26 Jun 2026 Susan Dale · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 3 Inaccurate and inconsistent record keeping View source Failure to provide handover information between care shifts View source Failure to follow the falls policy for suspected head, neck, back or hip injury View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Susan Dale · 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
Susan Dale, a resident of Westfields Residential Home, fell while being assisted with her morning routine on 8 April 2026 and later deteriorated, was taken to hospital, and died on 18 April 2026. The principal concerns were inaccurate and inconsistent records about the fall, moving her despite a recorded possible head injury without prompt clinical assessment, and the absence of an effective handover to staff taking over her care.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Inaccurate and inconsistent record keeping
Wider context from the report “(1) The record keeping in the home appears to be inaccurate and inconsistent
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to provide handover information between care shifts
Wider context from the report “(3) The senior care worker who came on shift later that day said she did not receive any hand over from the staff going off shift . This is a concern as observations need to be carried out when someone has fallen and banged their head and a handover would detail such incidents and whether there are any concerns with residents .
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the falls policy for suspected head, neck, back or hip injury
Wider context from the report “(2) The falls policy of the home states that there are number of scenarios to consider before lifting a resident for the floor and states that the resident should not be moved until clinical assistance arrive . One such situation is if head, neck, back or hip injury is suspected . The incident log on advanced care cloud states there was ahead injury yet Mrs Dale was moved and no clinician saw her until she worsened and ambulance was called . Inaccuracies in reporting can lead to missed opportunities to provide care and inaccurate time recording of incidents can lead to the accurate appraisal of the developing clinic picture being made more difficult which in turn would lead to a delay in medical assistance being sought. This could lead to resident safety being compromised and deaths occurring.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct an unannounced inspection assessing record keeping, falls management and staff handover processes.
Verbatim wording from the response “Following receipt of the Regulation 28 Report, CQC have initiated a review of this incident in line with our specific incident guidance. CQC also conducted an unannounced inspection of Westfield Residential Home on 21 July 2026. The matters of concern highlighted in the Regulation 28 Report helped to inform our inspection activity and ensure there was a particular focus on record keeping, safe management of falls and handover processes.” Source location Response from Care Quality Commission
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No regulatory action is currently required because inspection found no ongoing risk issues relating to the concerns.
Verbatim wording from the response “During our unannounced inspection, in respect of any ongoing risk posed to service users, CQC did not identify any issues relating to the matters of concern raised that would require any regulatory action.” Source location Response from Care Quality Commission
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Inspection evidence identified no concerns with handover processes between staff.
Verbatim wording from the response “In relation to our recent inspection of the service last month, we reviewed handover processes as part of our assessment of whether the service was providing safe care and treatment to all who use the service. Evidence available and gathered in relation to handover processes between staff did not identify any concerns.” Source location Response from Care Quality Commission
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Inspection evidence did not demonstrate poor record keeping overall, although sampling could not exclude shortfalls in individual records.
Verbatim wording from the response “During our recent inspection of the service last month, we reviewed record keeping in overarching general terms. Evidence available and gathered did not demonstrate poor record keeping overall, however, it is important to note that CQC’s inspection methodology follows a sampling approach, and therefore this does not mean there were not some shortfalls in some records.” Source location Response from Care Quality Commission
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Inspection evidence identified no concerns with the home's management of falls for current service users.
Verbatim wording from the response “In relation to our recent inspection of the service last month, we reviewed falls management as part of our assessment of whether the service was providing safe care and treatment to all who use the service. Evidence available and gathered in respect of this identified no concerns with the management of falls.” Source location Response from Care Quality Commission
Open published response
19 Apr 2026 Paul HUTCHINSON · Prevention of Future Deaths report West London
View report summary
Concerns raised 5 Failure to standardise staff training on evacuation, alarm, telecare and fire suppression procedures View source Failure of Fire Risk Assessments to account for vulnerable residents at special risk View source Lack of timescales for regular reviews of PCFRAs and personal emergency evacuation arrangements View source Lack of specific requirements for PCFRAs and personal emergency evacuation plans with agreed formats and risk factors View source Lack of specific requirements for emergency equipment and staff training View source See 2 more concerns
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.
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AI-generated summary
Paul HUTCHINSON · 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
Paul HUTCHINSON died of burns after setting himself alight while smoking in his Extra Care Sheltered Accommodation on 21 January 2025. The report raised concerns about the lack of specific requirements for individual fire risk and evacuation assessments, non-standardised staff training, and whether fire risk assessments adequately considered vulnerable residents who may be unable to self-evacuate.
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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to standardise staff training on evacuation, alarm, telecare and fire suppression procedures
Wider context from the report “2. Staff training is not standardised for ECSA (or sheltered accommodation more generally) and may not include, for example, evacuation strategy, emergency evacuation plans, the use of telecare/fire alarm system and fire suppression systems .
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of Fire Risk Assessments to account for vulnerable residents at special risk
Wider context from the report “3. Fire Risk Assessments for premises providing ECSA and sheltered accommodation more generally may not contemplate vulnerable residents as forming 'any group of persons identified...as being especially at risk' (see article 9(7)(b) of the 2005 Regulations). Vulnerable residents may be at special risk because of (for example) smoking or cooking practices and may have a compromised ability to self-evacuate. The concern is that Fire Risk Assessments do not take this into account .
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of timescales for regular reviews of PCFRAs and personal emergency evacuation arrangements
Wider context from the report “1. The Regulatory Reform (Fire Safety) Order 2005 and the Fire Safety (Residential Evacuation Plans) Regulations 2025 do not appear to apply to the individual flats in ECSA because they are private dwellings. The concern is that there is no specific requirement for a PCFRA (or a personal emergency evacuation through the PCFRA) with an agreed format and risk factors, a requirement for emergency equipment and staff training and a timescale for regular reviews (including where the individual circumstances of a person in care change) . This concern may apply to others in formal residential care.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of specific requirements for PCFRAs and personal emergency evacuation plans with agreed formats and risk factors
Wider context from the report “1. The Regulatory Reform (Fire Safety) Order 2005 and the Fire Safety (Residential Evacuation Plans) Regulations 2025 do not appear to apply to the individual flats in ECSA because they are private dwellings. The concern is that there is no specific requirement for a PCFRA (or a personal emergency evacuation through the PCFRA) with an agreed format and risk factors , a requirement for emergency equipment and staff training and a timescale for regular reviews (including where the individual circumstances of a person in care change). This concern may apply to others in formal residential care.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of specific requirements for emergency equipment and staff training
Wider context from the report “1. The Regulatory Reform (Fire Safety) Order 2005 and the Fire Safety (Residential Evacuation Plans) Regulations 2025 do not appear to apply to the individual flats in ECSA because they are private dwellings. The concern is that there is no specific requirement for a PCFRA (or a personal emergency evacuation through the PCFRA) with an agreed format and risk factors, a requirement for emergency equipment and staff training and a timescale for regular reviews (including where the individual circumstances of a person in care change). This concern may apply to others in formal residential care.
” Open source report
8 Apr 2026 Gary STARBUCK · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Lack of mandated care standards for privately treated patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Gary STARBUCK · 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
Gary STARBUCK developed metastatic cutaneous squamous cell carcinoma after recurrent skin cancer affecting his right pinna and died at home on 16 August 2021 following palliative care. The concern was that mandated care standards, including referral to specialist skin multidisciplinary teams, applied to NHS patients but not necessarily to privately treated patients, creating a risk that privately treated patients could receive inferior care and a risk of death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of mandated care standards for privately treated patients
Wider context from the report “The Inquest heard evidence that Mr. Starbuck’s care and treatment for his skin cancers was initially provided privately. National guidance published by the National Institute for Health and Care Excellence (NICE) sets out that any patient with a high risk Squamous Cell Carcinoma (SCC) should be referred to a specialist skin MDT (SSMDT.). Specifically, this is something which should have occurred following excision of a SCC. This is mandated practice within the NHS and the overwhelming evidence before me was that this applied to clinicians practicing in NHS.
The situation in relation to patients being treated privately was less clear; evidence from several witnesses ranged from the position that this guidance was as binding on clinicians treating patients privately as in NHS, to the guidance was just that ‘guidance’ to be applied by the clinician within the framework of care being provided privately. The latter was relevant in the context of how clinicians treating patients privately would access the SSMDT. The evidence received was that normally this was via the treating clinician taking the patient to the relevant NHS SSMDT or in less frequent occasions where the Hospital had a private SSMDT to deal with patients being treated privately.
No mandatory policy exists beyond the NICE guidance. As a consequence, whilst the policy is mandated for patients in receipt of NHS Care and Treatment, it is not mandatory for patients being treated for the same conditions privately.
There are many clinicians who import the NICE Guidelines into their private practice, along with NHS Trusts who accept referrals from clinicians treating patients privately into the SSMDT for consideration. However, as this is not mandated practice for either clinicians or convenors of SSMDT’s , the consequence is that patients treated privately are at risk of receiving inferior care to those treated under the NHS , often within the same physical hospital setting.
I am concerned that there is a lacuna in mandated care standards for patients treated privately by clinicians within the regulatory framework which gives rise to a risk of death.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop rating characteristics clarifying expected standards of good care.
Verbatim wording from the response “Our current assessment framework and associated guidance is published on the internet and is available to providers and the public. The assessment framework is currently under review, and the new framework and guidance will also be publicly available. To ensure providers are clear about what good looks like rating characteristics are also being developed. We will continue to work with other stakeholders to raise awareness of our expectations in the independent sector.” Source location Response from Care Quality Commission
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the new assessment framework and associated guidance.
Verbatim wording from the response “Our current assessment framework and associated guidance is published on the internet and is available to providers and the public. The assessment framework is currently under review, and the new framework and guidance will also be publicly available. To ensure providers are clear about what good looks like rating characteristics are also being developed. We will continue to work with other stakeholders to raise awareness of our expectations in the independent sector.” Source location Response from Care Quality Commission
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mandating private providers to follow NICE guidance is outside regulatory authority because NICE guidelines are generally not legally mandated.
Verbatim wording from the response “Your concerns relate specifically to guidance published by the National Institute for Health and Care Excellence (NICE) not being mandated for use by private providers.” Source location Response from Care Quality Commission
Open published response
31 Mar 2026 Mr John Hay · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 5 Unclear process for escalating cases to obtain medical input View source Failure of the care team to assess situations and make care decisions View source Unclear process for notifying the responsible person about missing or spent medication View source Failure to complete and clinically review care-plan risk assessments View source Insufficient coverage of blood-thinner-related scenarios in care-plan risk assessments View source See 2 more concerns
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
Mr John Hay · 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 John Hay, who lived alone and received domiciliary care, suffered an unwitnessed fall at home on 26 September 2024 and later died from a subdural haemorrhage on 2 October 2024. The report raised concerns about incomplete risk assessment, unclear escalation for medical input after a fall, and unclear processes for addressing missing or spent medication.
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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Unclear process for escalating cases to obtain medical input
Wider context from the report “2. The process/system for escalation to get medical input was unclear. In the current case, it was accepted with the benefit of hindsight that when a frail elderly person on blood thinners suffers a fall, a medical assessment should probably be done. However, after the morning visit, it was Mr Hay himself who made the decision (despite having suffered a fall and having a diagnosis of dementia) without input from his family. At the time of the evening visit, the care team contacted the son for a decision rather than simply assessing the situation and making a decision.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of the care team to assess situations and make care decisions
Wider context from the report “2. The process/system for escalation to get medical input was unclear. In the current case, it was accepted with the benefit of hindsight that when a frail elderly person on blood thinners suffers a fall, a medical assessment should probably be done. However, after the morning visit, it was Mr Hay himself who made the decision (despite having suffered a fall and having a diagnosis of dementia) without input from his family. At the time of the evening visit, the care team contacted the son for a decision rather than simply assessing the situation and making a decision.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Unclear process for notifying the responsible person about missing or spent medication
Wider context from the report “3. The process/system by which missing or spent medication is actioned was unclear. In the current case, Mr Hay’s son was responsible for ordering medication. However, the system by which the care team would notify him was unclear.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and clinically review care-plan risk assessments
Wider context from the report “1. The Risk Assessment in the Care Plan is neither completed nor reviewed with nursing or medical input , but includes, amongst other things, actions to be taken when a person is on blood thinners. In the present case, the only scenario covered was in relation to a person who has “heavy bleeding”. The obligation to complete the risk assessment and determine actions falls upon the care team, none of whom have any medical training, aside from basic first aid.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Insufficient coverage of blood-thinner-related scenarios in care-plan risk assessments
Wider context from the report “1. The Risk Assessment in the Care Plan is neither completed nor reviewed with nursing or medical input, but includes, amongst other things, actions to be taken when a person is on blood thinners. In the present case, the only scenario covered was in relation to a person who has “heavy bleeding” . The obligation to complete the risk assessment and determine actions falls upon the care team, none of whom have any medical training, aside from basic first aid.
” Open source report
4 Mar 2026 Roman Louie BARR · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 6 Risk to critically unwell patients and families when families transport patients to hospital during time-critical emergencies View source Delays in ambulance handover reducing emergency ambulance availability View source Failure to reliably identify excessive or repeated requests for salbutamol inhalers View source Lack of a consistent follow-up process for salbutamol overuse patterns View source Limited awareness of the significance of salbutamol overuse in patients and families View source Failure of NHS Pathways triage wording to be readily understood by callers in distress View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Roman Louie 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
Roman Louie Barr suffered an asthma attack on 14 December 2023 and died after no ambulance was available for several hours, leading his family to transport him to hospital. The principal concerns were limited awareness and follow-up of excessive salbutamol use, ambulance handover delays affecting emergency availability, risks to families transporting critically unwell patients, and unclear NHS Pathways triage wording.
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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Risk to critically unwell patients and families when families transport patients to hospital during time-critical emergencies
Wider context from the report “4. Risks when families transport critically unwell patients
The absence of an available ambulance for several hours resulted in the family transporting Roman to hospital themselves, exposing both him and his family to significant risk during a time-critical medical emergency .
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance handover reducing emergency ambulance availability
Wider context from the report “3. Ambulance handover delays affecting emergency availability
Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought , reducing emergency response capacity during periods of high demand.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably identify excessive or repeated requests for salbutamol inhalers
Wider context from the report “2. Identification and follow-up of reliever overuse
Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems , and there may be no consistent process for follow-up when such patterns occur, meaning deteriorating asthma may go unrecognised.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of a consistent follow-up process for salbutamol overuse patterns
Wider context from the report “2. Identification and follow-up of reliever overuse
Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems, and there may be no consistent process for follow-up when such patterns occur , meaning deteriorating asthma may go unrecognised.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Limited awareness of the significance of salbutamol overuse in patients and families
Wider context from the report “1. Limited awareness of salbutamol overuse
Evidence showed that patients and families may not appreciate the clinical significance of increased use of the blue (salbutamol) inhaler or its association with poorly controlled asthma .
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of NHS Pathways triage wording to be readily understood by callers in distress
Wider context from the report “5. Clarity of NHS Pathways triage wording
Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information . This raises a concern that, given the reliance on scripted triage systems, such scripts may not always use wording that is easily understood by lay callers in distress .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Take regulatory enforcement action against ambulance services that cannot meet emergency response times for critically unwell patients.
Verbatim wording from the response “We have given consideration to point 3 above. In inspections of NHS Ambulance Services across England in recent years, we have had cause to take enforcement action where ambulance services are unable to meet response times for those patients who are critically unwell – typically those, as with Mr Barr, who would meet the category 1 or 2 threshold for requiring an emergency ambulance in a mean average time of 7 or 18 minutes or less respectively.” Source location Response from Care Quality Commission
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Take regulatory action against NHS trusts where emergency departments do not accept ambulance handovers within safe and responsive times.
Verbatim wording from the response “We have also taken regulatory actions against NHS trusts where the emergency departments are not taking handover from ambulance crews in safe and responsive times. Equally this was with recognition of how delays in getting people discharged home who were waiting in the same trusts’ hospital wards without criteria to reside was the critical factor in not having beds to admit patients who required them in an” Source location Response from Care Quality Commission
Open published response
4 Mar 2026 Roman Louie BARR · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 6 Limited awareness of salbutamol overuse and its association with poorly controlled asthma View source Delays in ambulance handover at local hospitals View source Failure to reliably identify excessive or repeated requests for salbutamol inhalers View source Failure of NHS Pathways triage wording to be readily understood by callers in distress View source Risk to critically unwell patients and families when no ambulance is available and families transport patients themselves View source Lack of a consistent follow-up process for salbutamol overuse patterns View source See 3 more concerns
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
Roman Louie 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
Roman Louie Barr suffered an asthma attack on 14 December 2023 and died after information indicating the need for an urgent ambulance response was not obtained, no ambulance was available for several hours, and his family transported him to hospital. The principal concerns included limited awareness and monitoring of excessive salbutamol use, ambulance handover delays affecting emergency availability, risks when families transport critically unwell patients, and unclear NHS Pathways triage wording.
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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Limited awareness of salbutamol overuse and its association with poorly controlled asthma
Wider context from the report “1. Limited awareness of salbutamol overuse
Evidence showed that patients and families may not appreciate the clinical significance of increased use of the blue (salbutamol) inhaler or its association with poorly controlled asthma .
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance handover at local hospitals
Wider context from the report “3. Ambulance handover delays affecting emergency availability
Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably identify excessive or repeated requests for salbutamol inhalers
Wider context from the report “2. Identification and follow-up of reliever overuse
Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems , and there may be no consistent process for follow-up when such patterns occur, meaning deteriorating asthma may go unrecognised.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of NHS Pathways triage wording to be readily understood by callers in distress
Wider context from the report “5. Clarity of NHS Pathways triage wording
Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information . This raises a concern that, given the reliance on scripted triage systems, such scripts may not always use wording that is easily understood by lay callers in distress .
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Risk to critically unwell patients and families when no ambulance is available and families transport patients themselves
Wider context from the report “4. Risks when families transport critically unwell patients
The absence of an available ambulance for several hours resulted in the family transporting Roman to hospital themselves, exposing both him and his family to significant risk during a time-critical medical emergency .
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of a consistent follow-up process for salbutamol overuse patterns
Wider context from the report “2. Identification and follow-up of reliever overuse
Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems, and there may be no consistent process for follow-up when such patterns occur , meaning deteriorating asthma may go unrecognised.
” Open source report
7 Feb 2026 Janet Springall · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 3 Failure to provide timely blood testing for suspected infection in ambulance-held patients View source Failure to provide timely intravenous fluids and antibiotics to ambulance-held patients with suspected infection View source Delays in transferring unwell patients from ambulances to the emergency department View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Janet Springall · 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
Janet Springall, who had a learning disability and was immunosuppressed, was taken to hospital with pneumonia and sepsis after being found unresponsive. She remained in an ambulance outside the emergency department for almost six hours amid exceptional pressures, and the report raises concern that delays in clinical assessment, blood testing and treatment may place similarly unwell patients at increased 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely blood testing for suspected infection in ambulance-held patients
Wider context from the report “My concern is that notwithstanding the hospital Trust seems to have made welcome improvements, patients such as Janet Springall remain at risk.
The Trust continues to experience significant pressures due to patient numbers, and unwell patients continue to remain in ambulances for some time before they are able to access the emergency department.
When a very unwell patient has to remain on an ambulance due to very high demands placed upon a hospital emergency department, believed by paramedics to have a life-threatening infection, then in the absence of a blood test and the timely administration of any necessary intravenous fluids and antibiotics, the chances of such a patient surviving can be significantly reduced by the time the patient is able to access the emergency department.
Janet Springall was very unwell by the time she arrived at hospital and was likely to die. Any realistic prospect she may recover had subsided by around 7.30pm, some 2.5 hours after arrival at hospital.
Other patients may not be as unwell as Janet was upon arrival at hospital, and may therefore have more chance of surviving, but they too may deteriorate significantly whilst remaining in the ambulance before it can be confirmed they have an infection and receive timely medical attention and treatment.
I believe it is necessary for to raise this concern, but it is not for me to be prescriptive about what should / can be done.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely intravenous fluids and antibiotics to ambulance-held patients with suspected infection
Wider context from the report “My concern is that notwithstanding the hospital Trust seems to have made welcome improvements, patients such as Janet Springall remain at risk.
The Trust continues to experience significant pressures due to patient numbers, and unwell patients continue to remain in ambulances for some time before they are able to access the emergency department.
When a very unwell patient has to remain on an ambulance due to very high demands placed upon a hospital emergency department, believed by paramedics to have a life-threatening infection, then in the absence of a blood test and the timely administration of any necessary intravenous fluids and antibiotics , the chances of such a patient surviving can be significantly reduced by the time the patient is able to access the emergency department.
Janet Springall was very unwell by the time she arrived at hospital and was likely to die. Any realistic prospect she may recover had subsided by around 7.30pm, some 2.5 hours after arrival at hospital.
Other patients may not be as unwell as Janet was upon arrival at hospital, and may therefore have more chance of surviving, but they too may deteriorate significantly whilst remaining in the ambulance before it can be confirmed they have an infection and receive timely medical attention and treatment .
I believe it is necessary for to raise this concern, but it is not for me to be prescriptive about what should / can be done.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring unwell patients from ambulances to the emergency department
Wider context from the report “My concern is that notwithstanding the hospital Trust seems to have made welcome improvements, patients such as Janet Springall remain at risk.
The Trust continues to experience significant pressures due to patient numbers, and unwell patients continue to remain in ambulances for some time before they are able to access the emergency department.
When a very unwell patient has to remain on an ambulance due to very high demands placed upon a hospital emergency department , believed by paramedics to have a life-threatening infection, then in the absence of a blood test and the timely administration of any necessary intravenous fluids and antibiotics, the chances of such a patient surviving can be significantly reduced by the time the patient is able to access the emergency department .
Janet Springall was very unwell by the time she arrived at hospital and was likely to die. Any realistic prospect she may recover had subsided by around 7.30pm, some 2.5 hours after arrival at hospital.
Other patients may not be as unwell as Janet was upon arrival at hospital, and may therefore have more chance of surviving, but they too may deteriorate significantly whilst remaining in the ambulance before it can be confirmed they have an infection and receive timely medical attention and treatment.
I believe it is necessary for to raise this concern, but it is not for me to be prescriptive about what should / can be done.
” 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 Continue using regulatory powers to ensure the trust maintains systems identifying deteriorating patients, including those waiting outside the department, and manages emergency-care pathway risks.
Verbatim wording from the response “CQC will continue to use its regulatory powers to ensure that the trust maintains effective systems to identify deteriorating patients, including those waiting outside the department, and manages risks within the emergency care pathway.” Source location Response from Care Quality Commission
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 monitoring ambulance handover delays and their impact on patient safety through regulatory activity and evidence from patients, staff, ambulance services and system partners.
Verbatim wording from the response “CQC will:” Source location Response from Care Quality Commission
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 Re-emphasise safe clinical escalation processes for patients awaiting ambulance offload, including when clinical staff should attend patients outside the department.
Verbatim wording from the response “CQC will:” Source location Response from Care Quality Commission
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 internal review found no evidence that CQC advised the trust not to treat patients remaining on ambulances.
Verbatim wording from the response “Our internal review has found no evidence; written or verbal within our records that CQC advised the trust not to treat patients on ambulances. CQC remain committed to encouraging care services to improve by working with the trust and system partners to ensure that patients receive safe and timely care, including during periods of sustained operational pressure.” Source location Response from Care Quality Commission
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 Providing operational clinical advice about where or how specific patients should be treated falls outside CQC’s remit.
Verbatim wording from the response “For clarity, CQC inspectors do not provide operational clinical advice to providers, including advice about how or where treatment should be delivered to specific patients. This is not within CQC remit, and inspection teams are trained to ensure that their role is to assess and report on the quality and safety of care, rather than to direct clinical practice. CQC recognises that informal conversations during inspections can sometimes lead to differing interpretations and CQC are committed to being as clear as possible about the limits of our role. However, CQC are unable to evidence that a conversation covering these issues took place during our inspection.” Source location Response from Care Quality Commission
Open published response
7 Feb 2026 Bonita Cleary · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 1 Lack of awareness among care and nursing staff about when CPR should be attempted View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Bonita Cleary · 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
Bonita Cleary, who was severely frail and largely bedbound, died after choking on food during a vacant episode while eating crumpet at a nursing care home. Although a DNACPR authorisation was in place, CPR was not initially commenced, and the report raises concern about a lack of awareness among care and nursing staff about when CPR should be attempted for potentially reversible causes such as choking.
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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness among care and nursing staff about when CPR should be attempted
Wider context from the report “• Bonita Cleary died due to a choking episode.
• This is a potentially reversible cause.
• Notwithstanding there was a DNACPR authorization in place, CPR ought to have been commenced
• On balance of probabilities, this would not have saved Bonita’s life, but for other vulnerable residents in a care setting, effective and timely CPR may prevent death;
• I am concerned that there is a lack of awareness amongst care and nursing staff within this organization and the care sector more widely about when CPR should be attempted , and that residents with a realistic chance of surviving may die as a result of a cause which was, in fact, potentially reversible .
• It is not for me to be prescriptive about what can / should be done, but there is a clear risk and therefore I raise this concern.
” 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 Prioritise the service for a comprehensive, unannounced inspection and examine lessons from the incident during that inspection.
Verbatim wording from the response “In terms of re-inspecting the service we have considered this. We have assessed other recent cases and notifications to see if there are other areas of concern, and will continue to review this dependent on the assurances we receive from the service. It is pertinent to note that, from January, CQC has reviewed its approach to prioritising inspections, meaning that this service falls into one of the higher priority categories: "Services with older ratings, to keep ratings current and reliable." We will therefore look at lessons learned from this incident at that next inspection. I cannot confirm the date of that inspection at this time as it will depend on our scheduling of inspections quarter by quarter, but it will be comprehensive and unannounced, and is categorised as a priority.” Source location Response from Care Quality Commission
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 broader DNACPR training and knowledge concern through the Senior Specialists team.
Verbatim wording from the response “In the meantime, we have shared the broader concerns raised regarding understanding of DNACPRs where there may be a reversible cause, with our Senior Specialists team. They have responsibility in CQC for upskilling staff in areas of practice. CQC is responsible for ensuring providers are compliant with regulations, but it also has an improvement function - thank you for highlighting this area of concern regarding training/knowledge, which the senior specialists will review.” Source location Response from Care Quality Commission
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 concerns about DNACPR decisions where reversible causes may exist with the Senior Specialists team.
Verbatim wording from the response “In the meantime, we have shared the broader concerns raised regarding understanding of DNACPRs where there may be a reversible cause, with our Senior Specialists team. They have responsibility in CQC for upskilling staff in areas of practice. CQC is responsible for ensuring providers are compliant with regulations, but it also has an improvement function - thank you for highlighting this area of concern regarding training/knowledge, which the senior specialists will review.” Source location Response from Care Quality Commission
Open published response
15 Jan 2026 Ronald Colin Nelson · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 2 Poor record keeping View source Insufficient compliance with care plans View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ronald Colin Nelson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ronald Colin Nelson died from aspiration pneumonia on a background of advanced dementia after developing pressure sores that deteriorated to category 4, with sacral osteomyelitis, following a period of being bed bound. The principal concerns were potential poor record keeping and inadequate compliance with care plans at the care home.
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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Poor record keeping
Wider context from the report “i) That there remain potential issues of poor record keeping .
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Insufficient compliance with care plans
Wider context from the report “ii) There are concerns over the level of compliance of care plans .
” 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 Complete an unannounced assessment and associated off-site review of the care home’s safety, care planning and record-keeping arrangements.
Verbatim wording from the response “An unannounced assessment was conducted at Mulberry Court Care Home on 17 and 18 February 2026. Further off-site assessment work continued such as reviewing documents and speaking with people. This assessment looked at key questions to determine if Mulberry Court Care Home is safe, effective, caring, responsive and well-led. Details of the assessment framework used to undertake this assessment can be found here: Assessment - Care Quality Commission.” Source location Response from Care Quality Commission
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record keeping and care planning were found to comply with regulations, with detailed, individualised, regularly reviewed records and plans.
Verbatim wording from the response “We found that record keeping and care planning at Mulberry Court Care Home is in line with the regulations. The provider ensured that daily records, care plans, risk assessments and contemporaneous records in relation to care delivery were detailed, individualised updated and reviewed regularly. This meant staff knew how to care for people in the service.” Source location Response from Care Quality Commission
Open published response
19 Dec 2025 Ramona Doreen Harbott · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 6 Failure to complete and audit improvements to pressure sore prevention and management View source Failure to complete early and appropriate pressure sore risk assessment View source Failure to provide appropriate pressure sore treatment View source Failure to use pressure sore preventative measures View source Failure to monitor residents' skin condition for pressure sores View source Failure to record pressure sore risk, skin monitoring and treatment information 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
Ramona Doreen Harbott · 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
Ramona Doreen Harbott was admitted to Windmill Manor Care Home with very limited mobility and a high risk of pressure sores. She developed serious sacral and heel pressure sores, and later died in hospital from sepsis having contracted pneumonia. Concerns included inadequate repositioning, skin monitoring, pressure sore treatment and record keeping, with improvements still ongoing and not yet completed and audited.
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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and audit improvements to pressure sore prevention and management
Wider context from the report “a. The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff. Although at high risk of pressure sores Mrs Harbott was not regularly repositioned until she had developed a sacral sore. Her skin condition was not monitored and recorded to the extent that though the sore was apparently being treated, it had become an unstageable necrotic wound by the time she was taken to hospital. The serious pressure sore on the right heel was not documented until it was seen on 23 January 2025 although it was likely well established for at least a week.
b. The coroner acknowledges that Barchester Health Care have since this death and the inquest hearing in November 2025 commenced an action plan of improvements including greater regional management oversight however the coroner remains concerned that the matters identified at the inquest regarding issues surrounding early and appropriate assessment of risk, use of preventative measures, skin monitoring, pressure sore treatment and record keeping are the subject of ongoing improvement which has yet to be completed and audited .
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to complete early and appropriate pressure sore risk assessment
Wider context from the report “a. The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff. Although at high risk of pressure sores Mrs Harbott was not regularly repositioned until she had developed a sacral sore. Her skin condition was not monitored and recorded to the extent that though the sore was apparently being treated, it had become an unstageable necrotic wound by the time she was taken to hospital. The serious pressure sore on the right heel was not documented until it was seen on 23 January 2025 although it was likely well established for at least a week.
b. The coroner acknowledges that Barchester Health Care have since this death and the inquest hearing in November 2025 commenced an action plan of improvements including greater regional management oversight however the coroner remains concerned that the matters identified at the inquest regarding issues surrounding early and appropriate assessment of risk , use of preventative measures, skin monitoring, pressure sore treatment and record keeping are the subject of ongoing improvement which has yet to be completed and audited.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate pressure sore treatment
Wider context from the report “a. The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff. Although at high risk of pressure sores Mrs Harbott was not regularly repositioned until she had developed a sacral sore. Her skin condition was not monitored and recorded to the extent that though the sore was apparently being treated, it had become an unstageable necrotic wound by the time she was taken to hospital. The serious pressure sore on the right heel was not documented until it was seen on 23 January 2025 although it was likely well established for at least a week.
b. The coroner acknowledges that Barchester Health Care have since this death and the inquest hearing in November 2025 commenced an action plan of improvements including greater regional management oversight however the coroner remains concerned that the matters identified at the inquest regarding issues surrounding early and appropriate assessment of risk, use of preventative measures, skin monitoring, pressure sore treatment and record keeping are the subject of ongoing improvement which has yet to be completed and audited.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to use pressure sore preventative measures
Wider context from the report “a. The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff . Although at high risk of pressure sores Mrs Harbott was not regularly repositioned until she had developed a sacral sore . Her skin condition was not monitored and recorded to the extent that though the sore was apparently being treated, it had become an unstageable necrotic wound by the time she was taken to hospital. The serious pressure sore on the right heel was not documented until it was seen on 23 January 2025 although it was likely well established for at least a week.
b. The coroner acknowledges that Barchester Health Care have since this death and the inquest hearing in November 2025 commenced an action plan of improvements including greater regional management oversight however the coroner remains concerned that the matters identified at the inquest regarding issues surrounding early and appropriate assessment of risk, use of preventative measures , skin monitoring, pressure sore treatment and record keeping are the subject of ongoing improvement which has yet to be completed and audited.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor residents' skin condition for pressure sores
Wider context from the report “a. The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff. Although at high risk of pressure sores Mrs Harbott was not regularly repositioned until she had developed a sacral sore. Her skin condition was not monitored and recorded to the extent that though the sore was apparently being treated, it had become an unstageable necrotic wound by the time she was taken to hospital. The serious pressure sore on the right heel was not documented until it was seen on 23 January 2025 although it was likely well established for at least a week.
b. The coroner acknowledges that Barchester Health Care have since this death and the inquest hearing in November 2025 commenced an action plan of improvements including greater regional management oversight however the coroner remains concerned that the matters identified at the inquest regarding issues surrounding early and appropriate assessment of risk, use of preventative measures, skin monitoring , pressure sore treatment and record keeping are the subject of ongoing improvement which has yet to be completed and audited.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to record pressure sore risk, skin monitoring and treatment information
Wider context from the report “a. The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff. Although at high risk of pressure sores Mrs Harbott was not regularly repositioned until she had developed a sacral sore. Her skin condition was not monitored and recorded to the extent that though the sore was apparently being treated, it had become an unstageable necrotic wound by the time she was taken to hospital. The serious pressure sore on the right heel was not documented until it was seen on 23 January 2025 although it was likely well established for at least a week.
b. The coroner acknowledges that Barchester Health Care have since this death and the inquest hearing in November 2025 commenced an action plan of improvements including greater regional management oversight however the coroner remains concerned that the matters identified at the inquest regarding issues surrounding early and appropriate assessment of risk, use of preventative measures, skin monitoring, pressure sore treatment and record keeping are the subject of ongoing improvement which has yet to be completed and audited.
” 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 whether criminal enforcement is appropriate in this case.
Verbatim wording from the response “Whilst we have received assurances about the steps taken to address the concerns, we will continue to monitor the safety and quality of care at Windmill Manor and we are considering any criminal enforcement that may be appropriate in this case. If we identify safety concerns in relation to pressure wound care, we will consider whether an unannounced inspection and/or further regulatory action is required.” Source location 2025-0637 - Response from Quality Care Commission
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 monitoring the safety and quality of care at Windmill Manor.
Verbatim wording from the response “Whilst we have received assurances about the steps taken to address the concerns, we will continue to monitor the safety and quality of care at Windmill Manor and we are considering any criminal enforcement that may be appropriate in this case. If we identify safety concerns in relation to pressure wound care, we will consider whether an unannounced inspection and/or further regulatory action is required.” Source location 2025-0637 - Response from Quality Care Commission
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 registered provider is legally responsible for ensuring service users receive safe care and treatment, including pressure wound care.
Verbatim wording from the response “Barchester Healthcare Homes Limited have advised us the above actions are now in place at Windmill Manor. As a CQC registered provider Barchester Healthcare Homes Limited is legally responsible for ensuring that all service users receive safe care and treatment.” Source location 2025-0637 - Response from Quality Care Commission
Open published response
5 Dec 2025 Alan Paul Peet · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Lack of management oversight and safeguards for nursing staff allocation decisions View source Failure to provide agency nurses with individual login rights to electronic care and medication systems View source Failure to maintain complete and comprehensible care notes View source Failure to ensure tracheostomy-trained nursing cover for residents requiring tracheostomy support 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
Alan Paul Peet · 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
Alan Paul Peet, who was quadriplegic following an accidental fall, was admitted to hospital after his condition deteriorated at Acer Mews Care Home on 26 July 2025. He was found to be septic, possibly due to bronchopneumonia, and died at Tameside General Hospital on 28 July 2025. Concerns included inadequate observation and record-keeping, lack of clear management oversight of tracheostomy-trained nursing cover, and agency staff lacking access to electronic systems.
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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of management oversight and safeguards for nursing staff allocation decisions
Wider context from the report “Mr Peet according to the evidence heard at the inquest was placed at Acer Mews Care Home. His care according to information from his family was provided at a cost of approximately £10,000 a week. This was because he required 24/7 one to one care in a nursing home setting because of the extent of his needs including management of his tracheostomy tube.
The inquest heard that at the home there were 2 units, with one registered nurse allocated to each unit. The remainder of the staff were Health Care Assistants.
On the day of his admission to hospital the nurse trained in tracheostomy management decided not to cover the unit Mr Peet was in even though there were 3 patients requiring support with tracheostomies on that unit. Instead, they chose to work on the other unit. This left a nurse untrained in tracheostomies on that unit.
It was unclear why there was no management oversight of this decision and what steps were in place at the time to avoid such a situation arising .
The inquest was also told that the agency nurse used on the day did not have log in rights to the electronic systems in place at the home including the medication system. It was indicated that the manager at the time was aware of this and that it was likely that the nurse could as a consequence only make entries under the details of the other nurse. During the course of the inquest, it was difficult to unpick who had made certain entries.
Even though Mr Peet was on one-to-one care and those involved could have no other residents to write up during the time they were caring for him the overall quality of the notes was extremely poor. Entries were limited and it was impossible to fully understand from the notes what had been observed and what had happened and at what point.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to provide agency nurses with individual login rights to electronic care and medication systems
Wider context from the report “Mr Peet according to the evidence heard at the inquest was placed at Acer Mews Care Home. His care according to information from his family was provided at a cost of approximately £10,000 a week. This was because he required 24/7 one to one care in a nursing home setting because of the extent of his needs including management of his tracheostomy tube.
The inquest heard that at the home there were 2 units, with one registered nurse allocated to each unit. The remainder of the staff were Health Care Assistants.
On the day of his admission to hospital the nurse trained in tracheostomy management decided not to cover the unit Mr Peet was in even though there were 3 patients requiring support with tracheostomies on that unit. Instead, they chose to work on the other unit. This left a nurse untrained in tracheostomies on that unit.
It was unclear why there was no management oversight of this decision and what steps were in place at the time to avoid such a situation arising.
The inquest was also told that the agency nurse used on the day did not have log in rights to the electronic systems in place at the home including the medication system . It was indicated that the manager at the time was aware of this and that it was likely that the nurse could as a consequence only make entries under the details of the other nurse . During the course of the inquest, it was difficult to unpick who had made certain entries .
Even though Mr Peet was on one-to-one care and those involved could have no other residents to write up during the time they were caring for him the overall quality of the notes was extremely poor. Entries were limited and it was impossible to fully understand from the notes what had been observed and what had happened and at what point.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain complete and comprehensible care notes
Wider context from the report “Mr Peet according to the evidence heard at the inquest was placed at Acer Mews Care Home. His care according to information from his family was provided at a cost of approximately £10,000 a week. This was because he required 24/7 one to one care in a nursing home setting because of the extent of his needs including management of his tracheostomy tube.
The inquest heard that at the home there were 2 units, with one registered nurse allocated to each unit. The remainder of the staff were Health Care Assistants.
On the day of his admission to hospital the nurse trained in tracheostomy management decided not to cover the unit Mr Peet was in even though there were 3 patients requiring support with tracheostomies on that unit. Instead, they chose to work on the other unit. This left a nurse untrained in tracheostomies on that unit.
It was unclear why there was no management oversight of this decision and what steps were in place at the time to avoid such a situation arising.
The inquest was also told that the agency nurse used on the day did not have log in rights to the electronic systems in place at the home including the medication system. It was indicated that the manager at the time was aware of this and that it was likely that the nurse could as a consequence only make entries under the details of the other nurse. During the course of the inquest, it was difficult to unpick who had made certain entries.
Even though Mr Peet was on one-to-one care and those involved could have no other residents to write up during the time they were caring for him the overall quality of the notes was extremely poor . Entries were limited and it was impossible to fully understand from the notes what had been observed and what had happened and at what point .
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure tracheostomy-trained nursing cover for residents requiring tracheostomy support
Wider context from the report “Mr Peet according to the evidence heard at the inquest was placed at Acer Mews Care Home. His care according to information from his family was provided at a cost of approximately £10,000 a week. This was because he required 24/7 one to one care in a nursing home setting because of the extent of his needs including management of his tracheostomy tube.
The inquest heard that at the home there were 2 units, with one registered nurse allocated to each unit. The remainder of the staff were Health Care Assistants.
On the day of his admission to hospital the nurse trained in tracheostomy management decided not to cover the unit Mr Peet was in even though there were 3 patients requiring support with tracheostomies on that unit . Instead, they chose to work on the other unit. This left a nurse untrained in tracheostomies on that unit .
It was unclear why there was no management oversight of this decision and what steps were in place at the time to avoid such a situation arising.
The inquest was also told that the agency nurse used on the day did not have log in rights to the electronic systems in place at the home including the medication system. It was indicated that the manager at the time was aware of this and that it was likely that the nurse could as a consequence only make entries under the details of the other nurse. During the course of the inquest, it was difficult to unpick who had made certain entries.
Even though Mr Peet was on one-to-one care and those involved could have no other residents to write up during the time they were caring for him the overall quality of the notes was extremely poor. Entries were limited and it was impossible to fully understand from the notes what had been observed and what had happened and at what point.
” Open source report
22 Oct 2025 Ricky James MONAHAN · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Unprotected fire escapes providing easy access to roofs in rehabilitation settings View source Lack of environmental risk assessment of fire escape and roof accessibility View source Lack of guidelines specifying required fire escape protections in rehabilitation settings View source Reliance on individual patient risk assessments instead of environmental access controls View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ricky James MONAHAN · 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
Ricky James MONAHAN, a resident of a rehabilitation unit detained under section 37 of the Mental Health Act, died after falling from a height on 18 March 2025. The report identified an unprotected fire escape accessible from the garden and roof, no environmental risk assessment of this access, reliance on individual risk assessments, and a lack of guidelines for protecting fire escapes in rehabilitation settings.
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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Unprotected fire escapes providing easy access to roofs in rehabilitation settings
Wider context from the report “1. Mr Monahan was in a 10 bedded rehabilitation unit and was detained under S37 of the Mental Health Act. There was an unprotected fire escape at the rear of the building which could be easily accessed from the garden which in turn gave easy access to the roof . No environmental risk assessment had been completed regarding how accessible the fire escape was and how it easily provided access to the roof due to inadequate railings at the top of the staircase . The trust relied on individual risk assessments when considering what controls were required for individual patients when accessing the garden.
2. The inquest heard how there are no current guidelines setting out what protections are required for fire escapes in rehabilitation settings. The lack of any guidelines presents a risk of future deaths and in my view, action should be 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of environmental risk assessment of fire escape and roof accessibility
Wider context from the report “1. Mr Monahan was in a 10 bedded rehabilitation unit and was detained under S37 of the Mental Health Act. There was an unprotected fire escape at the rear of the building which could be easily accessed from the garden which in turn gave easy access to the roof. No environmental risk assessment had been completed regarding how accessible the fire escape was and how it easily provided access to the roof due to inadequate railings at the top of the staircase. The trust relied on individual risk assessments when considering what controls were required for individual patients when accessing the garden.
2. The inquest heard how there are no current guidelines setting out what protections are required for fire escapes in rehabilitation settings. The lack of any guidelines presents a risk of future deaths and in my view, action should be 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of guidelines specifying required fire escape protections in rehabilitation settings
Wider context from the report “1. Mr Monahan was in a 10 bedded rehabilitation unit and was detained under S37 of the Mental Health Act. There was an unprotected fire escape at the rear of the building which could be easily accessed from the garden which in turn gave easy access to the roof. No environmental risk assessment had been completed regarding how accessible the fire escape was and how it easily provided access to the roof due to inadequate railings at the top of the staircase. The trust relied on individual risk assessments when considering what controls were required for individual patients when accessing the garden.
2. The inquest heard how there are no current guidelines setting out what protections are required for fire escapes in rehabilitation settings . The lack of any guidelines presents a risk of future deaths and in my view, action should be 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Reliance on individual patient risk assessments instead of environmental access controls
Wider context from the report “1. Mr Monahan was in a 10 bedded rehabilitation unit and was detained under S37 of the Mental Health Act. There was an unprotected fire escape at the rear of the building which could be easily accessed from the garden which in turn gave easy access to the roof. No environmental risk assessment had been completed regarding how accessible the fire escape was and how it easily provided access to the roof due to inadequate railings at the top of the staircase. The trust relied on individual risk assessments when considering what controls were required for individual patients when accessing the garden .
2. The inquest heard how there are no current guidelines setting out what protections are required for fire escapes in rehabilitation settings. The lack of any guidelines presents a risk of future deaths and in my view, action should be taken.
” 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 Signpost registered providers to fire-safety and environmental-premises guidance through the CQC website.
Verbatim wording from the response “Your concerns relate specifically to the availability of national or local guidance. We are unable to comment directly on this point due to it being outside the remit of our regulatory scope. We are currently not aware of guidelines regarding fire escapes specifically in rehabilitation settings. However, the CQC signposts registered providers to information regarding fire safety and the environmental safety of their premises on our website.” Source location Response from Care Quality Commission
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 Request environmental risk assessments and observe ward environments during inspections to assess premises safety.
Verbatim wording from the response “As part of our inspection process, CQC will routinely ask for the most recent environmental risk assessment to provide assurance that providers have made the premises safe for people who use the service. CQC inspectors will also observe the ward environment as part of an inspection. In our inspection in October 2023, CQC found that there were risk assessments in place in all ward areas which removed or reduced any risks they identified. The report in October 2023 does not make specific reference to the external fire escape.” Source location Response from Care Quality Commission
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 National or local guidance on fire-escape protections is outside the regulatory scope and cannot be directly addressed.
Verbatim wording from the response “Your concerns relate specifically to the availability of national or local guidance. We are unable to comment directly on this point due to it being outside the remit of our regulatory scope. We are currently not aware of guidelines regarding fire escapes specifically in rehabilitation settings. However, the CQC signposts registered providers to information regarding fire safety and the environmental safety of their premises on our website.” Source location Response from Care Quality Commission
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 Specific environmental risk assessments are not required; providers must instead take reasonable steps to manage health and safety risks.
Verbatim wording from the response “We do not specify that all providers must carry out specific environmental risk assessments, however providers must make sure that the premises and any equipment used is safe and where applicable, available in sufficient quantities. CQC understands that there may be inherent risks in carrying out care and treatment, and we will not consider it to be unsafe if providers can demonstrate that they have taken all reasonable steps to ensure the health and safety of people using their services and to manage risks that may arise during care and treatment.” Source location Response from Care Quality Commission
Open published response
Concerns raised 11 Lack of robust clinical governance and multidisciplinary team processes for community urology services View source Delays in assessment, diagnosis, treatment and transfer of postoperative sepsis View source Lack of robust assessment and guidelines for independent private-sector practising privileges View source Lack of appraisal and mandatory assessment of community urology clinicians View source Lack of multidisciplinary assessment and senior consultant oversight of community urology patients View source Lack of independent review of deaths for learning and practice change View source Failure of senior clinicians to retain responsibility for patients throughout private hospital care View source Lack of regular morbidity and mortality review of community urology complications View source Failure to assess whether patients are fit for operative procedures at the hospital View source Failure to fully inform patients of clinicians’ relevant experience View source Failure to integrate community urology services with hospital-based consultant-led urology services View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Keith James Hankin · 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
Keith James Hankin was admitted for an elective optical urethrotomy on 8 September 2023, developed sepsis shortly after the procedure, was transferred to Worthing Hospital, and died there on 11 September 2023. The report identifies concerns about poor clinical governance and lack of integration, oversight and clinician assessment within the Community Urology Service, as well as multiple omissions in his pre-operative, intra-operative and post-operative care at Goring Hall Hospital, including delays in recognising and treating sepsis and transferring him for further management.
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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of robust clinical governance and multidisciplinary team processes for community urology services
Wider context from the report “1. Lack of clinical governance of the Community Urology Service (CUS) by the Integrated Care Board (ICB) who commissioned the service and Sussex Medical Chambers (SMC) who were responsible for providing the service
The Integrated Care Board contracted Sussex Medical Chambers to provide a Community Urology Service through any qualified provider in 2015 and renewed the contract through a competitive tendering process twice subsequently. The ICB used a generic contract supplied by NHS England to contract the service. Neither the IB nor SMC were able to provide any evidence of robust clinical governance or multi-disciplinary team processes to ensure best practice of urology services from inception to date.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Delays in assessment, diagnosis, treatment and transfer of postoperative sepsis
Wider context from the report “6. Management of Mr Hankin at Goring Hall Hospital
There were multiple omissions in the pre-operative, intra-operative and post operative care provided by Goring Hall Hospital which individually and collectively contributed to Mr Hankin’s death. This included a failure to recognise Mr Hankin underlying medical co-morbidities rendered him unfit to have his operative procedure at the hospital. More specifically the post-operative assessment and support provided by the consultant anaesthetist and surgeon led to a delay in assessing and diagnosing sepsis and thereafter giving appropriate and timely antibiotics and facilitating an earlier transfer to the NHS Hospital for further management . This gives rise to a concern that there was a lack of understanding by the senior clinicians (in the absence of any local and national guidelines provided at the inquest) requiring them to remain responsible for the care of patients throughout their time in a private hospital rather than delegating the care to a Resident Medical Officer who is more likely than not to be insufficiently experienced in managing such critical situations.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of robust assessment and guidelines for independent private-sector practising privileges
Wider context from the report “4. Practicing Privileges within the private sector
████████ set up and led the CUS under the auspices of SMC. The ICB contractually required this service to be run by a consultant urologist. ████████ had not held a formal consultant urologist position within the NHS prior to tendering for this work. It remains unclear as to how ████████ was provided with practicing privileges at a private hospital as a consultant and was therefore able to practice independently and without scrutiny. This gives rise to a concern that there is a lack of robust assessment and guidelines, both locally and nationally, as to how clinicians are given practising privileges to work independently outside of the NHS to the potential detriment of patient care. It also gives rise to a concern that patients are not being fully informed of the relevant experience of such clinicians thereby breaching the statutory duty of candour responsibility of all hospitals.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of appraisal and mandatory assessment of community urology clinicians
Wider context from the report “3. Lack of appraisal and mandatory assessment of clinicians employed by CUS
There was an absence of any appraisal and/or mandatory assessments within the CUS or the ICB and SMC for the associate specialist clinicians who were working extra-contractually outside of their NHS work. No evidence was provided as to their experience and competency. This gives rise to a concern that their working practices are insufficiently assessed and fails to fulfil GMC ‘good practice’ guidelines. Likewise, no evidence was provided regarding regular morbidity and mortality reviews of complications by the ICB, CUS and SMC such as when patients re-present to NHS hospitals with complications arising from the CUS.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of multidisciplinary assessment and senior consultant oversight of community urology patients
Wider context from the report “2. Lack of Integration of the Community Urology service with NHS Hospital Urology Services
The CUS provided community-based urology services with non-consultant grade urologists without any oversight or integration with hospital-based consultant led urology services. Whilst there was an opportunity for CUS to refer more complex patients to NHS Hospital Trusts the ‘silo’ effect of these 2 services was such that they effectively worked independently of each other. The absence of a robust multidisciplinary team assessment within the CUS and the lack of senior clinical oversight of community urology patients by NHS consultant clinicians leads to a concern that the urology service is fragmented and does not effectively support urology patients within the region to confirm best practice and optimal 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of independent review of deaths for learning and practice change
Wider context from the report “5. Learning from Mr Hankin’s death
The ICB did not independently review the circumstances of Mr Hankin’s death to confirm if there was any learning or changes in practice to prevent further deaths. Likewise, SMC relied on ████████ to inform them and investigate Mr Hankin’s death without considering the inherent conflict of interest in so doing . The lack of an independent review prevented any proactive learning and changes in practice following the death of Mr Hankin. This gives rise to a concern that the system within the ICB and SMC are insufficiently robust and could – as it was with Mr Hankin – prevent transparency and openness as to the circumstances of his death and limit any learning and or necessary changes in practice to prevent future deaths.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of senior clinicians to retain responsibility for patients throughout private hospital care
Wider context from the report “6. Management of Mr Hankin at Goring Hall Hospital
There were multiple omissions in the pre-operative, intra-operative and post operative care provided by Goring Hall Hospital which individually and collectively contributed to Mr Hankin’s death. This included a failure to recognise Mr Hankin underlying medical co-morbidities rendered him unfit to have his operative procedure at the hospital. More specifically the post-operative assessment and support provided by the consultant anaesthetist and surgeon led to a delay in assessing and diagnosing sepsis and thereafter giving appropriate and timely antibiotics and facilitating an earlier transfer to the NHS Hospital for further management. This gives rise to a concern that there was a lack of understanding by the senior clinicians (in the absence of any local and national guidelines provided at the inquest) requiring them to remain responsible for the care of patients throughout their time in a private hospital rather than delegating the care to a Resident Medical Officer who is more likely than not to be insufficiently experienced in managing such critical situations.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of regular morbidity and mortality review of community urology complications
Wider context from the report “3. Lack of appraisal and mandatory assessment of clinicians employed by CUS
There was an absence of any appraisal and/or mandatory assessments within the CUS or the ICB and SMC for the associate specialist clinicians who were working extra-contractually outside of their NHS work. No evidence was provided as to their experience and competency. This gives rise to a concern that their working practices are insufficiently assessed and fails to fulfil GMC ‘good practice’ guidelines. Likewise, no evidence was provided regarding regular morbidity and mortality reviews of complications by the ICB, CUS and SMC such as when patients re-present to NHS hospitals with complications arising from the CUS.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to assess whether patients are fit for operative procedures at the hospital
Wider context from the report “6. Management of Mr Hankin at Goring Hall Hospital
There were multiple omissions in the pre-operative, intra-operative and post operative care provided by Goring Hall Hospital which individually and collectively contributed to Mr Hankin’s death. This included a failure to recognise Mr Hankin underlying medical co-morbidities rendered him unfit to have his operative procedure at the hospital . More specifically the post-operative assessment and support provided by the consultant anaesthetist and surgeon led to a delay in assessing and diagnosing sepsis and thereafter giving appropriate and timely antibiotics and facilitating an earlier transfer to the NHS Hospital for further management. This gives rise to a concern that there was a lack of understanding by the senior clinicians (in the absence of any local and national guidelines provided at the inquest) requiring them to remain responsible for the care of patients throughout their time in a private hospital rather than delegating the care to a Resident Medical Officer who is more likely than not to be insufficiently experienced in managing such critical situations.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to fully inform patients of clinicians’ relevant experience
Wider context from the report “4. Practicing Privileges within the private sector
████████ set up and led the CUS under the auspices of SMC. The ICB contractually required this service to be run by a consultant urologist. ████████ had not held a formal consultant urologist position within the NHS prior to tendering for this work. It remains unclear as to how ████████ was provided with practicing privileges at a private hospital as a consultant and was therefore able to practice independently and without scrutiny. This gives rise to a concern that there is a lack of robust assessment and guidelines, both locally and nationally, as to how clinicians are given practising privileges to work independently outside of the NHS to the potential detriment of patient care. It also gives rise to a concern that patients are not being fully informed of the relevant experience of such clinicians thereby breaching the statutory duty of candour responsibility of all hospitals.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to integrate community urology services with hospital-based consultant-led urology services
Wider context from the report “2. Lack of Integration of the Community Urology service with NHS Hospital Urology Services
The CUS provided community-based urology services with non-consultant grade urologists without any oversight or integration with hospital-based consultant led urology services . Whilst there was an opportunity for CUS to refer more complex patients to NHS Hospital Trusts the ‘silo’ effect of these 2 services was such that they effectively worked independently of each other . The absence of a robust multidisciplinary team assessment within the CUS and the lack of senior clinical oversight of community urology patients by NHS consultant clinicians leads to a concern that the urology service is fragmented and does not effectively support urology patients within the region to confirm best practice and optimal treatment.
” 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 Oversight and governance of Integrated Care Boards fall outside the regulatory scope of this respondent.
Verbatim wording from the response “We are unable to comment on the aspects of this concern that relate to the Integrated Care Board (ICB) as it falls outside the scope of our regulatory responsibilities. The Integrated Care Board (ICB), as a named respondent in this case, would be best placed to address this point and provide further clarification.” Source location Response from Care Quality Commission
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 Existing appraisal and performance-review arrangements for Community Urology Service clinicians were considered consistent with nationally recognised independent-sector arrangements.
Verbatim wording from the response “We were satisfied that this demonstrated that appraisals were performed in line with nationally recognised arrangements for individuals working in the independent sector.” Source location Response from Care Quality Commission
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 Sussex Medical Chambers’ clinical governance and multidisciplinary arrangements were considered acceptable under Regulation 17.
Verbatim wording from the response “We were satisfied that the evidence provided demonstrated acceptable arrangements under Regulation 17: Good Governance.” Source location Response from Care Quality Commission
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 Failures by individual clinicians fall outside prosecutorial remit because prosecutorial powers extend only to registered providers or registered managers.
Verbatim wording from the response “CQC’s prosecutorial powers only extend to registered persons. A registered person means either the provider or their registered manager. Failures by individuals are not within our remit; therefore, we cannot pursue this matter any further.” Source location Response from Care Quality Commission
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 Integrated Care Board is best placed to address concerns about its oversight, governance and performance.
Verbatim wording from the response “While the Care Quality Commission (CQC) has statutory powers to regulate providers of health and social care services, we do not hold regulatory authority over Integrated Care Boards (ICBs). Responsibility for the oversight, governance, and performance of ICBs lies with NHS England.” Source location Response from Care Quality Commission
Open published response
3 Sep 2025 Margaret Bailey · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of ability and equipment for carers to carry out basic observations of unwell clients View source Lack of an algorithm for office call handlers to triage clients who appear unwell and determine a course of action View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Margaret Bailey · 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
Margaret Bailey, who was bed-bound and wholly dependent on personal care, became unwell at home on 17 December 2023, later vomited while resting in bed, and was found unresponsive. The medical cause of death was aspiration of gastric contents following an episode of vomiting. Concerns included the absence of a triage algorithm for calls reporting that a client was unwell and the lack of equipment or ability to take basic observations, including a temperature reading.
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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of ability and equipment for carers to carry out basic observations of unwell clients
Wider context from the report “2. There was no ability for the carer reporting that Margaret was unwell to carry out any basic observations, neither before the call to the office nor after it , in order that Margaret could be monitored as per the advice given or to at least provide a baseline for monitoring, not even a temperature reading . Most family homes, caring for children or physically vulnerable adults, would have at least a thermometer, and perhaps a pulse oximeter, maybe even a blood pressure machine.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of an algorithm for office call handlers to triage clients who appear unwell and determine a course of action
Wider context from the report “1. On the ‘office’ receiving a call from a carer reporting, as here, that a client appears to be unwell there is no algorithm for the call handler (who tends to be an assistant manager/manager but with no medical background) to follow to triage the client, setting out why the client appears unwell and to then determine a course of action . The direction of the conversation is simply left to the ‘office’.
” 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 Department of Health and Social Care may be better placed to address concerns about call-handler triage algorithms.
Verbatim wording from the response “We have given careful consideration to this point and note that this report has also been sent to the Secretary of State for Health and Social Care. The Department of Health and Social Care may be of greater assistance in addressing this aspect of your concerns because currently in line with CQC’s Scope of Registration the regulated activity of Personal care is defined as physical assistance given to a person in connection with:” Source location Response from Care Quality Commission
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 Amending regulations to permit homecare agencies to undertake medical or nursing observations is outside CQC’s scope and powers.
Verbatim wording from the response “In summary it is outside CQC scope and powers to amend the regulations in order that HCAs who are limited by the definition of Personal care would be allowed to take on medical or nursing observations and we have noted that you have also sent this report to The Secretary of State for Health and Social Care who may be better placed to address this issue if they believe a change in the Regulations is required.” Source location Response from Care Quality Commission
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 Secretary of State for Health and Social Care may be better placed to consider whether regulatory changes are required.
Verbatim wording from the response “In summary it is outside CQC scope and powers to amend the regulations in order that HCAs who are limited by the definition of Personal care would be allowed to take on medical or nursing observations and we have noted that you have also sent this report to The Secretary of State for Health and Social Care who may be better placed to address this issue if they believe a change in the Regulations is required.” Source location Response from Care Quality Commission
Open published response
14 Jul 2025 Myles Edward SCRIVEN · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 6 Lack of knowledge of requirements for patients with learning disabilities and autism View source Failure to understand and use the Learning Disabilities Register View source Failure to liaise with the Learning Disabilities Service to address missing support arrangements View source Failure to undertake rigorous and detailed internal incident review for learning View source Failure to record numeric observations properly View source Failure to make appropriate adjustments for patients with learning disabilities and autism 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
Myles Edward SCRIVEN · 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
Myles Edward Scriven died at Huddersfield Royal Infirmary on 16 April 2023. The report states that he had several contacts with Dalton Surgery while suffering from an ongoing pulmonary embolism, none of which resulted in referral to secondary care, and that the handling of his care contributed to his death. Concerns also included insufficient adjustments and understanding of his autism and learning disabilities, failure to record numeric observations properly, and failure to undertake a rigorous internal review.
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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of requirements for patients with learning disabilities and autism
Wider context from the report “While the rider of Neglect does not attach to the actions of the Dalton Surgery, the fact remains that between 16 and 20 March 2023 Myles had several contacts with the Dalton Surgery while he was suffering with an on going Pulmonary Embolism. Non of these resulted in a referral to secondary care. The combined evidence of three expert witnesses was that the manner in which his care was handled at this stage contributed to his death.
The following are concerns that I have arising from the evidence in he Inquest.
1. Ignorance of what was required for Myles in the circumstances of his Learning Disability and Autism - the GPs clearly only had a superficial grasp of the regulatory requirements and realities to do with Learning Disabilities . They are clearly well intentioned and caring but their appreciation and approach seems to have been based entirely on professional experience and good intentions rather than real knowledge of what was required and how to implement it.
Notably:
•They repeatedly used the words learning difficulties and learning disabilities interchangeably and apparently randomly – I am not told that Myles had a personal preference about which to use that they deferred to. Essentially, they seem to have been ignorant as to the distinction.
•They made only the most modest adjustments for Myles's Learning Disabilities and Autism.
•They clearly had very little grasp of what the Learning Disabilities Register was and how it worked. Neither of the GPs who gave evidence were able to provide a solid, reliable version of how it operated in their practice, when or/if Myles had been entered on to it, whether it was distinct from the psychiatric review - one seemed to conflate the two and the other said that it was something managed by a Nurse in the practice. It is quite evident that correspondence was coming in from Learning Disabilities Psychiatry but nothing at all from Social Services. This is not something that seems to have triggered any particular reaction at the GP level. They seemed to operate on the basis that the Learning Disabilities ’box had been ticked’ and that nothing further was needed. In fact, Myles seems to have been on the Register from 2020 but by the 20 October 2022 when he had been at hospital in relation to his PE he had no Learning Disability Social Worker and concomitantly no VIP passport on admission to hospital . The GPs clearly had no idea of how important all this was. I heard evidence from a secondary care Learning Disabilities Professional that they, in secondary care, rely a great deal on primary care to get these things sorted out. Here, nothing went back from the Practice to the Learning Disabilities Service to chase these things.
2. The failure of the GP to record numeric observations properly on 20 March 2023.
3. The failure of the Dalton Surgery to undertake any rigorous and detailed internal review for learning purposes after this incident.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to understand and use the Learning Disabilities Register
Wider context from the report “While the rider of Neglect does not attach to the actions of the Dalton Surgery, the fact remains that between 16 and 20 March 2023 Myles had several contacts with the Dalton Surgery while he was suffering with an on going Pulmonary Embolism. Non of these resulted in a referral to secondary care. The combined evidence of three expert witnesses was that the manner in which his care was handled at this stage contributed to his death.
The following are concerns that I have arising from the evidence in he Inquest.
1. Ignorance of what was required for Myles in the circumstances of his Learning Disability and Autism - the GPs clearly only had a superficial grasp of the regulatory requirements and realities to do with Learning Disabilities. They are clearly well intentioned and caring but their appreciation and approach seems to have been based entirely on professional experience and good intentions rather than real knowledge of what was required and how to implement it.
Notably:
•They repeatedly used the words learning difficulties and learning disabilities interchangeably and apparently randomly – I am not told that Myles had a personal preference about which to use that they deferred to. Essentially, they seem to have been ignorant as to the distinction.
•They made only the most modest adjustments for Myles's Learning Disabilities and Autism.
•They clearly had very little grasp of what the Learning Disabilities Register was and how it worked. Neither of the GPs who gave evidence were able to provide a solid, reliable version of how it operated in their practice, when or/if Myles had been entered on to it, whether it was distinct from the psychiatric review - one seemed to conflate the two and the other said that it was something managed by a Nurse in the practice. It is quite evident that correspondence was coming in from Learning Disabilities Psychiatry but nothing at all from Social Services. This is not something that seems to have triggered any particular reaction at the GP level. They seemed to operate on the basis that the Learning Disabilities ’box had been ticked’ and that nothing further was needed. In fact, Myles seems to have been on the Register from 2020 but by the 20 October 2022 when he had been at hospital in relation to his PE he had no Learning Disability Social Worker and concomitantly no VIP passport on admission to hospital . The GPs clearly had no idea of how important all this was. I heard evidence from a secondary care Learning Disabilities Professional that they, in secondary care, rely a great deal on primary care to get these things sorted out. Here, nothing went back from the Practice to the Learning Disabilities Service to chase these things.
2. The failure of the GP to record numeric observations properly on 20 March 2023.
3. The failure of the Dalton Surgery to undertake any rigorous and detailed internal review for learning purposes after this incident.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to liaise with the Learning Disabilities Service to address missing support arrangements
Wider context from the report “While the rider of Neglect does not attach to the actions of the Dalton Surgery, the fact remains that between 16 and 20 March 2023 Myles had several contacts with the Dalton Surgery while he was suffering with an on going Pulmonary Embolism. Non of these resulted in a referral to secondary care. The combined evidence of three expert witnesses was that the manner in which his care was handled at this stage contributed to his death.
The following are concerns that I have arising from the evidence in he Inquest.
1. Ignorance of what was required for Myles in the circumstances of his Learning Disability and Autism - the GPs clearly only had a superficial grasp of the regulatory requirements and realities to do with Learning Disabilities. They are clearly well intentioned and caring but their appreciation and approach seems to have been based entirely on professional experience and good intentions rather than real knowledge of what was required and how to implement it.
Notably:
•They repeatedly used the words learning difficulties and learning disabilities interchangeably and apparently randomly – I am not told that Myles had a personal preference about which to use that they deferred to. Essentially, they seem to have been ignorant as to the distinction.
•They made only the most modest adjustments for Myles's Learning Disabilities and Autism.
•They clearly had very little grasp of what the Learning Disabilities Register was and how it worked. Neither of the GPs who gave evidence were able to provide a solid, reliable version of how it operated in their practice, when or/if Myles had been entered on to it, whether it was distinct from the psychiatric review - one seemed to conflate the two and the other said that it was something managed by a Nurse in the practice. It is quite evident that correspondence was coming in from Learning Disabilities Psychiatry but nothing at all from Social Services. This is not something that seems to have triggered any particular reaction at the GP level. They seemed to operate on the basis that the Learning Disabilities ’box had been ticked’ and that nothing further was needed. In fact, Myles seems to have been on the Register from 2020 but by the 20 October 2022 when he had been at hospital in relation to his PE he had no Learning Disability Social Worker and concomitantly no VIP passport on admission to hospital . The GPs clearly had no idea of how important all this was. I heard evidence from a secondary care Learning Disabilities Professional that they, in secondary care, rely a great deal on primary care to get these things sorted out. Here, nothing went back from the Practice to the Learning Disabilities Service to chase these things.
2. The failure of the GP to record numeric observations properly on 20 March 2023.
3. The failure of the Dalton Surgery to undertake any rigorous and detailed internal review for learning purposes after this incident.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake rigorous and detailed internal incident review for learning
Wider context from the report “While the rider of Neglect does not attach to the actions of the Dalton Surgery, the fact remains that between 16 and 20 March 2023 Myles had several contacts with the Dalton Surgery while he was suffering with an on going Pulmonary Embolism. Non of these resulted in a referral to secondary care. The combined evidence of three expert witnesses was that the manner in which his care was handled at this stage contributed to his death.
The following are concerns that I have arising from the evidence in he Inquest.
1. Ignorance of what was required for Myles in the circumstances of his Learning Disability and Autism - the GPs clearly only had a superficial grasp of the regulatory requirements and realities to do with Learning Disabilities. They are clearly well intentioned and caring but their appreciation and approach seems to have been based entirely on professional experience and good intentions rather than real knowledge of what was required and how to implement it.
Notably:
•They repeatedly used the words learning difficulties and learning disabilities interchangeably and apparently randomly – I am not told that Myles had a personal preference about which to use that they deferred to. Essentially, they seem to have been ignorant as to the distinction.
•They made only the most modest adjustments for Myles's Learning Disabilities and Autism.
•They clearly had very little grasp of what the Learning Disabilities Register was and how it worked. Neither of the GPs who gave evidence were able to provide a solid, reliable version of how it operated in their practice, when or/if Myles had been entered on to it, whether it was distinct from the psychiatric review - one seemed to conflate the two and the other said that it was something managed by a Nurse in the practice. It is quite evident that correspondence was coming in from Learning Disabilities Psychiatry but nothing at all from Social Services. This is not something that seems to have triggered any particular reaction at the GP level. They seemed to operate on the basis that the Learning Disabilities ’box had been ticked’ and that nothing further was needed. In fact, Myles seems to have been on the Register from 2020 but by the 20 October 2022 when he had been at hospital in relation to his PE he had no Learning Disability Social Worker and concomitantly no VIP passport on admission to hospital . The GPs clearly had no idea of how important all this was. I heard evidence from a secondary care Learning Disabilities Professional that they, in secondary care, rely a great deal on primary care to get these things sorted out. Here, nothing went back from the Practice to the Learning Disabilities Service to chase these things.
2. The failure of the GP to record numeric observations properly on 20 March 2023.
3. The failure of the Dalton Surgery to undertake any rigorous and detailed internal review for learning purposes after this incident.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to record numeric observations properly
Wider context from the report “While the rider of Neglect does not attach to the actions of the Dalton Surgery, the fact remains that between 16 and 20 March 2023 Myles had several contacts with the Dalton Surgery while he was suffering with an on going Pulmonary Embolism. Non of these resulted in a referral to secondary care. The combined evidence of three expert witnesses was that the manner in which his care was handled at this stage contributed to his death.
The following are concerns that I have arising from the evidence in he Inquest.
1. Ignorance of what was required for Myles in the circumstances of his Learning Disability and Autism - the GPs clearly only had a superficial grasp of the regulatory requirements and realities to do with Learning Disabilities. They are clearly well intentioned and caring but their appreciation and approach seems to have been based entirely on professional experience and good intentions rather than real knowledge of what was required and how to implement it.
Notably:
•They repeatedly used the words learning difficulties and learning disabilities interchangeably and apparently randomly – I am not told that Myles had a personal preference about which to use that they deferred to. Essentially, they seem to have been ignorant as to the distinction.
•They made only the most modest adjustments for Myles's Learning Disabilities and Autism.
•They clearly had very little grasp of what the Learning Disabilities Register was and how it worked. Neither of the GPs who gave evidence were able to provide a solid, reliable version of how it operated in their practice, when or/if Myles had been entered on to it, whether it was distinct from the psychiatric review - one seemed to conflate the two and the other said that it was something managed by a Nurse in the practice. It is quite evident that correspondence was coming in from Learning Disabilities Psychiatry but nothing at all from Social Services. This is not something that seems to have triggered any particular reaction at the GP level. They seemed to operate on the basis that the Learning Disabilities ’box had been ticked’ and that nothing further was needed. In fact, Myles seems to have been on the Register from 2020 but by the 20 October 2022 when he had been at hospital in relation to his PE he had no Learning Disability Social Worker and concomitantly no VIP passport on admission to hospital . The GPs clearly had no idea of how important all this was. I heard evidence from a secondary care Learning Disabilities Professional that they, in secondary care, rely a great deal on primary care to get these things sorted out. Here, nothing went back from the Practice to the Learning Disabilities Service to chase these things.
2. The failure of the GP to record numeric observations properly on 20 March 2023.
3. The failure of the Dalton Surgery to undertake any rigorous and detailed internal review for learning purposes after this incident.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to make appropriate adjustments for patients with learning disabilities and autism
Wider context from the report “While the rider of Neglect does not attach to the actions of the Dalton Surgery, the fact remains that between 16 and 20 March 2023 Myles had several contacts with the Dalton Surgery while he was suffering with an on going Pulmonary Embolism. Non of these resulted in a referral to secondary care. The combined evidence of three expert witnesses was that the manner in which his care was handled at this stage contributed to his death.
The following are concerns that I have arising from the evidence in he Inquest.
1. Ignorance of what was required for Myles in the circumstances of his Learning Disability and Autism - the GPs clearly only had a superficial grasp of the regulatory requirements and realities to do with Learning Disabilities. They are clearly well intentioned and caring but their appreciation and approach seems to have been based entirely on professional experience and good intentions rather than real knowledge of what was required and how to implement it.
Notably:
•They repeatedly used the words learning difficulties and learning disabilities interchangeably and apparently randomly – I am not told that Myles had a personal preference about which to use that they deferred to. Essentially, they seem to have been ignorant as to the distinction.
•They made only the most modest adjustments for Myles's Learning Disabilities and Autism.
•They clearly had very little grasp of what the Learning Disabilities Register was and how it worked. Neither of the GPs who gave evidence were able to provide a solid, reliable version of how it operated in their practice, when or/if Myles had been entered on to it, whether it was distinct from the psychiatric review - one seemed to conflate the two and the other said that it was something managed by a Nurse in the practice. It is quite evident that correspondence was coming in from Learning Disabilities Psychiatry but nothing at all from Social Services. This is not something that seems to have triggered any particular reaction at the GP level. They seemed to operate on the basis that the Learning Disabilities ’box had been ticked’ and that nothing further was needed. In fact, Myles seems to have been on the Register from 2020 but by the 20 October 2022 when he had been at hospital in relation to his PE he had no Learning Disability Social Worker and concomitantly no VIP passport on admission to hospital . The GPs clearly had no idea of how important all this was. I heard evidence from a secondary care Learning Disabilities Professional that they, in secondary care, rely a great deal on primary care to get these things sorted out. Here, nothing went back from the Practice to the Learning Disabilities Service to chase these things.
2. The failure of the GP to record numeric observations properly on 20 March 2023.
3. The failure of the Dalton Surgery to undertake any rigorous and detailed internal review for learning purposes after this incident.
” 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 Use the Oliver McGowan Code of Practice when assessing providers’ compliance with learning disability and autism training requirements.
Verbatim wording from the response “On the 19th June 2025, the Oliver McGowan Code of Practice was published and laid before parliament by the Department of Health and Social Care. The code commenced on 6th September 2025 and is now legal guidance. The purpose of the code is to explain what is meant by training that is ‘appropriate to the person’s role’ and to provide guidance on how to ensure all staff receive such training.” Source location Response from Care Quality Commission (1)
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 inspection guidance on assessing safe care for people with learning disabilities and autistic people.
Verbatim wording from the response “In response to the known challenges faced by people with a learning disability and autistic people when they access primary care services, as well as feedback from people with lived experience, CQC had already begun a program of work focusing on the health inequalities faced by this population group. This includes taking action to review how we consider whether a GP practice is providing safe care and treatment for people with a learning disability and autistic people. Specifically, we are reviewing and will update the guidance in respect of this, that we provide for our inspection teams to follow. This aims to prompt inspectors to carry out a more thorough assessment than currently takes place and give them the necessary tools to do so. Our regulatory leadership teams are leading on this.” Source location Response from Care Quality Commission (2)
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 Use the Oliver McGowan Code of Practice when assessing providers’ compliance with relevant training regulations.
Verbatim wording from the response “Compliance with the standards set out in the code of practice, is expected to ensure that every person receives high quality learning disability and autism training that meets their learning needs and is appropriate to their role. Importantly, this aims to improve the experiences and outcomes of autistic people and people with a learning disability when they access CQC regulated health and social care services. This means that CQC registered providers must ensure they provide each member of staff with training that meets the standards set out in the Code in order to deliver the best possible outcomes. CQC will use the Oliver McGowan Code of Practice when considering whether providers are meeting the requirements of relevant regulations.” Source location Response from Care Quality Commission (2)
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 Run bespoke sessions for inspection teams on mandatory learning-disability and autism training requirements and the Oliver McGowan Code of Practice.
Verbatim wording from the response “Throughout September, the CQC’s autistic people and people with a learning disability team will be running bespoke upskilling sessions on the mandatory training requirement and code of practice with the aim of equipping inspection teams with the knowledge and skills they need to regulate this requirement effectively and consistently. Specifically pertinent to the case of Myles Scriven, the code of practice enables both providers and CQC to consider the extent to which learning is put into practice.” Source location Response from Care Quality Commission (2)
Open published response
14 Jul 2025 Myles Edward Scriven · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 4 Failure to audit the impact and outcomes of learning disability and autism training and provision View source Failure to act on relevant electronic patient record entries across clinical colleagues View source Lack of required adjustments for patients with learning disabilities and autism View source Failure to apply Mental Capacity Act principle 2 in clinical decision-making 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
Myles Edward Scriven · 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
Myles Edward Scriven died at Huddersfield Royal Infirmary on 16 April 2023. The report states that lack of adjustments for his Autism and Learning Disabilities contributed to incorrect decisions about his care and medication. The principal concern was that existing training, policies and support arrangements were not effectively applied or audited to ensure safe care and medication decisions.
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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to audit the impact and outcomes of learning disability and autism training and provision
Wider context from the report “(brief summary of matters of concern)
The rider of Neglect attaches to the actions of the Calderdale and Huddersfield NHS Foundation Trust (‘the Trust’). It relates to the lack of adjustments, that were identified as being required to treat Myles safely in the context of his Learning Disabilities (‘LD’) and Autism notably during his admission 20-25 October 2022. It is true that evidence from Trust witnesses has been sufficient to demonstrate that the Trust is aware of the issues arising in this case at least in terms of training and professional input. It has an ongoing programme of training in relation to Learning Disabilities and Autism in clinical care and they have people in post enhancing Learning Disability provision. The crux of the remaining concern is in relation to auditing the impact of all of this in terms of auditing the outcome of this work . To be fair, Trust evidence was that there is now auditing of mental capacity assessments and there is dedicated nursing leadership walkaround of all wards auditing LD and autism policies being applied . However, there is this remaining evidential reality: much of what is now in place was already in place in 2022 – not least key personnel who gave evidence at the Inquest, but also VIP passports, training and all the underlying regulatory underpinning. But in Myles’s case it simply had no impact whatsoever. One witness’s own ‘spot-on’ entries in the EPR on 21 October were just not acted upon by colleagues and had zero effect when he went on leave thereafter. Clinicians were applying Mental Capacity Act principle 1 but not 2. ‘Culturally’ speaking, that one obtaining in secondary care after the witness went on leave seems to have been stuck in another era. So, the question is - how it is proposed to ensure full compliance with best practice and by when?
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to act on relevant electronic patient record entries across clinical colleagues
Wider context from the report “(brief summary of matters of concern)
The rider of Neglect attaches to the actions of the Calderdale and Huddersfield NHS Foundation Trust (‘the Trust’). It relates to the lack of adjustments, that were identified as being required to treat Myles safely in the context of his Learning Disabilities (‘LD’) and Autism notably during his admission 20-25 October 2022. It is true that evidence from Trust witnesses has been sufficient to demonstrate that the Trust is aware of the issues arising in this case at least in terms of training and professional input. It has an ongoing programme of training in relation to Learning Disabilities and Autism in clinical care and they have people in post enhancing Learning Disability provision. The crux of the remaining concern is in relation to auditing the impact of all of this in terms of auditing the outcome of this work. To be fair, Trust evidence was that there is now auditing of mental capacity assessments and there is dedicated nursing leadership walkaround of all wards auditing LD and autism policies being applied. However, there is this remaining evidential reality: much of what is now in place was already in place in 2022 – not least key personnel who gave evidence at the Inquest, but also VIP passports, training and all the underlying regulatory underpinning. But in Myles’s case it simply had no impact whatsoever. One witness’s own ‘spot-on’ entries in the EPR on 21 October were just not acted upon by colleagues and had zero effect when he went on leave thereafter . Clinicians were applying Mental Capacity Act principle 1 but not 2. ‘Culturally’ speaking, that one obtaining in secondary care after the witness went on leave seems to have been stuck in another era. So, the question is - how it is proposed to ensure full compliance with best practice and by when?
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of required adjustments for patients with learning disabilities and autism
Wider context from the report “(brief summary of matters of concern)
The rider of Neglect attaches to the actions of the Calderdale and Huddersfield NHS Foundation Trust (‘the Trust’). It relates to the lack of adjustments, that were identified as being required to treat Myles safely in the context of his Learning Disabilities (‘LD’) and Autism notably during his admission 20-25 October 2022. It is true that evidence from Trust witnesses has been sufficient to demonstrate that the Trust is aware of the issues arising in this case at least in terms of training and professional input. It has an ongoing programme of training in relation to Learning Disabilities and Autism in clinical care and they have people in post enhancing Learning Disability provision. The crux of the remaining concern is in relation to auditing the impact of all of this in terms of auditing the outcome of this work. To be fair, Trust evidence was that there is now auditing of mental capacity assessments and there is dedicated nursing leadership walkaround of all wards auditing LD and autism policies being applied. However, there is this remaining evidential reality: much of what is now in place was already in place in 2022 – not least key personnel who gave evidence at the Inquest, but also VIP passports, training and all the underlying regulatory underpinning. But in Myles’s case it simply had no impact whatsoever. One witness’s own ‘spot-on’ entries in the EPR on 21 October were just not acted upon by colleagues and had zero effect when he went on leave thereafter. Clinicians were applying Mental Capacity Act principle 1 but not 2. ‘Culturally’ speaking, that one obtaining in secondary care after the witness went on leave seems to have been stuck in another era. So, the question is - how it is proposed to ensure full compliance with best practice and by when?
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to apply Mental Capacity Act principle 2 in clinical decision-making
Wider context from the report “(brief summary of matters of concern)
The rider of Neglect attaches to the actions of the Calderdale and Huddersfield NHS Foundation Trust (‘the Trust’). It relates to the lack of adjustments, that were identified as being required to treat Myles safely in the context of his Learning Disabilities (‘LD’) and Autism notably during his admission 20-25 October 2022. It is true that evidence from Trust witnesses has been sufficient to demonstrate that the Trust is aware of the issues arising in this case at least in terms of training and professional input. It has an ongoing programme of training in relation to Learning Disabilities and Autism in clinical care and they have people in post enhancing Learning Disability provision. The crux of the remaining concern is in relation to auditing the impact of all of this in terms of auditing the outcome of this work. To be fair, Trust evidence was that there is now auditing of mental capacity assessments and there is dedicated nursing leadership walkaround of all wards auditing LD and autism policies being applied. However, there is this remaining evidential reality: much of what is now in place was already in place in 2022 – not least key personnel who gave evidence at the Inquest, but also VIP passports, training and all the underlying regulatory underpinning. But in Myles’s case it simply had no impact whatsoever. One witness’s own ‘spot-on’ entries in the EPR on 21 October were just not acted upon by colleagues and had zero effect when he went on leave thereafter. Clinicians were applying Mental Capacity Act principle 1 but not 2 . ‘Culturally’ speaking, that one obtaining in secondary care after the witness went on leave seems to have been stuck in another era. So, the question is - how it is proposed to ensure full compliance with best practice and by when?
” Open source report
Concerns raised 4 Failure to put recommended falls prevention equipment in place View source Reluctance to provide adequate resources for falls prevention equipment View source Failure to apply for DoLS assessments for residents lacking mental capacity View source Failure to pass on Community Falls Service recommendations to family and social services View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Patricia Heaviside · 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
Patricia Heaviside, a resident of Howlish Hall Care Home, suffered an unwitnessed fall on 4 October 2024, fractured her left hip, and died on 26 December 2024 as a consequence of the fracture. Concerns included the failure to implement recommended falls-prevention equipment, failures to share relevant information with family and social services, and apparent reluctance to provide adequate resources for falls prevention. The report also raised concerns that no DoLS assessment application appeared to have been made despite her lack of mental capacity and inability to keep herself safe.
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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to put recommended falls prevention equipment in place
Wider context from the report “(1) Despite recommendations for falls prevention equipment being made by the Community Falls Service in August 2023, no falls prevention equipment was put in place by the time of the Deceased’s fall in fall October 2024
(2) Despite the social worker expressing concern about the lack of falls prevention equipment on 27 September 2024, no falls equipment was put in place prior to the Deceased’s fall on 4 October 2024.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Reluctance to provide adequate resources for falls prevention equipment
Wider context from the report “(4) On 5 August 2024 (following a fall, but before the more significant fall on 4 October 2024), the Deceased’s family were told by the Deputy Manager of Howlish Hall that the owner of Howlish Hall “probably wouldn’t want to pay for a sensor mat” .
(5) I received evidence that, subsequent to the Deceased’s death, there had been a reluctance on the part of ████████ (who was believed to be the owner of Howlish Hall Care Home) to provide adequate resources for falls prevention equipment .
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to apply for DoLS assessments for residents lacking mental capacity
Wider context from the report “(6) Despite it being recognised that the Deceased lacked mental capacity to make decisions about where she lived and was unable to keep herself safe, it appears that the home did not make any application for a DoLS assessment for the Deceased . Indeed I received evidence that when a new home manager was appointed at Howlish Hall in January 2025 none of the residents were subject to a DoLS, despite a large number of the residents lacking mental capacity .
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to pass on Community Falls Service recommendations to family and social services
Wider context from the report “(3) Information about the Community Falls Service recommendations was not passed on to the family, or to social services.
” 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 Impose registration conditions requiring the provider to safeguard residents from falls, confirm suitable equipment is in place, and update care plans.
Verbatim wording from the response “During the inspection on 2, 3, 9 and 11 July 2025 and subsequent concerns shared with us by Durham County Council, we had significant concerns in relation to falls management at the service. As stated above, we took urgent action to impose conditions on the provider’s registration. One of the conditions included a requirement for the provider to take steps to safeguard people from the risk of falls, including confirmation that appropriate equipment was in situ and service users care plans reflected the level of support and equipment they required to reduce the risks associated with falls.” Source location 2025-0354 Response from Care Quailty Commission
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 Sensor mats provide an early warning enabling swift responses but do not physically prevent falls.
Verbatim wording from the response “CQC expects care providers to follow the NICE guidelines on falls management (https://www.nice.org.uk/guidance/ng249/chapter/Recommendations#interventions-to-reduce-the-risk-of-falls). We expect providers to take a multi-factorial approach to falls management which includes measures such as conducting medication reviews, encouraging the person to remain physically active and removing hazards from the environment. Whilst sensor mats are useful as an early warning system that alerts care staff to potential falls or movements to enable swift responses to prevent injuries, they do not physically prevent a person having a fall.” Source location 2025-0354 Response from Care Quailty Commission
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 provider is best placed to address whether sensor mats should have been supplied for an individual's assessed needs.
Verbatim wording from the response “4. On 5 August 2024 (following a fall, but before the more significant fall on 4 October 2024), the Deceased’s family were told by the Deputy Manager of Howlish Hall that the owner of Howlish Hall “probably wouldn’t want to pay for a sensor mat”.” Source location 2025-0354 Response from Care Quailty Commission
Open published response
19 May 2025 John Charles Spencer · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 1 Failure of GP out-of-hours surgeries to access key GP medical history information after patient consent View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Charles Spencer · 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 Charles Spencer became unwell on 17 May 2024 and died on 21 May 2024 after a bowel perforation caused by obstruction within a recurrent right inguinal hernia, resulting in purulent peritonitis. The principal concern was that the GP out-of-hours surgery could not access his relevant GP medical history because different computer systems prevented the exchange of information, potentially affecting the examinations undertaken when patients do not report relevant history.
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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of GP out-of-hours surgeries to access key GP medical history information after patient consent
Wider context from the report “(1) The GP medical history summary, populated by the GP that a patient is registered to, is not always accessible to a GP out of hours surgery. Evidence was given that there are various reasons for this, including the patient not providing consent for the exchange of this information. However, on some occasions, even when a patient has consented, the patient record systems utilised by the GP registered practice and the GP out of hours surgery, insofar as being different computer systems or for whatever other technological reason, prevented the exchange of information into the GP out of hours surgery. In this case, evidence was heard that the GP practice was using the EMIS system and that the urgent treatment centre (GP out of hours surgery) was using SystmOne. That fact caused the GP out of hours surgery to not be able to access Mr Spencer’s GP medical summary. This situation generates a concern that, providing the patient has consented, key medical information may not be conveyed to the GP out of hours surgery which should be accessible to allow the appropriate exchange of medical information to inform what examinations should take place in an out of hours setting . This concern is particularly significant in circumstances where the patient does not say and/or present with the points in the medical history relevant to the GPs determination about what further examinations should occur flowing from the medical history of the patient.
” 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 Scrutinise providers’ handling of correspondence, clinical coding, information sharing, patient pathways and significant-event learning during inspection and monitoring activity.
Verbatim wording from the response “As CQC is aware that computer systems across healthcare providers are often unable to communicate with each other we have taken steps to mitigate this issue. For example, we ensure that we look closely at how providers deal with incoming correspondence (e.g. letters from secondary care or other health and social care providers), coding, sharing of information with other healthcare providers and patient pathways during our inspection and monitoring activity. We also look closely at how they identify, record and learn from significant events such as this one and were satisfied with the significant event analysis undertaken by City Health Care Partnership in relation to this matter.” Source location Response from Care Quality Commission
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Decisions about providers’ computer systems and IT infrastructure are a commissioning matter, not under CQC’s direct control.
Verbatim wording from the response “It is not within the CQC’s role or remit to dictate the computer systems that providers operate or the IT infrastructure in use as this is a commissioning matter and not something we have any direct control over.” Source location Response from Care Quality Commission
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 Dictating providers’ computer systems and IT infrastructure is outside CQC’s role and remit.
Verbatim wording from the response “It is not within the CQC’s role or remit to dictate the computer systems that providers operate or the IT infrastructure in use as this is a commissioning matter and not something we have any direct control over.” Source location Response from Care Quality Commission
Open published response
13 May 2025 Rose Annie Harfleet · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Failure to routinely obtain and listen to parents’ or guardians’ information about children with profound disabilities View source Lack of guidance for managing children with profound disabilities in hospital settings View source Failure to recognise and act on parents’ ongoing concerns about children on hospital wards View source Failure to routinely offer learning disability liaison nurse support in the emergency department View source See 1 more concern
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AI-generated summary
Rose Annie Harfleet · 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
Rose Annie Harfleet, aged 12, died in hospital on 30 January 2024 after presenting with abdominal pain and vomiting, later identified as a caecal volvulus causing intestinal obstruction and bowel ischaemia. The report raised concerns about failures to recognise and respond to her deterioration, obtain and act on information from her mother, provide appropriate monitoring and surgical review, and offer learning disability liaison support. It also identified a lack of guidance for managing and consulting with children with profound disabilities in hospital settings.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely obtain and listen to parents’ or guardians’ information about children with profound disabilities
Wider context from the report “2. Guidelines - consultation with parents and guardians of children with profound disabilities within a hospital setting
Rose’s mother was devoted to Rose and was very able to advocate on Rose’s behalf as well as being best placed to provide the vital information about her signs and symptoms given Rose was unable to do this for herself. The importance of obtaining this information was not understood by the paediatric consultant who took no history from Rose’s mother and underestimated the severity of her signs and symptoms. The consequence of this was that Rose’s voice – through her mother as her advocate – was not heard and she was not therefore able to actively participate in the care and management that was provided to Rose, the corollary of which resulted in poor clinical decision making which contributed to Rose’s death. This gives rise to a concern that by not listening to parents or guardians as a matter of course leads to discrimination of disabled children.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for managing children with profound disabilities in hospital settings
Wider context from the report “1. The management of children with profound disabilities within a hospital setting
Rose was a deeply loved child who brought great joy to her mother, wider family and all that knew her. During the inquest hearing no national or local guidance was forthcoming to assist medical and nursing staff, within a conventional hospital setting, to appropriately manage patients such as Rose who had a global developmental delay and was wholly reliant on her mother to advocate on her behalf . This gives rise to a concern that this omission adversely impacts the care that patients such as Rose receive.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and act on parents’ ongoing concerns about children on hospital wards
Wider context from the report “3. Nursing and Medical care on the ward
In the absence of local and national guidelines, the importance of listening and responding to Rose’s mothers ongoing concerns about her daughter when she was transferred to the ward were not recognised by the nursing and medical staff and consequently not acted upon thereby contributing to Rose’s death. There appears to be a prevailing culture that in the absence of a patient being able to explain their symptoms themselves the voice of the parent or guardian is not given the significance it should be for the most vulnerable in a hospital setting.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely offer learning disability liaison nurse support in the emergency department
Wider context from the report “4. LeDeR Role
Rose’s admission was during the working week, yet there was no consideration or offer given to Rose or her mother during her time in the Emergency Department to being introduced to a learning Disability Liaison Nurse . This led to Rose’s mother being unsupported during this admission or for a nursing professional to be able to liaise and advocate for Rose and her mother with medical and nursing staff in the emergency department. This again gives rise to a concern that patients such as Rose and her mother are adversely impacted on the care that they receive in the absence of local and national guidelines that this should be routinely available and offered as a matter of course.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish interim guidance on mandatory learning disability and autism training for providers and CQC staff.
Verbatim wording from the response “Speaking with and respecting patients’ families is a key aspect of the mandatory learning disability and autism training (aka the Oliver McGowan training) so all clinicians involved should be aware of this. A difficulty with regard to the implementation and regulation of providing this training has been the delay to the publication of the Code of Practice. This will give providers and CQC staff clearer guidance on the requirements of the training and for CQC to regulate. Interim guidance is available on our website.” Source location Response from Care Quality Commission
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National or local guidance on managing children with profound disabilities in hospital is outside the regulatory scope.
Verbatim wording from the response “Your concerns relate specifically to the availability of national or local guidance. We are unable to comment directly on this point due to it being outside of the remit of our regulatory scope, and there are other respondents who would be best placed to respond directly to this question.” Source location Response from Care Quality Commission
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Other respondents are better placed to address national or local guidance on managing children with profound disabilities in hospital.
Verbatim wording from the response “Your concerns relate specifically to the availability of national or local guidance. We are unable to comment directly on this point due to it being outside of the remit of our regulatory scope, and there are other respondents who would be best placed to respond directly to this question.” Source location Response from Care Quality Commission
Open published response
9 Apr 2025 Bernard Lyon · Prevention of Future Deaths report Manchester South
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Concerns raised 8 Lack of a process to inform families about care home concerns and improvement plans View source Failure of CQC participation in multi-agency care home oversight meetings View source Delays in ambulance handover to the emergency department View source Delays in providing antibiotics in accordance with sepsis needs during high emergency-department demand View source Failure of agency staff to communicate effectively in English with residents and colleagues View source Lack of suitable non-acute or community provision for medically optimised patients View source Lack of sufficient management capacity in the care home View source Insufficient emergency-department bed capacity causing delays in patient transfer View source See 5 more concerns
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AI-generated summary
Bernard Lyon · 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
Bernard Lyon, who had dysphagia and was living at Hyde Nursing Home, developed sepsis and aspiration pneumonia and died at Tameside General Hospital on 30 January 2024. The report describes concerns about the nursing home's management capacity, staffing and adherence to his modified diet plan, as well as multi-agency oversight, communication with families, ambulance handover delays and delays in administering antibiotics in a very busy emergency department.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of a process to inform families about care home concerns and improvement plans
Wider context from the report “4. The inquest was told that there was no process to let a family know of concerns that agencies had about a care home or that it was subject to an improvement plan . This meant that families were being left to make decisions about where to place family members unaware of the actual situation and 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. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of CQC participation in multi-agency care home oversight meetings
Wider context from the report “3. The inquest was told that the Local Authority regularly held MAC meetings to look at care home issues from a multi-agency perspective. The CQC was invited but rarely attended the meetings . As a consequence, the flow of information to the CQC was reduced .
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance handover to the emergency department
Wider context from the report “5. The evidence given to the inquest indicated significant delays in the handover from the ambulance to the ED team . This was due to pressure on the ED but meant that ambulances were tied up for longer than necessary and then had a knock-on impact on the ability of the ambulance service to respond to calls. The inquest was told that TGH had made efforts to improve the turnaround time, and it was currently at just an average time of 23.22 minutes. There was further evidence that TGH were not unusual amongst hospitals in the Northwest with the turnaround time at other hospitals running at over 1 hour.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Delays in providing antibiotics in accordance with sepsis needs during high emergency-department demand
Wider context from the report “6. The Emergency Department at TGH was extremely busy on the day Mr Lyon arrived which was not unusual. The sheer volume of patients who were seriously ill meant that there was a delay in him being given antibiotics in accordance with his need . The Trust had taken steps to address this, but it was accepted that where there was a significant demand on an ED compliance with the national sepsis guidance was far more difficult to achieve .
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of agency staff to communicate effectively in English with residents and colleagues
Wider context from the report “2. The home relied on agency staff who the inquest was told struggled to have sufficient grasp of the English language to understand instructions given and to communicate with residents .
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of suitable non-acute or community provision for medically optimised patients
Wider context from the report “7. The inquest was told that the build-up of patients and levels of demand in the ED at TGH were not unusual and continued. As an illustration of the ongoing nature of the demand in recent months one patient has waited in ED for 3 days for a bed. The delay in transfer was due to an ongoing demand for beds and delayed discharges of patients medically optimised but with no suitable non acute/community provision being available .
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficient management capacity in the care home
Wider context from the report “1. The care home in question was recognised as having too few managers for it to be effectively managed but was allowed to continue to operate and was seeking to expand
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Insufficient emergency-department bed capacity causing delays in patient transfer
Wider context from the report “7. The inquest was told that the build-up of patients and levels of demand in the ED at TGH were not unusual and continued. As an illustration of the ongoing nature of the demand in recent months one patient has waited in ED for 3 days for a bed. The delay in transfer was due to an ongoing demand for beds and delayed discharges of patients medically optimised but with no suitable non acute/community provision being available.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor urgent and emergency service performance through Trust engagement and available data.
Verbatim wording from the response “Resourcing of the ED service and others across the country is a known risk and is subject to ongoing monitoring through engagement with the Trust and available data. Waiting times and other national targets receive close monitoring. CQC carry out inspections of urgent and emergency services in those trusts that are performing poorly in line with national ED targets. In comparison to other Manchester trusts and similar trusts in the Northwest, Tameside and Glossop Integrated Care NHS Foundation Trust has not flagged as one of the poorest performers in relation to ambulance waits outside the department and waiting times within the department. Performance data is always discussed in engagement with the Trust.” Source location Response from CQC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Attend multi-agency meetings when concerns about care homes arise.
Verbatim wording from the response “CQC are surprised that this is the view of the Local Authority, as we have regular meetings with both the commissioners and the quality team and will always attend MAC meetings where there are concerns.” Source location Response from CQC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Seek evidence that providers using agency staff have verified their training, skills and command of English.
Verbatim wording from the response “Where CQC identify that agency staff are being employed, we will seek evidence that the registered provider has carried out due diligence to be satisfied that the staff have been suitably trained and have the requisite skills, including command of English. Where we find this is not the case, we will raise this with the provider and this may constitute a breach of the regulation, with associated regulatory action.” Source location Response from CQC
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Inspect urgent and emergency services in trusts performing poorly against national emergency-department targets.
Verbatim wording from the response “Resourcing of the ED service and others across the country is a known risk and is subject to ongoing monitoring through engagement with the Trust and available data. Waiting times and other national targets receive close monitoring. CQC carry out inspections of urgent and emergency services in those trusts that are performing poorly in line with national ED targets. In comparison to other Manchester trusts and similar trusts in the Northwest, Tameside and Glossop Integrated Care NHS Foundation Trust has not flagged as one of the poorest performers in relation to ambulance waits outside the department and waiting times within the department. Performance data is always discussed in engagement with the Trust.” Source location Response from CQC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Secretary of State may be better placed to address hospital bed demand and delayed discharges because the issue involves complex competing budgetary demands.
Verbatim wording from the response “We have given careful consideration to this point and note that this report has also been sent to the Secretary of State for Health and Social Care and believe they will be of greater assistance in addressing this aspect of your concerns, the picture being complex with competing demands on budgets and the subsequent effects on patient care. CQC continue to monitor through engagement with the Trust and draw on our findings from CQC’s national NHS patient survey programme and statutory reports, our inspection activity, bespoke research into people’s experiences, insight from key stakeholders, and the evidence that our expert staff have collected throughout the year about the quality and safety of services in all areas of health and care. Our inspections in urgent and emergency care across the country found issues around triage and patient flow that affect” Source location Response from CQC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CQC relies on ongoing monitoring, performance data and targeted inspections for emergency services rather than additional action on emergency-department resourcing.
Verbatim wording from the response “Resourcing of the ED service and others across the country is a known risk and is subject to ongoing monitoring through engagement with the Trust and available data. Waiting times and other national targets receive close monitoring. CQC carry out inspections of urgent and emergency services in those trusts that are performing poorly in line with national ED targets. In comparison to other Manchester trusts and similar trusts in the Northwest, Tameside and Glossop Integrated Care NHS Foundation Trust has not flagged as one of the poorest performers in relation to ambulance waits outside the department and waiting times within the department. Performance data is always discussed in engagement with the Trust.” Source location Response from CQC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The provider is responsible for determining staffing and management arrangements because legislation does not prescribe the number of managers.
Verbatim wording from the response “There are no further stipulations within the Health and Social Care Act about the numbers of managers a registered provider must have, and it would be a matter for the provider to determine the staffing and management arrangements of the home to ensure they were structured in a way that enabled the safe delivery of the regulated activities. CQC’s role is then to assess through assessment and inspection, the efficacy of those arrangements and whether leadership and governance is sufficiently robust.” Source location Response from CQC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CQC disputes that it rarely attended multi-agency meetings, stating it regularly meets commissioners and attends meetings where concerns exist.
Verbatim wording from the response “CQC are surprised that this is the view of the Local Authority, as we have regular meetings with both the commissioners and the quality team and will always attend MAC meetings where there are concerns.” Source location Response from CQC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The local authority may be better placed to address informing families about care-home concerns and improvement plans.
Verbatim wording from the response “We have given careful consideration to this point and note that this report has also been sent to Tameside Metropolitan Borough Council who may be of greater assistance in addressing this aspect of your concerns. We note that Mr Lyon was receiving Continuing Healthcare Funding and therefore his partner was in contact with healthcare professionals who would be in a position to advise her about the suitability of any placement. Our reports are published on our websites and the report from our inspection in June 2023 made reference to the fact that the home was working towards an action plan.” Source location Response from CQC
Open published response
13 Mar 2025 Mr Paul Timothy Dunne · Prevention of Future Deaths report South London
View report summary
Concerns raised 12 Failure of Mental Health Trust leadership to recognise serious professional knowledge and judgment deficits View source Failure to direct staff to the need for 1:1 monitoring View source Failure to apply A&E risk assessment and staffing policies to mental health staff View source Absence of audit of absconsions and mental health liaison in A&E View source Failure to recognise high-risk mental health patients View source Incorrect understanding of Mental Health Act assessment criteria View source Failure to acknowledge communicated patient risk View source Failure to complete required duplicate A&E clinical record entries by mental health staff View source Lack of shared access to mental health and A&E clinical records View source Failure to document mental health assessments when no recording location is available View source Inconsistent risk assessment documentation and training across departments View source Gaps in mental health professionals’ knowledge and clinical judgment View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mr Paul Timothy Dunne · 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 Paul Dunne was brought to A&E after a paracetamol overdose and was considered at high risk of suicide, but did not receive continuous 1:1 observation. He absconded several times and was found dead after suspending himself in a nearby children's playground. Concerns included failures in risk assessment, observation, communication, documentation and escalation, as well as separate clinical-record systems used by mental health and A&E staff.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of Mental Health Trust leadership to recognise serious professional knowledge and judgment deficits
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to direct staff to the need for 1:1 monitoring
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need . When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to apply A&E risk assessment and staffing policies to mental health staff
Wider context from the report “2. The Mental Health Trust
• Staff and it appears the director even at the time of the inquest did not appreciate that the A&E policies (Missing Persons, Shared Care) which required risk assessment after an absconsion and alerting managers to the need for extra temporary staff if 1:1 monitoring was needed, also applied to MH staff.
• Evidence was heard that staff in KCH A&E and Oxleas NH Trust had been trained on different risk assessment documents. Although meetings had been reinstated between departments, there had been no audit of absconsions or MH liaison in A&E.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Absence of audit of absconsions and mental health liaison in A&E
Wider context from the report “2. The Mental Health Trust
• Staff and it appears the director even at the time of the inquest did not appreciate that the A&E policies (Missing Persons, Shared Care) which required risk assessment after an absconsion and alerting managers to the need for extra temporary staff if 1:1 monitoring was needed, also applied to MH staff.
• Evidence was heard that staff in KCH A&E and Oxleas NH Trust had been trained on different risk assessment documents. Although meetings had been reinstated between departments, there had been no audit of absconsions or MH liaison in A&E.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise high-risk mental health patients
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk , despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Incorrect understanding of Mental Health Act assessment criteria
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to acknowledge communicated patient risk
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to complete required duplicate A&E clinical record entries by mental health staff
Wider context from the report “3. MH staff and A&E staff write their clinical records in different systems and hospital staff do not have access to MH Rio records. MH staff attending A&E departments are asked to make a double entry in the A&E records as well. Here that was omitted, potentially with fatal risks. Moving to a combined electronic system (now identified as EPIC) has long been the aim of the local health providers, but evidence was heard that the pace of introduction, which is very slow, is in the hands of national NHS leadership.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of shared access to mental health and A&E clinical records
Wider context from the report “3. MH staff and A&E staff write their clinical records in different systems and hospital staff do not have access to MH Rio records . MH staff attending A&E departments are asked to make a double entry in the A&E records as well. Here that was omitted, potentially with fatal risks. Moving to a combined electronic system (now identified as EPIC) has long been the aim of the local health providers, but evidence was heard that the pace of introduction, which is very slow, is in the hands of national NHS leadership.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to document mental health assessments when no recording location is available
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment , as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Inconsistent risk assessment documentation and training across departments
Wider context from the report “2. The Mental Health Trust
• Staff and it appears the director even at the time of the inquest did not appreciate that the A&E policies (Missing Persons, Shared Care) which required risk assessment after an absconsion and alerting managers to the need for extra temporary staff if 1:1 monitoring was needed, also applied to MH staff.
• Evidence was heard that staff in KCH A&E and Oxleas NH Trust had been trained on different risk assessment documents. Although meetings had been reinstated between departments, there had been no audit of absconsions or MH liaison in A&E.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Gaps in mental health professionals’ knowledge and clinical judgment
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Investigating or acting against individual healthcare professionals falls outside the regulator’s authority.
Verbatim wording from the response “1. We recognise the distress and concern these events have caused and acknowledge the importance of accountability where there are apparent shortfalls in professional conduct or decision-making. However, it is important to clarify that the Care Quality Commission’s regulatory remit, as established under the Health and Social Care Act (2008) and the associated Regulated Activities Regulations (2014), is focused on assessing and holding providers rather than individual staff accountable for meeting fundamental standards of care. While we do not have the authority to investigate or act against individual healthcare professionals, we expect providers to ensure that their staff are competent, appropriately trained, and supported to deliver safe and effective care.” Source location Response from Care Quality Commission
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Providers are responsible for ensuring staff competence, appropriate training and support to deliver safe, effective care.
Verbatim wording from the response “1. We recognise the distress and concern these events have caused and acknowledge the importance of accountability where there are apparent shortfalls in professional conduct or decision-making. However, it is important to clarify that the Care Quality Commission’s regulatory remit, as established under the Health and Social Care Act (2008) and the associated Regulated Activities Regulations (2014), is focused on assessing and holding providers rather than individual staff accountable for meeting fundamental standards of care. While we do not have the authority to investigate or act against individual healthcare professionals, we expect providers to ensure that their staff are competent, appropriately trained, and supported to deliver safe and effective care.” Source location Response from Care Quality Commission
Open published response
27 Feb 2025 Philip Lesnes · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Choking hazard from adhesive gel products View source Failure to include adhesive gel products in care home risk assessments View source Exposure of older and cognitively impaired users to adhesive gel products View source Absence of choking-risk warnings on adhesive gel product packaging and information leaflets View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Philip Lesnes · 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
Philip Lesnes, who was living in a care home and had dementia, was found with denture adhesive gel in his mouth, ears and nose on 23 June 2024. His breathing became laboured, he was taken to hospital, and he died that day; the inquest recorded choking and inhalation of adhesive gel among the medical causes of death. Concerns included the product’s choking risk, its potential use by older people or people with cognitive decline, the need to consider it in care-home risk assessments, and the absence of choking warnings on its packaging or leaflet.
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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Choking hazard from adhesive gel products
Wider context from the report “2. I have concerns with regard to the following:
i. The choking risk which this product poses. The qualities of the product are such that a thick adhesive gel can become lodged deep into the respiratory system and can be extremely difficult to remove
ii. Such a product is likely to be used by the older generation and those who may be suffering from a decline of brain functioning.
iii. Such a product should be considered as part of any risk assessment for those living in a care home setting.
iv. There is no warning on the product packaging or on the enclosed information leaflet as to the risk of choking.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to include adhesive gel products in care home risk assessments
Wider context from the report “2. I have concerns with regard to the following:
i. The choking risk which this product poses. The qualities of the product are such that a thick adhesive gel can become lodged deep into the respiratory system and can be extremely difficult to remove
ii. Such a product is likely to be used by the older generation and those who may be suffering from a decline of brain functioning.
iii. Such a product should be considered as part of any risk assessment for those living in a care home setting.
iv. There is no warning on the product packaging or on the enclosed information leaflet as to the risk of choking.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Exposure of older and cognitively impaired users to adhesive gel products
Wider context from the report “2. I have concerns with regard to the following:
i. The choking risk which this product poses. The qualities of the product are such that a thick adhesive gel can become lodged deep into the respiratory system and can be extremely difficult to remove
ii. Such a product is likely to be used by the older generation and those who may be suffering from a decline of brain functioning.
iii. Such a product should be considered as part of any risk assessment for those living in a care home setting.
iv. There is no warning on the product packaging or on the enclosed information leaflet as to the risk of choking.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Absence of choking-risk warnings on adhesive gel product packaging and information leaflets
Wider context from the report “2. I have concerns with regard to the following:
i. The choking risk which this product poses. The qualities of the product are such that a thick adhesive gel can become lodged deep into the respiratory system and can be extremely difficult to remove
ii. Such a product is likely to be used by the older generation and those who may be suffering from a decline of brain functioning.
iii. Such a product should be considered as part of any risk assessment for those living in a care home setting.
iv. There is no warning on the product packaging or on the enclosed information leaflet as to the risk of choking.
” 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 Feature the incident and generic denture-adhesive risks on the Learning from safety incidents webpage, including provider risk-assessment and care-planning guidance.
Verbatim wording from the response “In terms of action that will be taken by CQC, it is recommended that this incident should be featured as an issue on CQC’s Learning from safety incidents webpage. This would help raise awareness and share the learning with providers to help prevent similar incidents in the future. This webpage should reference:” Source location Response from CQC
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 Raising denture adhesive packaging risks with product manufacturers is outside the respondent’s remit.
Verbatim wording from the response “I note you have requested the Chief Executive Officer (CEO) of Fixodent should consider placing a warning on packaging so it is clear ingestion of the product is a potential risk. It is important to consider brands beyond just Fixodent (the CEO of which is listed as the other named respondent in the Regulation 28 report). There are several brands of denture adhesive gel available which will potentially carry the same choking risk due to the substance consistency. The patent safety leaflets of two popular brands of denture adhesive were reviewed and neither contained choking as a hazard, though they do advise what to do in the event of ingesting or inhaling. It is not within the CQC’s remit to raise this issue with the CEOs of these companies, so further action may be required by HM Coroner and/or the Office for Product Safety and Standards.” Source location Response from CQC
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 Further action on denture adhesive packaging risks may be required by the coroner or Office for Product Safety and Standards.
Verbatim wording from the response “I note you have requested the Chief Executive Officer (CEO) of Fixodent should consider placing a warning on packaging so it is clear ingestion of the product is a potential risk. It is important to consider brands beyond just Fixodent (the CEO of which is listed as the other named respondent in the Regulation 28 report). There are several brands of denture adhesive gel available which will potentially carry the same choking risk due to the substance consistency. The patent safety leaflets of two popular brands of denture adhesive were reviewed and neither contained choking as a hazard, though they do advise what to do in the event of ingesting or inhaling. It is not within the CQC’s remit to raise this issue with the CEOs of these companies, so further action may be required by HM Coroner and/or the Office for Product Safety and Standards.” Source location Response from CQC
Open published response
24 Feb 2025 Pamela Anne Marking · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 10 Failure to clearly explain and differentiate the Physician Associate role from medically qualified practitioners View source Lack of updated guidelines for rapid sequence induction of anaesthesia in emergency surgery View source Inadequate medical supervision of Physician Associates managing undifferentiated Emergency Department patients View source Unavailability of promptly accessible suction for aspiration during rapid sequence induction View source Failure to inform patients and families that Physician Associates are not medically qualified View source Lack of public understanding of the Physician Associate role View source Lack of guidance on TIVA dosing and timing for rapid sequence induction View source Lack of updated guidance on cricoid pressure and other airway-protection measures during rapid sequence induction View source Failure to prevent Physician Associates undertaking roles outside their competency View source Lack of regulated scope-of-practice guidance and recognised training for Physician Associates View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Pamela Anne Marking · 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
Pamela Anne Marking was admitted with abdominal symptoms, was diagnosed with a nosebleed by a Physician Associate and discharged without medical review or direct medical supervision. She later returned with small bowel obstruction caused by an incarcerated femoral hernia and aspirated feculent fluid during induction of anaesthesia for emergency surgery, subsequently dying from respiratory failure and sepsis. The concerns included the Physician Associate’s role, supervision and scope of practice, and the absence of updated guidance for rapid sequence induction, TIVA and airway protection.
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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly explain and differentiate the Physician Associate role from medically qualified practitioners
Wider context from the report “1. The term ‘Physician Associate’ is misleading to the public
Mrs Marking’s son was under the mistaken belief that the Physician Associate was a doctor by this title in circumstances where no steps were taken by the Emergency Department or the Physician Associate to explain or clearly differentiate their role from that of medically qualified practitioners .
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of updated guidelines for rapid sequence induction of anaesthesia in emergency surgery
Wider context from the report “6. Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia for emergency surgery
Mrs Marking required a rapid sequence induction to protect her airway from aspiration of bowel contents as a consequence of small bowel obstruction. The consultant anaesthetist gave evidence that the ‘traditional’ use of consecutive syringes of induction agent and muscle relaxant was obsolete, and it was common practice locally and nationally to routinely undertake a RSI with Total Intravenous Anaesthesia, in the absence of updated local or national guidelines to support this practice .
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Inadequate medical supervision of Physician Associates managing undifferentiated Emergency Department patients
Wider context from the report “5. Lack of guidelines for direct supervision and consideration of an appropriate level of autonomy for Physician Associates
Whilst there were discussions with the ‘supervising’ consultant the Physician Associate was effectively acting independently in the diagnosis, treatment, management and discharge of Mrs Marking without independent oversight by a medical practitioner . This gives rise to a concern that inadequate supervision or excessive delegation of undifferentiated patients in the Emergency Department to Physician Associates compromises patient safety.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Unavailability of promptly accessible suction for aspiration during rapid sequence induction
Wider context from the report “8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic
Evidence was heard that cricoid pressure was ineffective it was not routinely applied for a RSI intubation. After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to inform patients and families that Physician Associates are not medically qualified
Wider context from the report “3. The right of patients and family to seek a second opinion
The lack of public knowledge that a Physician Associate is not medically qualified has the potential to hinder requests by patients and their relatives who would wish to seek an opinion from a medical practitioner. It also raises issues of informed consent and protection of patient rights if the public are not aware or have not been properly informed that they are being treated by a Physician Associate rather than a medically qualified doctor.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of public understanding of the Physician Associate role
Wider context from the report “2. Lack of public understanding of the role of Physician Associate
Witnesses from the Trust gave evidence that a Physician Associate was clinically equivalent to a Tier 2 resident doctor without evidence to support this belief. This blurring of roles without public knowledge and understanding of the role of a Physician Associate has the potential to devalue and undermine public confidence in the medical profession whilst allowing Physician Associates to potentially undertake roles outside of their competency thereby compromising patient safety.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on TIVA dosing and timing for rapid sequence induction
Wider context from the report “7. Lack of ‘Updated’ National Guidelines to support the use of TIVA for RSI
Other than empirically increasing the rate of infusion of TIVA agents (Propofol and Remifentanil) no evidence was forthcoming as to the target range required to ensure and confirm an adequate depth of anaesthesia for patients or the length of time required prior to and following the administration of a muscle relaxant (Rocuronium) to facilitate intubation. This is despite TIVA being known to provide a slower onset of anaesthesia and approximately 50% of all anaesthetic related deaths are due to aspiration (NAP 4).
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of updated guidance on cricoid pressure and other airway-protection measures during rapid sequence induction
Wider context from the report “8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic
Evidence was heard that cricoid pressure was ineffective it was not routinely applied for a RSI intubation . After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent Physician Associates undertaking roles outside their competency
Wider context from the report “2. Lack of public understanding of the role of Physician Associate
Witnesses from the Trust gave evidence that a Physician Associate was clinically equivalent to a Tier 2 resident doctor without evidence to support this belief. This blurring of roles without public knowledge and understanding of the role of a Physician Associate has the potential to devalue and undermine public confidence in the medical profession whilst allowing Physician Associates to potentially undertake roles outside of their competency thereby compromising patient safety .
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of regulated scope-of-practice guidance and recognised training for Physician Associates
Wider context from the report “4. Lack of national and local guidelines and regulation of the scope of practice for a Physician Associate
A diagnosis of epistaxis was made by the Physician Associate without appreciating the relevance of the vomiting and lower abdominal discomfort and in the absence of understanding the need to undertake palpation of the groins in an abdominal examination in a patient who was unable to give a proper clinical history because of short term memory loss. No evidence was presented that the management of Mrs Marking was subject to a reflective practice review. Given their limited training and in the absence of any national or local recognised hospital training for Physician Associates once appointed , this gives rise to a concern they are working outside of their capabilities .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess providers’ arrangements for safe recruitment, adequate staffing, supervision, accountability, governance, information-sharing and inclusive care involving Physician Associates.
Verbatim wording from the response “We use these regulations when we assess if a provider is safe, effective, caring, responsive and well-led. The role of Physician Associates relates to:” Source location Response from CQC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing CQC guidance and provider governance, supervision and competence requirements apply to Physician Associates in secondary care.
Verbatim wording from the response “The CQC guidance whilst written for Physician Associates in primary care, is largely applicable in secondary care settings too.” Source location Response from CQC
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 Updated national guidance for RSI, TIVA and cricoid pressure falls outside the regulatory scope.
Verbatim wording from the response “We are unable to comment on this point due to it being outside of the remit of our regulatory scope.” Source location Response from CQC
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 General Medical Council is best placed to address public terminology, role understanding and second-opinion rights.
Verbatim wording from the response “We are unable to comment on this point due to it being outside of the remit of our regulatory scope. Please note that the General Medical Council is a Respondent and would be best placed to respond to this question.” Source location Response from CQC
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 Public terminology, role understanding and second-opinion rights fall outside the regulatory scope.
Verbatim wording from the response “We are unable to comment on this point due to it being outside of the remit of our regulatory scope. Please note that the General Medical Council is a Respondent and would be best placed to respond to this question.” Source location Response from CQC
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 General Medical Council is responsible for regulating individual Physician Associates, rather than this regulator.
Verbatim wording from the response “Whilst we have legal powers to regulate providers of health and social care, we do not have any powers to regulate individual practitioners, such as Physician Associates. That is the duty of the General Medical Council from 13 December 2024. Prior to this date, Physicians Associates were not regulated by a formal body. Physicians Associates are encouraged to join the General Medical Council’s register if already practising in the UK, however there is a transition period of two years, after which, Physicians Associates must legally be registered with the General Medical Council. (Links: NHS England » Update on physician associates and anaesthesia associates ahead of GMC regulation, Registration - GMC)” Source location Response from CQC
Open published response
21 Feb 2025 Mr Luke Alexander Worrell · Prevention of Future Deaths report London South
View report summary
Concerns raised 2 Lack of clinical staff awareness of Clozapine's potential fatal side effects View source Inappropriate use of community treatment orders where sufficient evidence supports retention on a Mental Health Act section View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Luke Alexander Worrell · 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 Luke Alexander Worrell, who had treatment-resistant schizophrenia and was taking Clozapine, developed persistent vomiting, dehydration and an ileus before suffering a ruptured oesophagus and dying in hospital on 2 January 2021. The report identified concerns about clinical staff failing to recognise the potentially fatal gastrointestinal side effects of Clozapine and about the inappropriate use of a community treatment order instead of continued detention under a mental health section. The inquest narrative also described failures to recognise the need for face-to-face psychiatric assessment after his deterioration following discharge.
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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical staff awareness of Clozapine's potential fatal side effects
Wider context from the report “1. The lack of awareness by a series of clinical staff of the potential fatal side effects of Clozapine
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Inappropriate use of community treatment orders where sufficient evidence supports retention on a Mental Health Act section
Wider context from the report “2. Inappropriate use of community treatment order , when there was sufficient evidence to keep on a MHA section .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deploy Mental Health Act Reviewers to advise and oversee assessment of Mental Health Act decisions, including the lawful and clinically justified use of Community Treatment Orders.
Verbatim wording from the response “To support this, the CQC has a team of dedicated Mental Health Act Reviewers who work alongside our integrated assessment and inspection teams. These specialists provide expert advice and oversight in assessing the use and application of the Mental Health Act across both inpatient and community mental health services, including the use of CTOs.” Source location Response from Care Quality Commission
Open published response
23 Dec 2024 David Christopher Peter Lodge · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 5 Failure to follow clinical recommendations for 30-minute observations View source Lack of internal investigation of serious incidents View source Failure to appropriately escalate NEWS2 scores above seven for specialist advice View source Failure to accurately assess pain in people unable to communicate with words View source Failure to carry out basic examinations for learning disabled adults at risk of pneumonia in the emergency department View source See 2 more concerns
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
David Christopher Peter Lodge · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Christopher Peter Lodge, who had a learning disability, was found unwell beside his deceased father after lying for up to four days and died at Hull Royal Infirmary on 13 January 2022 from bilateral pneumonia. Concerns included inadequate pain assessment, no chest examination, failure to appropriately escalate high NEWS2 scores or transfer him to intensive care, and missed opportunities to learn from the death through a serious 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. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to follow clinical recommendations for 30-minute observations
Wider context from the report “(3) NEWS2 scores above seven are not appropriately escalated for specialist advice. Clinical recommendations for 30 minute observations were not being followed. An independent expert, a Consultant in Intensive Care, gave evidence to the court that Mr Lodge should have been admitted to the Intensive Care Unit at Hull Royal Infirmary at which Mr Lodge would have undergone closer examinations on a lower patient to nurse ratio.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of internal investigation of serious incidents
Wider context from the report “(4) Opportunities for learning from serious incidents are being lost. No internal investigation or other form of serious incident investigation was undertaken. The court heard evidence from independent experts who opined that it would be expected, following a death in these circumstances, for there to have been an internal review to consider improvements to include input from a specialist with a learning disability team.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately escalate NEWS2 scores above seven for specialist advice
Wider context from the report “(3) NEWS2 scores above seven are not appropriately escalated for specialist advice. Clinical recommendations for 30 minute observations were not being followed. An independent expert, a Consultant in Intensive Care, gave evidence to the court that Mr Lodge should have been admitted to the Intensive Care Unit at Hull Royal Infirmary at which Mr Lodge would have undergone closer examinations on a lower patient to nurse ratio.
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately assess pain in people unable to communicate with words
Wider context from the report “(1) Pain is not accurately assessed in people who are unable to communicate with words. The court heard evidence that Mr Lodge at no point was provided pain relief, despite requests from the attending family member who was speaking on his behalf. An independent expert, a Consultant in Emergency Medicine, gave evidence that there was no evidence of reasonable adjustments in respect of assessing Mr Lodge’s pain to account for his baseline condition .
” 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out basic examinations for learning disabled adults at risk of pneumonia in the emergency department
Wider context from the report “(2) Basic examinations, including chest examinations, are not being carried out for learning disabled adults at risk of pneumonia in the emergency department. The treating physicians in evidence agreed that there should have been a high index of suspicion of pneumonia in Mr Lodge’s case and that it is one of the leading causes of death for people with learning disabilities. The court heard evidence that Mr Lodge did not have a chest examination carried out on him due to him not presenting any signs of respiratory distress. The independent expert gave evidence that a thorough examination should have been undertaken and that there was the opportunity to do so after the sedation medication was given.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations