 and died after a cardiac arrest caused by ventricular tachycardia deteriorating into ventricular fibrillation. Concerns included an 18-month gap without a functioning REVEAL heart-monitoring device, delayed replacement processes, and a significantly delayed outpatient letter containing medication and investigation information. The report also identified stretched team capacity and resources and stated that necessary actions to address these issues were not confirmed.
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. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in sending outpatient letters containing important clinical information
Wider context from the report “2. Kellum’s outpatient letter from ████████ to both the GP and to Nottingham University Hospitals NHS Trust (where shared care was provided) was very delayed , with the outpatient appointment completed in March 21, and the letter not reaching its destinations until mid June 21, after Kellums death . This letter contained important information re a change in medication dosage and a request for NUH to arrange a further investigation. Again this issue appeared to be one of team capacity and resources.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to robustly manage the list of children waiting for replacement devices
Wider context from the report “1. Kellum was without a REVEAL device to monitor his heart rate and rhythm for an 18 month period, despite this being an agreed necessary part of his treatment. The evidence from ████████, Consultant Paediatric Cardiologist, was that there was no robust system for clearly identifying when a battery within a REVEAL device, came to the end of its life, nor was there a robust system for managing the list of children waiting for a replacement device. Also that the waiting list for a device change was excessively long (over 12 months for urgent cases, and longer for those less urgent). Also that capacity and resources were very stretched as the Specialist Paediatric Cardiology team dealing with these issues, was small, and covering both East and West Midlands.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in REVEAL device replacement
Wider context from the report “1. Kellum was without a REVEAL device to monitor his heart rate and rhythm for an 18 month period, despite this being an agreed necessary part of his treatment. The evidence from ████████, Consultant Paediatric Cardiologist, was that there was no robust system for clearly identifying when a battery within a REVEAL device, came to the end of its life, nor was there a robust system for managing the list of children waiting for a replacement device. Also that the waiting list for a device change was excessively long (over 12 months for urgent cases, and longer for those less urgent) . Also that capacity and resources were very stretched as the Specialist Paediatric Cardiology team dealing with these issues, was small, and covering both East and West Midlands.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly identify REVEAL device battery end of life
Wider context from the report “1. Kellum was without a REVEAL device to monitor his heart rate and rhythm for an 18 month period, despite this being an agreed necessary part of his treatment. The evidence from ████████, Consultant Paediatric Cardiologist, was that there was no robust system for clearly identifying when a battery within a REVEAL device, came to the end of its life , nor was there a robust system for managing the list of children waiting for a replacement device. Also that the waiting list for a device change was excessively long (over 12 months for urgent cases, and longer for those less urgent). Also that capacity and resources were very stretched as the Specialist Paediatric Cardiology team dealing with these issues, was small, and covering both East and West Midlands.
” Open source report
19 May 2022 Spencer George BARR · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Lack of central points of contact for inter-agency referrals and information sharing View source Lack of a universal approach to inter-agency cooperation View source Failure of organisations to accept direct referrals from other agencies View source Failure to share relevant information adequately between agencies View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Spencer George BARR · 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
Spencer George BARR was found unresponsive at home on 9 December 2021 and was declared deceased by paramedics after an overdose involving opioids, cocaine and pregabalin. He had a long history of substance misuse and labile mental health and was under the care of probation, addiction and mental health services. The principal concerns were inadequate sharing of information and cooperation between agencies, the lack of central points of contact, and limitations on inter-agency referrals.
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. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of central points of contact for inter-agency referrals and information sharing
Wider context from the report “4. Additionally, I am concerned that there appear to be no central points of contact for agencies to facilitate that co-operation . I heard evidence that CGL has no central point of contact for referrals being made/to allow sharing of information - instead relying on information being conveyed via specific individuals. I am therefore concerned that where there is no central point of contact, there is a risk of information not being passed on in a timely manner when a specified person is absent from work for whatever reason . Consideration should be given to central points of contact being created within each agency, and ensuring that those points of contact are shared between agencies to ensure information can flow freely between them.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a universal approach to inter-agency cooperation
Wider context from the report “3. I heard evidence that Birmingham Women's and Children's NHS Foundation Trust are now taking steps to improve intra-agency co-operation in an attempt to mitigate against the risk of further deaths in the future. However, I heard evidence that other agencies may not be aware of their own limitations when it comes to inter-agency co-operation. For instance, CGL gave evidence that they had no concerns regarding their co-operation with other services, but Birmingham Women's and Children's NHS Foundation Trust indicated that the connections between their respective agencies was poor. I am therefore concerned that there is no universal approach being taken by all agencies to improve inter-agency cooperation , and consideration should be given to the formation of a working group being set up between all agencies to ensure a coordinated approach is taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of organisations to accept direct referrals from other agencies
Wider context from the report “5. Furthermore, I heard evidence that certain organisations do not accept direct referrals or share information between agencies. For instance, I heard that CGL solely depend on referrals from GP practices and do not allow referrals direct from other agencies . Consideration therefore should be given as to whether there a better system of interagency referral is possible
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant information adequately between agencies
Wider context from the report “2. I heard evidence that full circumstances surrounding Spencer's deterioration and drug relapse in November 2021 - namely that he had received a significant back payment of benefits totalling over £5,000 from the DWP resulting in him purchasing drugs and overdosing - were not adequately conveyed between agencies , and as such agencies were unaware of the heightened risk of potential self harm and death that was posed by these circumstances. Inter-agency co-operation therefore appears to be inadequate , and consideration should be given to ensuring clinicians receive better training when it comes to the sharing of relevant information between agencies.
” Open source report
10 Sep 2019 Gurdeep Singh Dundhal · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5 Delays in organising timely mental health assessments View source Failure to obtain and have available key information and documentation for mental health assessments View source Failure to undertake internal investigations into assessment delays and resource concerns View source Failure to engage with other agencies to learn lessons from complex cases View source Failure to place patients on the recommended Mental Health Act section View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gurdeep Singh Dundhal · 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
Gurdeep Singh Dundhal, who had paranoid schizophrenia and used illicit substances, died after jumping from the fifth storey of a car park on 27 April 2019; he passed away in hospital on 28 April 2019. The concerns included delays and resource problems in arranging a mental health assessment, missing information during the assessment, the decision to use section 2 rather than the recommended section 3, and failure to investigate and learn lessons across agencies.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in organising timely mental health assessments
Wider context from the report “1. There was a delay in organising the assessment of Mr Dundhal when he was detained on S5(2) of the Mental Health Act on 11/04/19. The evidence confirmed there appeared to be confusion as to who was undertaking the assessment between Walsall MBC and Birmingham City Council . In addition there was a lack of resources to enable the assessment to be carried out in a timely manner . This meant the assessment was carried out just a few hours before the time period for the S5(2) was to expire.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and have available key information and documentation for mental health assessments
Wider context from the report “2. Evidence at the inquest from the approved Mental health practitioner confirmed that key information and documentation were either unavailable and/or not asked for during the mental health act assessment on 14/04/19. I was unable to confirm which at the inquest. This meant the true nature of Mr Dundhal’s long term condition was not known and the assessors were unable to see the “bigger picture”. The delay in arranging the assessment contributed to the lack of available information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake internal investigations into assessment delays and resource concerns
Wider context from the report “4. Walsall MBC has failed to undertake an internal investigation into the delays and resources concerns during the assessment in April 19 . They have also failed to engage with other agencies to ensure lessons are learnt. It is essential in complex cases like this that all agencies work together after a tragedy to ensure lessons are learnt to protect others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to engage with other agencies to learn lessons from complex cases
Wider context from the report “4. Walsall MBC has failed to undertake an internal investigation into the delays and resources concerns during the assessment in April 19. They have also failed to engage with other agencies to ensure lessons are learnt . It is essential in complex cases like this that all agencies work together after a tragedy to ensure lessons are learnt to protect others .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to place patients on the recommended Mental Health Act section
Wider context from the report “3. When Mr Dundhal was admitted to hospital on 15/03/19 he was placed on S2 of the Mental Health Act when his clinical team had specifically recommended he be placed on S3 . No explanation was available for this . Evidence at the inquest suggested this was a decision made by the Approved Mental health practitioner from Birmingham City Council. Consideration needs to given as to why a S3 was not put in place in accordance with the recommendation .
” 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 Redistribute safer inter-agency information-sharing guidance within the urgent care team and through local governance meetings.
Verbatim wording from the response “I would like to reassure you, however, that FTB records are held electronically and these are easily available to be shared where appropriate. Although we are unable to establish the precise circumstances of this call, as a direct result of your report, we have redistributed the safer inter agency information sharing guidance within the urgent care team and at the local governance meetings to ensure that any lessons to be learnt are implemented.” Source location 2019-0294-Response-by-Birmingham-Womens-and-Childrens-NHS-Trust
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 Continue engaging with other agencies to learn from incidents and improve patient care.
Verbatim wording from the response “We will continue to engage with other agencies to enable the Trust to learn from incidents and improve patient care.” Source location 2019-0294-Response-by-Birmingham-Womens-and-Childrens-NHS-Trust
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 Trust could not fully investigate the records request because it could not identify the telephone number used by the Approved Mental Health Practitioner.
Verbatim wording from the response “In preparing this response, we have obtained the call logs from 14 April 2019, providing the telephone numbers which called in to the Access Centre on that day. We were concerned to hear at the inquest that the request for Mr Dundhal’s records was made and not complied with. Unfortunately, we have not been able to establish the telephone number which the Approved Mental Health Practitioner called from and as such we are limited in our investigations on this point.” Source location 2019-0294-Response-by-Birmingham-Womens-and-Childrens-NHS-Trust
Open published response
14 Sep 2018 Daniel Hubert Collins · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Transfer of necessary mental health care placing responsibility for initiating contact on patients View source Failure to follow up with receiving services and patients after mental health care transfers View source Failure to notify the receiving mental health service about care transfers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Daniel Hubert Collins · 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
Daniel Hubert Collins attempted to take his own life by overdose on 07/04/18 and was discharged from hospital and then from the FTB crisis team, with responsibility placed on him to contact counselling services. He went missing on 26/04/18 and was found deceased in woodland on 28/04/18; the medical cause of death was venlafaxine overdose. The report identified concern that the transfer between mental health services was not communicated or followed up, creating a risk that patients in or recently out of crisis could be lost to mental health services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Transfer of necessary mental health care placing responsibility for initiating contact on patients
Wider context from the report “One mental health service, FTB crisis team, transferred necessary mental health care to a second service Living Well consortium (LWC), putting the responsibility of making contact on the patient (aged 22, and only 72 hours post-attempting to take his own life). The rational was “it is part of their recovery, empowers them and gives them choices”. FTB crisis team did not alert LWC to the transfer and did not follow up with LWC or the patient that contact had been made. There was/is no system in place to require FTB crisis team to notify LWC about the transfer or trigger a follow up with LWC/the patient. Therefore, patients are at risk of being lost to the mental health service whilst in crisis/only recently out of crisis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up with receiving services and patients after mental health care transfers
Wider context from the report “One mental health service, FTB crisis team, transferred necessary mental health care to a second service Living Well consortium (LWC), putting the responsibility of making contact on the patient (aged 22, and only 72 hours post-attempting to take his own life). The rational was “it is part of their recovery, empowers them and gives them choices”. FTB crisis team did not alert LWC to the transfer and did not follow up with LWC or the patient that contact had been made. There was/is no system in place to require FTB crisis team to notify LWC about the transfer or trigger a follow up with LWC/the patient . Therefore, patients are at risk of being lost to the mental health service whilst in crisis/only recently out of crisis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the receiving mental health service about care transfers
Wider context from the report “One mental health service, FTB crisis team, transferred necessary mental health care to a second service Living Well consortium (LWC), putting the responsibility of making contact on the patient (aged 22, and only 72 hours post-attempting to take his own life). The rational was “it is part of their recovery, empowers them and gives them choices”. FTB crisis team did not alert LWC to the transfer and did not follow up with LWC or the patient that contact had been made. There was/is no system in place to require FTB crisis team to notify LWC about the transfer or trigger a follow up with LWC/the patient. Therefore, patients are at risk of being lost to the mental health service whilst in crisis/only recently out of crisis.
” Open source report
21 Aug 2018 Kiarah Faith Adora Allen · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Insufficient nursing and clinical staffing for very sick babies View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kiarah Faith Adora Allen · 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
Kiarah Faith Adora Allen was born extremely prematurely and died after an inadvertent total parenteral nutrition fluid overload during a change of treatment, which led to severe metabolic complications and cardiac failure. The report identified unsafe staffing levels, failure to follow the correct procedure, and failure to learn from a previous similar incident. The principal concern was that staffing levels were insufficient when the neonatal unit was full.
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. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient nursing and clinical staffing for very sick babies
Wider context from the report “1. I heard evidence in the inquest that at the time this incident occurred there were unsafe levels of nursing and clinical staff . The funding provided for nurses assumed the unit was only 85% full. Therefore when the unit was full, there were insufficient numbers of nurses and doctors . Consideration needs to be given to providing additional funding to enable the unit to be appropriately staffed for the very sick babies they care for.
” 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 the neonatal workforce plan and continue recruitment to restore staffing capacity.
Verbatim wording from the response “• Action 5: A new workforce plan will be developed by the senior leadership in neonates.
o The workforce plan is live, but recovery through increased recruitment is on-going.” Source location 2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
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 Allocate nurses to specific babies on every shift and reinforce the allocation process through staff communications.
Verbatim wording from the response “• Action 2: Nurses are allocated to specific babies each shift.
o The nurse in charge (NIC) is allocating babies to nurse every shift. This is being reinforced through the staff weekly newsletter.” Source location 2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
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 Reconstruct and align the NICU e-roster with the workforce plan.
Verbatim wording from the response “• Action 24: Head of Nursing to complete and implement a NICU workforce plan.
o The Workforce plan is being implemented and the NICU e-roster has been reconstructed and aligned to the workforce plan.” Source location 2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
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 Price the Vocera system for staff to summon colleague support.
Verbatim wording from the response “• Action 13: Head of Nursing to price the vocera system for staff to be able to summon support from colleagues, if required.
o Pricing for Vocera for all clinical areas is a current on-going task.” Source location 2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
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 Move babies where possible to support the safest care, while embedding the practice fully.
Verbatim wording from the response “• Action 9: Previous shift NIC to review babies and move them where necessary.
o Within current practice, the NIC is moving babies where ever possible to permit the safest possible care, however this is not yet fully embedded.” Source location 2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Open published response
15 Mar 2017 Leah Abby Ratheram · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Lack of early approved social worker involvement in Mental Health Act assessments View source Unclear responsibility for patients during transfer between mental health services View source Failure to share and access mental health records effectively between organisations View source Lack of coordinated mental health care during crisis and transfer View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Leah Abby Ratheram · 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
Leah Abby Ratheram, who had autism, foetal alcohol syndrome and a history of self-harm, died after being found hanging from a tree on 7 October 2016. The report raised concerns about the lack of coordinated care and unclear responsibility between mental health organisations, ineffective sharing of records and risk information, and uncertainty about the Mental Health Act assessment 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. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of early approved social worker involvement in Mental Health Act assessments
Wider context from the report “3. The Mental Health Act assessment process was followed in this case was unclear. An approved social worked declined to be involved until the assessment had been completed. There is a concern that lack of involvement of this specialty at any early stage will affect the quality of mental health act assessments and the safety of patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for patients during transfer between mental health services
Wider context from the report “1. Adults aged between 18 – 25 now have mental health services provided by two organisations – Forward Thinking Birmingham and Birmingham and Solihull Mental Health Trust. If a patient presents in crisis to A&E they will be seen by someone from the RAID team who work for Birmingham and Solihull Mental Health Trust. If they require ongoing treatment they will be referred to forward Thinking Birmingham. There is a concern that patients will have no coordinated approach to their care at a time of crisis. It is also unclear who will ultimately be responsible for the patient, particularly during the period of transfer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share and access mental health records effectively between organisations
Wider context from the report “2. Both organisations use different record keeping systems. There is a real risk that information will not be shared effectively and key risk factors will be missed in the handover process. It was unclear how staff from each organisation would access each other’s records when patients present to one or other of the services.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of coordinated mental health care during crisis and transfer
Wider context from the report “1. Adults aged between 18 – 25 now have mental health services provided by two organisations – Forward Thinking Birmingham and Birmingham and Solihull Mental Health Trust. If a patient presents in crisis to A&E they will be seen by someone from the RAID team who work for Birmingham and Solihull Mental Health Trust. If they require ongoing treatment they will be referred to forward Thinking Birmingham. There is a concern that patients will have no coordinated approach to their care at a time of crisis. It is also unclear who will ultimately be responsible for the patient, particularly during the period of transfer.
” Open source report
Concerns raised 3 Inadequate frequency of anti-factor Xa review for pregnant women with mechanical valves View source Failure of clinicians managing pregnant women with mechanical heart valves to understand the thrombosis risk and anticoagulation implications View source Insufficient clexane dosing for pregnant women with mechanical valves View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Hireiti Kufletsion · 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
Hireiti Kufletsion died at Queen Elizabeth Hospital Birmingham on 20 November 2014 from thrombosis of a mechanical mitral valve during the first trimester of pregnancy. The report identified failures to adequately investigate the valve, seek specialist cardiology advice and prescribe adequate doses of clexane, with concerns that pregnant women with mechanical heart valves may be at risk from insufficient anticoagulation and inadequate clinical understanding of the associated thrombosis risk.
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. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate frequency of anti-factor Xa review for pregnant women with mechanical valves
Wider context from the report “(1) In giving evidence ████████ stated that from time to time she does see at her Obstetric/Cardiac clinic pregnant patients with mechanical valves who have had their warfarin changed to clexane at other hospitals in the region on too low a dose of clexane (i.e. not a twice daily 60mg/kg dose). Likewise she is aware that review of anti-factor Xa may not be arranged to occur with adequate frequency (once a week) . Therefore pregnant women with mechanical valves may be at risk from being prescribed insufficient doses of clexane with insufficient review of their anti-factor Xa .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of clinicians managing pregnant women with mechanical heart valves to understand the thrombosis risk and anticoagulation implications
Wider context from the report “(2) It was apparent from evidence given by clinicians at the Birmingham Heartlands Hospital that they did not understand the extent and gravity of the increased risk of thrombosis to pregnant women with mechanical heart valves and this affected the course of investigations into the deceased’s condition ultimately resulting in a delay in diagnosis until it was too late. Whilst this issue has now been brought to the full attention of all departments within the Birmingham Heartlands Hospital, it is reasonable to assume that there are haematologists, cardiologists and obstetricians without specialist cardio-obstetric knowledge across the country that do not appreciate the implications during pregnancies of patients with a mechanical heart valve for anti-coagulation therapy but maybe involved in the management and care of such patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham Women'S and Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient clexane dosing for pregnant women with mechanical valves
Wider context from the report “(1) In giving evidence ████████ stated that from time to time she does see at her Obstetric/Cardiac clinic pregnant patients with mechanical valves who have had their warfarin changed to clexane at other hospitals in the region on too low a dose of clexane (i.e. not a twice daily 60mg/kg dose) . Likewise she is aware that review of anti-factor Xa may not be arranged to occur with adequate frequency (once a week). Therefore pregnant women with mechanical valves may be at risk from being prescribed insufficient doses of clexane with insufficient review of their anti-factor Xa.
” Open source report
Pin
Request correction
Addressed to Birmingham Women'S NHS Foundation Trust, now represented here by Birmingham Women'S and Children'S NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations