Concerns raised 6 Lack of clear and timely internal and external fall reporting View source Failure to clearly document medical advice obtained after resident falls View source Failure to promptly re-evaluate and amend care plans after significant events View source Failure to provide effective, individually tailored monitoring measures for residents at high risk of falls View source Failure to obtain timely medical advice after a resident fall View source Failure to maintain accessible and retained resident records 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
Sylvia Margaret Louisa SAVAGE · 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
Sylvia Margaret Louisa Savage died on 25 April 2023 at the University Hospital of North Durham from bronchopneumonia, following a fall from her bed at Redwell Hills Care Home on 18 March 2023 and subsequent injuries and decline in health. The concerns included unclear fall-reporting arrangements, ineffective monitoring of her mobilisation, inadequate post-fall medical assessment, missing or insufficient care records, and failure to promptly reassess her care plan after falls.
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 clear and timely internal and external fall reporting
Wider context from the report “1. There was I heard no clear definition of when to report falls externally & internally - this to me is perhaps the reason why the fall Mrs Savage suffered on 1/2/23 was not recorded internally, all be it CQC were notified on this occasion. The fall on 18/3/23 was not reported to CQC and whilst I understand staff at the care home did not know the outcome of Mrs Savage's treatment in hospital - she left the home by ambulance and did not return. This seems an occurrence worthy of reporting – It strikes me some clearer reporting structure is necessary - timely and accurate reporting both internally and to regulators allows for those concerned to assess the care home and decide on whether there are risks/issues that need addressing and protect residents. I would suggest over reporting is preferable to under reporting.
” 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 clearly document medical advice obtained after resident falls
Wider context from the report “3. Mrs Savage's fall in February 2023 was it appears reported to her GP by her daughter and that led to a nurse attending the home to examine her. Staff at the home do not appear to have done so themselves. It is of concern that after a fall the staff within the home should have a mechanism to ensure medical advice is obtained in a timely fashion and that it is documented clearly and not be reliant on family members summoning help for residents themselves when they have become aware of an 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 promptly re-evaluate and amend care plans after significant events
Wider context from the report “5. The evidence I have heard is after Mrs Savage's fall on 1/2/23 and when it became clear the sensor mat was not working as intended - this should have prompted staff to return to the care plans and re-evaluate them - it did not . Indeed one care home witness stated as Mrs Savage had not had 3 falls in 3 months no change to her plan was needed. Given the second fall Mrs Savage had some weeks later gave her injuries that led to her death this approach appears flawed. Whilst I acknowledge work is ongoing in this area it appears that prompt re-evaluation of the care plans after events such as a fall are necessary to prevent injury and death - I would ask for some reassurance that significant events are captured by staff and in turn their significance is carefully considered and if necessary changes made to 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 Failure to provide effective, individually tailored monitoring measures for residents at high risk of falls
Wider context from the report “2. The evidence is clear that the provided sensor mat was not an efficient way of monitoring Mrs Savage when she attempted to mobilise . It was well known in the home that Mrs Savage defeated it's purpose by moving or unplugging it. There seems to have been a lack of thought as to an alternative measure . The wall mounted sensor, for example was seen by the expert as a reasonable measure - the home manager said he could consider them and the regional manager indicated they were used in the company, but not at the care home where Mrs Savage was residing. It seems to me the council should have an armoury of measures to pick from to tailor to the needs of the individual resident not just limited to one particular measure . The risk of death is obvious to others if persons at high risk of falls are not known to be moving by those charged with looking after them.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain timely medical advice after a resident fall
Wider context from the report “3. Mrs Savage's fall in February 2023 was it appears reported to her GP by her daughter and that led to a nurse attending the home to examine her. Staff at the home do not appear to have done so themselves. It is of concern that after a fall the staff within the home should have a mechanism to ensure medical advice is obtained in a timely fashion and that it is documented clearly and not be reliant on family members summoning help for residents themselves when they have become aware of an 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 maintain accessible and retained resident records
Wider context from the report “4. The absence of records has hindered my investigation into Mrs Savage's death. The expert in her evidence made it clear - good recording keeping allows staff to monitor changes in condition, allows new staff or those returning from time off to reacquaint themselves with residents condition and allows clinicians to make diagnosis - without access to good records I can see a clear risk to the care of residents . It is also surprising to me the complete reliance on paper records which in Mrs Savage’s case have been lost . I would have expected to see electronic recording of information and electronic storage of it. I note the roll out of this in the company has been paused whilst the company is awaiting sale and my concern is whether the electronic recording and storage will be implemented - to me immediate access to records of a resident or the absence of them creates a concern .
” Open source report
15 Nov 2024 Yousef Al-Kharboush and 2 others · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Lack of requirements for section 10 exempt entities to report adverse-event findings to the MHRA and other relevant organisations View source Unclear thresholds for section 10 entity reporting to NHSE and the CQC View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Yousef Al-Kharboush and 2 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Aviva Otte died in January 2014 after receiving TPN provided and compounded by an NHS establishment; the TPN was, on balance, contaminated with Bacillus cereus. Oscar Barker and Yousef Al-Kharboush died in June 2014 after receiving TPN compounded by a commercial provider that was also contaminated with Bacillus cereus. The principal concerns were unclear or absent requirements for section 10 exempt entities to report adverse-event findings and uncertainty about reporting thresholds and wider dissemination of information that could help other providers assess risks.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of requirements for section 10 exempt entities to report adverse-event findings to the MHRA and other relevant organisations
Wider context from the report “(1) There is no requirement for a section 10 exempt entity to report any of its findings to the MHRA or indeed to other Trusts or the industry in general if an adverse event occurs.
(2) The current reporting structures (for a section 10 entity) involve reporting to NHSE and the CQC but the threshold of necessity for such reporting appears unclear and, in essence, up to the Trust.
(3) There may be times when section 10 entities reach conclusions which would assist the wider industry and help to assist both other Trusts and commercial organisations in assessing their own risks and improving the provision of highly specific medication to a group of vulnerable patients.
(4) the same may also be true of commercial organisations but they have the power of the MHRA controlling and effecting recalls and actions and the wider dissemination of information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Unclear thresholds for section 10 entity reporting to NHSE and the CQC
Wider context from the report “(1) There is no requirement for a section 10 exempt entity to report any of its findings to the MHRA or indeed to other Trusts or the industry in general if an adverse event occurs.
(2) The current reporting structures (for a section 10 entity) involve reporting to NHSE and the CQC but the threshold of necessity for such reporting appears unclear and, in essence, up to the Trust.
(3) There may be times when section 10 entities reach conclusions which would assist the wider industry and help to assist both other Trusts and commercial organisations in assessing their own risks and improving the provision of highly specific medication to a group of vulnerable patients.
(4) the same may also be true of commercial organisations but they have the power of the MHRA controlling and effecting recalls and actions and the wider dissemination of information.
” 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 Reporting requirements for trusts are now more clearly defined than they were in 2014.
Verbatim wording from the response “Key matter of concern (2) is that:” Source location Response from CQC
Open published response
4 Nov 2024 Janet Brown Townend · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 8 Failure to consider reassessment of capacity View source Inaccurate recording of Early Warning Signs View source Insufficient time spent providing care and completing care duties View source Failure to escalate concerns about sickness View source Failure to follow up on intended GP support View source Failure to escalate concerns about reduced food intake View source Failure to escalate Early Warning Signs View source Failure to escalate concerns about unwise refusals of care, food and medical intervention View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Janet Brown Townend · 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 Brown Townend, who had diabetes and other comorbidities, developed an infected foot wound that progressed to sepsis despite hospital treatment, and she died on 15 October 2023. Concerns arose about the care provided by carers, including brief visits, failure to escalate poor nutrition, sickness and early warning signs, inaccurate records, and failure to follow up or escalate refusals of care and medical intervention.
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 consider reassessment of capacity
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend. Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks; ;
b) Carers did not escalate any concerns when Ms Townend was not eating. As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness. There were a number of times Ms Townend presented with having been sick and this was not considered as a concern;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present. The EWS were always recorded as no concerns. This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell. This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention. This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her 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 Inaccurate recording of Early Warning Signs
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend. Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks; ;
b) Carers did not escalate any concerns when Ms Townend was not eating. As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness. There were a number of times Ms Townend presented with having been sick and this was not considered as a concern;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present. The EWS were always recorded as no concerns . This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell. This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention. This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her 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 Insufficient time spent providing care and completing care duties
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend . Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks ; ;
b) Carers did not escalate any concerns when Ms Townend was not eating. As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness. There were a number of times Ms Townend presented with having been sick and this was not considered as a concern;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present. The EWS were always recorded as no concerns. This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell. This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention. This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her 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 escalate concerns about sickness
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend. Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks; ;
b) Carers did not escalate any concerns when Ms Townend was not eating. As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness . There were a number of times Ms Townend presented with having been sick and this was not considered as a concern ;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present. The EWS were always recorded as no concerns. This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell. This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention. This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her 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 follow up on intended GP support
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend. Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks; ;
b) Carers did not escalate any concerns when Ms Townend was not eating. As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness. There were a number of times Ms Townend presented with having been sick and this was not considered as a concern;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present. The EWS were always recorded as no concerns. This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell . This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done ;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention. This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her 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 escalate concerns about reduced food intake
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend. Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks; ;
b) Carers did not escalate any concerns when Ms Townend was not eating . As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness. There were a number of times Ms Townend presented with having been sick and this was not considered as a concern;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present. The EWS were always recorded as no concerns. This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell. This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention. This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her 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 escalate Early Warning Signs
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend. Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks; ;
b) Carers did not escalate any concerns when Ms Townend was not eating. As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness. There were a number of times Ms Townend presented with having been sick and this was not considered as a concern;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present . The EWS were always recorded as no concerns. This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated ;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell. This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention. This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her 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 escalate concerns about unwise refusals of care, food and medical intervention
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend. Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks; ;
b) Carers did not escalate any concerns when Ms Townend was not eating. As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness. There were a number of times Ms Townend presented with having been sick and this was not considered as a concern;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present. The EWS were always recorded as no concerns. This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell. This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention . This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her capacity.
” 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 Obtain immediate assurances from the provider about its safeguarding processes.
Verbatim wording from the response “Neither inspection of Bridlington identified concerns regarding staffs ability to recognise and escalate safeguarding concerns. The inspection of Bridlington in January 2020 found staff had a good understanding of safeguarding processes (Appendix 1). In response to the concerns raised by the coroner concerning the death of Janet Brown, the CQC has received an action plan from the provider addressing staff understanding of the mental capacity act. We intend to undertake an unannounced assessment of the service which will include safeguarding and decision making. We have also requested immediate assurances from the provider regarding their safeguarding processes.” Source location Response from CQC
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 Obtain and review the service’s care records to determine whether further regulatory action is needed.
Verbatim wording from the response “We have reviewed all our records and cannot find that we received a statutory notification in relation to Janet Brown’s death. Failure to provide statutory notifications in accordance with Regulation 16 of the Care Quality Commission (Registration) Regulations 2009 is a criminal offence and we have contacted the service to about this. The provider has advised us that the death did not occur while services were being provided in the carrying on of a regulated activity and no further regulated activity was completed following the admission to hospital. We have requested Janet Brown’s care records so this can be reviewed, and so that we can consider whether any other regulatory action needs to be taken.” Source location Response from CQC
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 Undertake an unannounced assessment covering visit duration, nutrition and hydration, health monitoring, escalation, record keeping, governance, safeguarding and decision-making.
Verbatim wording from the response “Both inspections of Bridlington found no concerns regarding the deployment of staff and the published reports include positive feedback from people about the support they received. In response to the concerns raised by the coroner concerning the death of Janet Brown, the CQC has received an action plan from the provider addressing the duration of staff visits. We intend to undertake an unannounced assessment of the service which will include staff having adequate time to meet people’s needs. CQC only neglects the carrying out of personal care, however, adequate” 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 Neither inspection raised concerns about staff failing to escalate health concerns, and the earlier inspection found appropriate healthcare referrals.
Verbatim wording from the response “Neither inspection of Bridlington raised concerns about staff not escalating concerns about people. The inspection of Bridlington in January 2020 found staff supported people to access health care professionals and referrals were made when required. (Appendix 1). In response to the concerns raised by the coroner concerning the death of Janet Brown, the CQC has received an action plan from the provider addressing how staff will monitor people’s health and well-being. We intend to undertake an unannounced assessment of the service which will include how people are supported to live healthier lives and how the provider will monitor peoples care (Appendix 1, Appendix 2).” 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 Neither inspection identified inaccurate record keeping; checks and audits were in place to support good governance.
Verbatim wording from the response “Neither inspection of Bridlington raised concerns about the accuracy of record keeping. In both cases, our inspections found checks and audits were in place to ensure good governance of the service. (Appendix 1, Appendix 2). In response to the concerns raised by the coroner concerning the death of Janet Brown, the CQC has received an action plan from the provider addressing staff training, oversight of records and processes for escalating concerns. We intend to undertake an” 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 Neither inspection identified concerns about recognising or escalating safeguarding issues, and staff showed good understanding of safeguarding processes.
Verbatim wording from the response “Neither inspection of Bridlington identified concerns regarding staffs ability to recognise and escalate safeguarding concerns. The inspection of Bridlington in January 2020 found staff had a good understanding of safeguarding processes (Appendix 1). In response to the concerns raised by the coroner concerning the death of Janet Brown, the CQC has received an action plan from the provider addressing staff understanding of the mental capacity act. We intend to undertake an unannounced assessment of the service which will include safeguarding and decision making. We have also requested immediate assurances from the provider regarding their safeguarding processes.” 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 Both inspections found no concerns regarding staff deployment, disputing that carers lacked adequate time to complete care tasks safely.
Verbatim wording from the response “Both inspections of Bridlington found no concerns regarding the deployment of staff and the published reports include positive feedback from people about the support they received. In response to the concerns raised by the coroner concerning the death of Janet Brown, the CQC has received an action plan from the provider addressing the duration of staff visits. We intend to undertake an unannounced assessment of the service which will include staff having adequate time to meet people’s needs. CQC only neglects the carrying out of personal care, however, adequate” 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 January 2020 inspection found no concerns about staff supporting people to access healthcare services and support.
Verbatim wording from the response “The inspection of Bridlington in January 2020 found no concerns regarding how staff supported people to access healthcare services and support (Appendix 1). In response to the concerns raised by the coroner concerning the death of Janet Brown, the CQC has received an action plan from the provider addressing their systems for monitoring people’s health effectively within the staff team. We intend to undertake an unannounced assessment of the service which will include governance processes and oversight of people’s care.” 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 January 2020 inspection found no concerns about supporting people with eating, drinking, nutrition or hydration needs.
Verbatim wording from the response “The inspection of Bridlington in January 2020 found no concerns regarding the support people received to eat and drink and/or the ongoing assessment and monitoring of people’s needs and support to access other healthcare services. The inspection of Bridlington in April 2023 did not include these areas. In response to the concerns raised by the coroner concerning the death of Janet Brown, the CQC has received an action plan from the provider addressing nutrition and hydration. We intend to undertake an unannounced assessment of the service which will include nutrition and hydration and how staff identify people’s changing needs and escalate concerns. (Appendix 1, Appendix 2).” Source location Response from CQC
Open published response
14 Oct 2024 Mia Louise Gauci-Lamport · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 11 Lack of specialist NHS paediatric neuro-consultant oversight View source Failure to maintain comprehensive, understandable, accurate and contemporaneous medical records View source Failure to undertake regular Paediatric Early Warning Score assessments View source Deficiencies in ongoing staff training View source Deficient clinical governance of management and investigation View source Failure to conduct regular audits of clinical practice View source Failure to provide sufficiently frequent direct night-time visual observations View source Failure to ensure robust procedures are in place View source Delays in fulfilling Duty of Candour obligations View source Failure to undertake regular multidisciplinary clinical reviews View source Lack of regular independent consultant oversight and coordination of investigations and multidisciplinary management 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
Mia Louise Gauci-Lamport · 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
Mia Louise Gauci-Lamport, who had treatment-resistant epilepsy and required full-time residential care, was found cyanotic and unresponsive at around 06.32 hours on 11 September 2023 after not being visually checked when a carer entered her room. Resuscitation was unsuccessful. The report raised concerns about inadequate night-time monitoring, incomplete medical records and insufficient clinical oversight and governance.
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 specialist NHS paediatric neuro-consultant oversight
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented.
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs.
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting 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 maintain comprehensive, understandable, accurate and contemporaneous medical records
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented .
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs.
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting 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 undertake regular Paediatric Early Warning Score assessments
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented.
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs.
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting 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 Deficiencies in ongoing staff training
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death, delay in fulfilling the Duty of Candour’ obligations, ongoing staff training , ensuring robust procedures were in place alongside regular audits of clinical practice. These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” 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 Deficient clinical governance of management and investigation
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death , delay in fulfilling the Duty of Candour’ obligations, ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice. These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” 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 conduct regular audits of clinical practice
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death, delay in fulfilling the Duty of Candour’ obligations, ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice . These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” 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 sufficiently frequent direct night-time visual observations
Wider context from the report “1. Lack of appropriate monitoring of Mia during the night :
Mia’s underlying illness caused seizures which were multifocal, complex and variable from tonic-clonic, myoclonic to cluster and absence seizures. Her care plan stipulated that carers should enter her room every 15 minutes to undertake visual observations throughout the night to ensure Mia was in a safe position, was breathing and not at risk of asphyxiation. However, this did not take place as frequently as specified . Moreover, it was common practice amongst some carers to review images from a video monitor placed over Mia’s cot rather than direct visualisation despite it being recognised that the monitor was insufficiently sensitive to reassure the carer that Mia was breathing, seizure free and safe from asphyxiation .
” 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 robust procedures are in place
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death, delay in fulfilling the Duty of Candour’ obligations, ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice. These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” 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 fulfilling Duty of Candour obligations
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death, delay in fulfilling the Duty of Candour’ obligations , ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice. These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” 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 regular multidisciplinary clinical reviews
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented.
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs .
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting 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 Lack of regular independent consultant oversight and coordination of investigations and multidisciplinary management
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented.
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs.
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting condition.
” 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 Request monthly updates on monitoring-frequency and Paediatric Early Warning System audits to assess ongoing implementation and identify practice gaps.
Verbatim wording from the response “In July 2024 following the coroner’s inquest and information from the independent investigator report, CQC requested monthly updates from TCT regarding the providers audits of frequency of monitoring of children and their Paediatric Early Warning System (PEWS). The audits and actions taken, provided CQC with assurance the leadership team continued to take positive action to address any gaps in practice that the audits identified.” Source location Response from CQC
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 Undertake a comprehensive inspection of the service, including assessment of overnight observations, care planning, clinical monitoring and governance.
Verbatim wording from the response “In December 2023 CQC had received key information and started to plan for an inspection in February. On February 20th to 21st 2024 the CQC undertook a comprehensive inspection of TCT as part of our regulatory response to the notification of Mia’s sad death. The inspection looked at all five key questions of whether TCT is Safe, Effective, Caring, Responsive and Well-led. (Please see attached PDF). CQC do not provide ratings for children’s homes that are registered with Ofsted, as per our policy.” 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 Strengthened monitoring policies, audits and governance arrangements were considered sufficient to address risks concerning night-time observations and safe care.
Verbatim wording from the response “Since the sad death of Connor Wellsted in 2022 and Mia’s death, CQC have undertaken three subsequent inspections which have demonstrated that TCT have taken the appropriate actions to ensure the governance processes around night time observations have been strengthened. CQC is assured with regard to its own regulatory functions, by the actions taken by TCT. Specifically this includes to strengthening the frequency of monitoring policy and increased their audits of the implementation of this policy.” 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 Existing shared NHS neurological care, local and tertiary access, and monthly multidisciplinary case discussions were considered sufficient clinical oversight.
Verbatim wording from the response “As per ████████’s witness statement it is our understanding that Mia was not without specialist NHS paediatric neuro-consultant care at any time as the paediatric neurology department at St George's Hospital (SGH), Tooting is the tertiary centre for paediatric neurology in the region. There is a shared care arrangement between the neurology department and the SGH and the paediatric department at Epsom hospital, therefore if Mia had required any specialist neurological care this would have been provided by Epsom hospital.” 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 delay in executing the Duty of Candour was not considered a breach of the Health and Social Care Regulations.
Verbatim wording from the response “During the February 2024 inspection we found all staff had received the appropriate level of training relevant to their role and the healthcare activity they deliver. The education team provided child and young person specific training as the need arose.
We also noted that “staff demonstrated knowledge of the Duty of Candour, to be open and transparent with people including when things go wrong with their care and treatment”. In Mia’s case there was a delay in executing the Duty of Candour, however the CQC did not deem this instance to be a breach of Health and Social Care Regulations.” Source location Response from CQC
Open published response
2 Oct 2024 Michael Sean Heath · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to ensure carers are informed of Mental Health Act admissions within 24 hours View source Failure to establish agreed communication means and maintain relevant patient information in an accessible central repository View source Failure to provide mental health patients with access to an independent mental health advocate View source Failure to ensure officers are trained to assess mental health-related calls and associated immediate risks View source Failure to determine when police are the appropriate agency for mental health-related enquiries View source Lack of connectivity between overseas and UK mental health services during repatriation of an ill patient View source Failure to consider wider circumstances and likely follow-on care before removing out-of-area patients from GP practice lists View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Sean Heath · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Sean Heath died on 25 August 2023 in an apartment from injuries involving his pericardial sac. The inquest jury determined that he died by taking his own life while suffering an acute mental health crisis. Principal concerns included police and mental health service responses, inter-agency communication, continuity of care after his return from Gibraltar, and access to appropriate mental health support.
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 ensure carers are informed of Mental Health Act admissions within 24 hours
Wider context from the report “In relation to the management of mental health patients that their carers are made aware of any admission under the Mental Health Act within 24 hours and those patients are supported with access to an independent mental health advocate;
” 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 establish agreed communication means and maintain relevant patient information in an accessible central repository
Wider context from the report “The means of communication is known and agreed between all mental health agencies to ensure all relevant patient information is held in an accessible central repository .
” 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 mental health patients with access to an independent mental health advocate
Wider context from the report “In relation to the management of mental health patients that their carers are made aware of any admission under the Mental Health Act within 24 hours and those patients are supported with access to an independent mental health advocate ;
” 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 officers are trained to assess mental health-related calls and associated immediate risks
Wider context from the report “In relation to Policing is the extent to which all officers are trained to assess the increasing number of calls to the police which are of a mental health nature , the risks associated with the consequences of not making the right assessment where there may be an immediate risk to life and when to accept that the police are the right agency to be involved in mental health related enquiries due to their powers of entry;
” 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 determine when police are the appropriate agency for mental health-related enquiries
Wider context from the report “In relation to Policing is the extent to which all officers are trained to assess the increasing number of calls to the police which are of a mental health nature, the risks associated with the consequences of not making the right assessment where there may be an immediate risk to life and when to accept that the police are the right agency to be involved in mental health related enquiries due to their powers of entry ;
” 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 connectivity between overseas and UK mental health services during repatriation of an ill patient
Wider context from the report “The apparent lack of connectivity between mental health services abroad and the UK upon repatriation whilst the patient remains ill ;
” 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 consider wider circumstances and likely follow-on care before removing out-of-area patients from GP practice lists
Wider context from the report “That there is a risk to patients generated by a decision to remove a patient from a GP practice list where the patient resides out of geographical area for that GP practice without considering the wider circumstances and the likely follow on care ; and
” 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 monitoring how providers work with other agencies during service transitions to prevent gaps in care.
Verbatim wording from the response “Our assessment of services includes how providers respond to patients transitioning between services. We will continue to work with providers to monitor how they are working effectively with other agencies to prevent gaps in a person’s care.” 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 Greater Manchester Police and the College of Policing are better placed to address police mental-health assessment and involvement concerns.
Verbatim wording from the response “We have given consideration to this point and have concluded that this, regretfully sits outside of CQC’s remit. We note that this report has also been sent to the Greater Manchester Police and the College of Policing and believe they will be of greater assistance in addressing this aspect of your concerns.” 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 Establishing communication arrangements and a central repository for information across mental-health agencies sits outside CQC’s remit.
Verbatim wording from the response “We have given careful consideration to this point and have concluded that this, regretfully sits outside of CQC remit. We note that this report has also been sent to the Department of Health and Social Care and believe they will be of greater assistance in addressing this aspect of your concerns.” 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 Department of Health and Social Care is better placed to address communication arrangements across mental-health agencies.
Verbatim wording from the response “We have given careful consideration to this point and have concluded that this, regretfully sits outside of CQC remit. We note that this report has also been sent to the Department of Health and Social Care and believe they will be of greater assistance in addressing this aspect of your concerns.” 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 Decisions to remove patients from GP practice lists based on geographical residence sit outside CQC’s remit.
Verbatim wording from the response “We have given careful consideration to this point and have concluded that this, regretfully sits outside of CQC remit. However, we would expect all GP practices to have clear policies and procedures in place for the removal of patients and have full regard for national guidance when considering the removal of patients from the register. CQC have produced a guide for providers, ‘CQC’s GP mythbuster 61: Patient registration’, which also includes published guidance from the British Medical Association (BMA): Guidance on patient registration. It is up to the individual practice to establish whether it is clinically appropriate to continue to provide care and treatment to patients who move outside of the geographical practice boundaries.” 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 Training police officers to assess mental-health calls and determine police involvement sits outside CQC’s remit.
Verbatim wording from the response “We have given consideration to this point and have concluded that this, regretfully sits outside of CQC’s remit. We note that this report has also been sent to the Greater Manchester Police and the College of Policing and believe they will be of greater assistance in addressing this aspect of your concerns.” 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 Individual GP practices are responsible for deciding whether geographically out-of-area patients should continue receiving care and treatment.
Verbatim wording from the response “We have given careful consideration to this point and have concluded that this, regretfully sits outside of CQC remit. However, we would expect all GP practices to have clear policies and procedures in place for the removal of patients and have full regard for national guidance when considering the removal of patients from the register. CQC have produced a guide for providers, ‘CQC’s GP mythbuster 61: Patient registration’, which also includes published guidance from the British Medical Association (BMA): Guidance on patient registration. It is up to the individual practice to establish whether it is clinically appropriate to continue to provide care and treatment to patients who move outside of the geographical practice boundaries.” Source location Response from CQC
Open published response
24 Sep 2024 George Neville Coulthard · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Delays in identifying suitable care home placements View source Limited access to tissue viability and district nursing information and support for wound care in the community View source Lack of effective communication about the required care pathway between discharging and community teams View source Failure of management teams to clarify the required level and type of care View source Unavailability of acute beds causing delays in allocating beds to patients requiring admission View source Failure to ensure internal care documentation reflects the correct care position 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
George Neville Coulthard · 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
George Neville Coulthard sustained skin wounds after an accidental fall, experienced gastrointestinal bleeds while in hospital, and later deteriorated and died at Bramhall Manor on 27 January 2024. The principal concerns were delays in discharge due to difficulty finding a suitable care home, ineffective communication about whether he required end-of-life care or rehabilitation, failure to clarify care arrangements, and limited community access to wound-care support.
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 Delays in identifying suitable care home placements
Wider context from the report “1. Mr Coulthard was assessed as being suitable for discharge on 18th December. He remained in an acute hospital setting for a further 4 weeks due to challenges in identifying a suitable care home . This was due to the inquest was told to a shortage of suitable places and the Christmas period. The impact of this on Mr Coulthard was that he remained in an acute setting when the inquest was told the care he required would have been better delivered in a care home /nursing home setting.
In addition the inquest heard evidence that it meant that an acute bed required for other patients was not available creating delays in allocating beds to patients requiring admission. The inquest was told that significant delays of this nature occur on a regular basis and are often exacerbated over the Christmas period.
” 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 access to tissue viability and district nursing information and support for wound care in the community
Wider context from the report “4. The evidence before the inquest was that whilst in the community prior to his final hospital admission the access to information and support, from tissue viability and district nursing teams, to care for and treat his wounds was very limited . Better access to wound care would have reduced the risk of further wound deterioration in the community and reduced the risk of him requiring inpatient care for his wounds. However the demands across GM on TVN and DN services made this 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 Lack of effective communication about the required care pathway between discharging and community teams
Wider context from the report “2. The lack of effective communication between the discharging team and the community teams meant that it was not understood if Mr Coulthard was on End of Life Care or for rehabilitation . The staff at the first home treated him as an end of life patient / palliative care patient as a consequence even though the paperwork suggested he may be a discharge to assess patient. As a consequence he was moved to another care home for rehabilitation although the evidence was that there was little purpose in the transfer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of management teams to clarify the required level and type of care
Wider context from the report “3. The inquest also heard evidence that the staff at the care home had queried what level and type of care was to be delivered to Mr Coulthard given his overall presentation. However there was no evidence that the management team had sought to clarify the position or ensure the internal documentation reflected the correct position.
” 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 acute beds causing delays in allocating beds to patients requiring admission
Wider context from the report “1. Mr Coulthard was assessed as being suitable for discharge on 18th December. He remained in an acute hospital setting for a further 4 weeks due to challenges in identifying a suitable care home. This was due to the inquest was told to a shortage of suitable places and the Christmas period. The impact of this on Mr Coulthard was that he remained in an acute setting when the inquest was told the care he required would have been better delivered in a care home /nursing home setting.
In addition the inquest heard evidence that it meant that an acute bed required for other patients was not available creating delays in allocating beds to patients requiring admission . The inquest was told that significant delays of this nature occur on a regular basis and are often exacerbated over the Christmas period.
” 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 internal care documentation reflects the correct care position
Wider context from the report “3. The inquest also heard evidence that the staff at the care home had queried what level and type of care was to be delivered to Mr Coulthard given his overall presentation. However there was no evidence that the management team had sought to clarify the position or ensure the internal documentation reflected the correct position .
” 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 Conduct a further Single Assessment Framework assessment reviewing previously identified shortfalls and whether the provider has sufficiently improved.
Verbatim wording from the response “As part of our processes, we are currently conducting a further assessment (under our new Single Assessment Framework) to review all the shortfalls identified at the last inspection and consider if there has been sufficient improvement. If we do not believe the registered provider has appropriately addressed the breaches of regulation to the extent” 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 Care home placement shortages and hospital discharge delays fall outside the regulator’s remit.
Verbatim wording from the response “We have given careful consideration to this point and have concluded that this, regretfully sits outside of CQC remit. We note that this report has also been sent to the Secretary of State and Greater Manchester Integrated Care and believe they will be of greater assistance in addressing this aspect of your concerns.” 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 Limited access to community tissue viability and district nursing wound care falls outside the regulator’s remit.
Verbatim wording from the response “We have considered this point and have concluded that, this regretfully sits outside of CQC remit. We believe the Secretary of State and Greater Manchester Integrated Care will be of greater assistance in addressing this aspect of your concerns.” 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 Secretary of State and Greater Manchester Integrated Care are considered better placed to address care placement shortages and discharge delays.
Verbatim wording from the response “We have given careful consideration to this point and have concluded that this, regretfully sits outside of CQC remit. We note that this report has also been sent to the Secretary of State and Greater Manchester Integrated Care and believe they will be of greater assistance in addressing this aspect of your concerns.” 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 Secretary of State and Greater Manchester Integrated Care are considered better placed to address limited community wound care access.
Verbatim wording from the response “We have considered this point and have concluded that, this regretfully sits outside of CQC remit. We believe the Secretary of State and Greater Manchester Integrated Care will be of greater assistance in addressing this aspect of your concerns.” Source location Response from CQC
Open published response
13 Sep 2024 Paul Rodney Batchelor · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Lack of safety information for users of nursing care beds with extensions View source Failure to formalise resident room checks in care home policy and procedures View source Failure to check residents who may be in distress View source Failure to ensure adequate support and retention of mattress extensions or bolsters on nursing care beds View source Lack of procedures for staff frightened or concerned about entering a resident’s room alone View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul Rodney Batchelor · 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 Rodney Batchelor, a frail elderly man in a care home for respite care, became wedged after a mattress extension fell through the frame of his extended nursing bed and died of positional asphyxia and bronchopneumonia. His cries for help went unattended for over an hour. The concerns were inadequate support for mattress extensions on extended beds and the lack of formalised procedures for staff responding to distressed residents at night, including when staff are frightened or concerned about entering a room alone.
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 safety information for users of nursing care beds with extensions
Wider context from the report “First Concern: There may be a lack of awareness of the need to ensure adequate support for the mattress extension or bolster when using nursing care beds with an extension frame fitted.
And that without adequate support there is a risk of death in that the mattress extension can fall through the bed frame creating a sufficient gap for a person to become wedged or stuck.
The lack of awareness of the risk may be compounded because when the mattress extension is fitted into the gap between the standard mattress and the footboard it may appear as though the bolster is adequately supported. Further that over time and use mattress deck extensions or other supporting framework can become detached or lost from the bed
Since this incident the court heard evidence that the care home and its sister care home have checked all existing extended profile beds and taken steps to ensure that they are fitted with the correct support.
However, the coroner is concerned that users of nursing care beds with extensions may need to be made aware of the circumstances of this death to prevent other deaths in similar circumstances .
” 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 formalise resident room checks in care home policy and procedures
Wider context from the report “Second Concern: The coroner notes that the care home has taken steps to ensure that any resident in distress and calling for help at night is heard. However, though the coroner has been shown minutes of briefings to care home staff conducted after Mr Batchelor’s death emphasising the need to conduct checks of residents by going into a resident’s room, she remains concerned that such briefings have not been formalised into care home policy and procedures . Nor do the minutes of those briefings explain what staff should do if they are frightened or concerned about entering a room on their own. There is the risk that rather than disturb a resident care home staff through, for example, fear or lack of time do not check a resident who may be 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 Failure to check residents who may be in distress
Wider context from the report “Second Concern: The coroner notes that the care home has taken steps to ensure that any resident in distress and calling for help at night is heard. However, though the coroner has been shown minutes of briefings to care home staff conducted after Mr Batchelor’s death emphasising the need to conduct checks of residents by going into a resident’s room, she remains concerned that such briefings have not been formalised into care home policy and procedures. Nor do the minutes of those briefings explain what staff should do if they are frightened or concerned about entering a room on their own. There is the risk that rather than disturb a resident care home staff through, for example, fear or lack of time do not check a resident who may be 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 Failure to ensure adequate support and retention of mattress extensions or bolsters on nursing care beds
Wider context from the report “First Concern: There may be a lack of awareness of the need to ensure adequate support for the mattress extension or bolster when using nursing care beds with an extension frame fitted .
And that without adequate support there is a risk of death in that the mattress extension can fall through the bed frame creating a sufficient gap for a person to become wedged or stuck .
The lack of awareness of the risk may be compounded because when the mattress extension is fitted into the gap between the standard mattress and the footboard it may appear as though the bolster is adequately supported. Further that over time and use mattress deck extensions or other supporting framework can become detached or lost from the bed
Since this incident the court heard evidence that the care home and its sister care home have checked all existing extended profile beds and taken steps to ensure that they are fitted with the correct support.
However, the coroner is concerned that users of nursing care beds with extensions may need to be made aware of the circumstances of this death to prevent other deaths in similar circumstances.
” 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 procedures for staff frightened or concerned about entering a resident’s room alone
Wider context from the report “Second Concern: The coroner notes that the care home has taken steps to ensure that any resident in distress and calling for help at night is heard. However, though the coroner has been shown minutes of briefings to care home staff conducted after Mr Batchelor’s death emphasising the need to conduct checks of residents by going into a resident’s room, she remains concerned that such briefings have not been formalised into care home policy and procedures. Nor do the minutes of those briefings explain what staff should do if they are frightened or concerned about entering a room on their own . There is the risk that rather than disturb a resident care home staff through, for example, fear or lack of time do not check a resident who may be in distress.
” 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 Highlight the national patient safety alert on beds and bedrails as an adult social care example on the website.
Verbatim wording from the response “As a result of this tragic event, CQC regulatory leadership and policy teams arranged for the specific NPSA to be highlighted as an example on our page: National Patient Safety Alerts in adult social care.” Source location Response from CQC
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 Clarify and publish links to MHRA medical-device guidance and its checklist, including profiling and adjustable beds, on the provider guidance webpage.
Verbatim wording from the response “We have highlighted the MHRA NPSA on beds and bedrails; their guidance on bedrails, their medical device guidance and their medical device checklist in our November 2024 provider bulletin. The medical device checklist lists profiling or adjustable beds and we have made this link clearer for providers.” Source location Response from CQC
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 Include references to the national patient safety alert and relevant MHRA guidance in the new assessment framework.
Verbatim wording from the response “In addition, our policy and regulatory leadership teams will be including references to the NPSA and relevant MHRA guidance into our new assessment framework, although we are currently developing our approach to this.” Source location Response from CQC
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 Promote national bed and bedrail safety alerts and guidance through provider bulletins.
Verbatim wording from the response “Last year CQC contributed to a MHRA national patient safety alert (NPSA) on beds and bedrails and their guidance on safe use of bedrails. CQC promoted both publications through our provider bulletins in September 2023. These bulletins are sent to health and social care organisations registered with the CQC and are addressed for action by the registered manager or a senior manager identified to the commission beforehand (called the ‘nominated individual’). The CQC already signposted providers to the MHRA bedrails guidance on our website page ‘Regulations for service providers and managers: related guidance’” Source location Response from CQC
Open published response
10 Sep 2024 James Astley · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Poor quality of fluid and nutrition charts View source Limited and insufficiently detailed documentation View source Failure to correctly complete MUST documentation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James Astley · 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
James Astley had dementia, was immobile, and became increasingly frail following worsening nutrition, fluid intake, and swallowing difficulties. He was admitted to hospital with urosepsis and dehydration and died there on 22 January 2024. The concerns included incorrectly completed MUST documentation, poor-quality fluid and nutrition charts, and limited, insufficiently detailed documentation 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 quality of fluid and nutrition charts
Wider context from the report “1. The inquest heard evidence that Mr Astley was at significant risk due to poor nutrition and fluid intake. However the MUST documentation was not correctly completed and the overall quality of fluid and nutrition charts was poor . As a consequence he became increasingly frail and the risk to his overall wellbeing and physiological reserves continued.
2. Overall documentation at the home was limited and lacked detail
” 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 and insufficiently detailed documentation
Wider context from the report “1. The inquest heard evidence that Mr Astley was at significant risk due to poor nutrition and fluid intake. However the MUST documentation was not correctly completed and the overall quality of fluid and nutrition charts was poor. As a consequence he became increasingly frail and the risk to his overall wellbeing and physiological reserves continued.
2. Overall documentation at the home was limited and lacked detail
” 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 correctly complete MUST documentation
Wider context from the report “1. The inquest heard evidence that Mr Astley was at significant risk due to poor nutrition and fluid intake. However the MUST documentation was not correctly completed and the overall quality of fluid and nutrition charts was poor. As a consequence he became increasingly frail and the risk to his overall wellbeing and physiological reserves continued.
2. Overall documentation at the home was limited and lacked detail
” 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 Conduct an assessment and inspection of Downshaw Lodge to verify required changes, including staff training, accurate needs assessment, care planning, and documentation.
Verbatim wording from the response “Subsequent to the Regulation 28 preventing future death report CQC have commenced an assessment at Downshaw Lodge to ensure the required changes have been made, especially in regard to ensuring staff have received the training and support needed to complete accurate assessment of people’s needs, take appropriate action and following care plans in line with people’s needs to ensure all care needs are met, and maintain accurate and contemporaneous needs. This assessment was commenced on 16 October 2024. Once this has been completed a report will be published on the CQC website with our findings. This can be found on the link” 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 Existing provider actions, multi-agency oversight and available documentation processes were considered sufficient to address identified care and recording risks.
Verbatim wording from the response “CQC first became aware of the death of Mr Astley on 30 January 2024 when a statutory notification of death was submitted by the provider. This was assessed by an inspector at the time who sought further information due to the notification indicating that a safeguarding referral had been raised against the care home. The safeguarding investigation records were reviewed and although areas of learning were noted for the provider, CQC was assured that the necessary actions were already in progress. These actions included ensuring all people living at the home had up to date and relevant care plans as well as training for staff around the use of the digital health service in order to effectively escalate health concerns.” Source location Response from CQC
Open published response
6 Sep 2024 John Francis HOWLETT · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of robust monitoring of care-home residents' nutritional status and fluid intake View source Failure to move patients from emergency departments onto wards in a timely manner due to capacity constraints View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Francis HOWLETT · 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 Francis Howlett had severe chronic obstructive pulmonary disease, was bedbound and required oxygen in a care home, where he became increasingly frail with poor nutrition and fluid intake. He developed an infection, was admitted to hospital, and died on 31 January 2024 after continuing to decline. Concerns included his spending 22 hours in an emergency department corridor and the care home’s inadequate systems for robustly monitoring his nutritional status and fluid intake.
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 monitoring of care-home residents' nutritional status and fluid intake
Wider context from the report “2. The evidence before the inquest indicated that the care home in question had been of concern in relation to the care offered to residents for some time. It was indicated that action plans were in place particularly in relation to safeguarding concerns given the vulnerability of residents. However despite those steps being in place and the concerns the systems were not in place at the care home to robustly monitor his nutritional status and fluid intake . He became increasingly frail with decreased physiological reserves as a consequence.
” 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 move patients from emergency departments onto wards in a timely manner due to capacity constraints
Wider context from the report “1. The inquest heard that on arrival at A and E at Tameside Hospital Mr Howlett spent 22 hours in a corridor despite suffering from an infection and the distress that this caused. The inquest was told that this was due to the demands on the department and the challenges of moving patients onto wards due to capacity issues . The inquest was told that this was not unique to that particular day or indeed to the hospital and was the picture across the country at that time .
” 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 monitoring The Lakes Care Centre to identify whether concerns escalate and require further regulatory action.
Verbatim wording from the response “The coroner noted in this regulation 28 report that despite action plans being in place in relation to safeguarding concerns, systems were not in place at the care home to robustly monitor Mr Howlett’s nutritional status and fluid intake. Our assessment finding indicated there continued to be some areas for improvement shortly after Mr Howlett’s death, but that action was being implemented and embedded at that time. Enforcement action was taken in response to these findings and CQC continue to monitor the service to identify if concerns around the service are escalated and require further action.” Source location Response from CQC
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 Take enforcement action in response to identified safety, risk-management and governance shortcomings at The Lakes Care Centre.
Verbatim wording from the response “The coroner noted in this regulation 28 report that despite action plans being in place in relation to safeguarding concerns, systems were not in place at the care home to robustly monitor Mr Howlett’s nutritional status and fluid intake. Our assessment finding indicated there continued to be some areas for improvement shortly after Mr Howlett’s death, but that action was being implemented and embedded at that time. Enforcement action was taken in response to these findings and CQC continue to monitor the service to identify if concerns around the service are escalated and require further action.” Source location Response from CQC
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 Assess The Lakes Care Centre against safety, effectiveness and leadership requirements, identifying required improvements and regulatory breaches.
Verbatim wording from the response “An assessment of The Lakes Care Centre was commenced on 22 April 2024 following concerns in relation to the care and support people were receiving. The key questions of ‘Is the service safe?’, ‘Is the service effective’ and ‘Is the service well led?’ were reviewed and the overall rating for these key questions and the service overall was ‘requires improvement’. At the time of this assessment The Lakes Care Centre had recently stopped operating as a nursing home but was still registered to deliver the regulated activity of ‘Treatment for Disease, Disorder or Injury’. The provider was asked to submit a notification to deregister from this regulated activity at the location and this was completed on 26 September 2024. The Lakes Care Centre continues to be registered for the regulated activity of ‘Accommodation for people requiring nursing or personal care’.” 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 reported emergency-department corridor wait caused by capacity pressures falls outside the regulator’s remit.
Verbatim wording from the response “We have given careful consideration to this point and have come to the conclusion that the concerns identified, namely, that Mr Howlett spent 22 hours in a corridor despite suffering from a chest infection due to demands on the department and capacity issues, a situation not unique to that particular day or hospital, sits outside of CQC remit. We 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.” 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 Responsibility for addressing the emergency-department corridor wait is directed to the Secretary of State for Health and Social Care.
Verbatim wording from the response “We have given careful consideration to this point and have come to the conclusion that the concerns identified, namely, that Mr Howlett spent 22 hours in a corridor despite suffering from a chest infection due to demands on the department and capacity issues, a situation not unique to that particular day or hospital, sits outside of CQC remit. We 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.” Source location Response from CQC
Open published response
25 Jun 2024 James Reginald Capstick · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 5 Failure to provide consistently good quality care View source Failure to maintain reliable clinical records View source Failure to perform and respond appropriately to basic checks and signs of life during resuscitation View source Unavailability of a defibrillator for attempted resuscitation in the care home View source Failure to retain and apply basic resuscitation 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.
×
AI-generated summary
James Reginald Capstick · 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
James Reginald Capstick died in hospital on 1 October 2022 after sustaining multiple rib fractures during more than 20 minutes of chest compressions when he was not in cardiac arrest, followed by respiratory insufficiency and pneumonia. The report raised concerns about the quality of care at Westmorland Court, the reliability of care records, the absence of a defibrillator at the time, and the failure to recognise signs of life during the resuscitation attempt.
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 consistently good quality care
Wider context from the report “(1) To Westmorland Court. The General Practitioner who came to give evidence said that care had improved since Reg's death but he still had concerns about care given and had to visit regularly every week to check residents -the only one of six homes he covers that requires this level of support. He said it was a struggle to provide good quality care and felt this report would be helpful -as I stated at inquest it is not intended in any way to be punitive but to put focus on areas that may be improved. A particular concern was clear evidence that examinations entered into Reg's notes were made at times when this was impossible because he was in hospital -this puts into question the reliability of notes generally.
” 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 reliable clinical records
Wider context from the report “(1) To Westmorland Court. The General Practitioner who came to give evidence said that care had improved since Reg's death but he still had concerns about care given and had to visit regularly every week to check residents -the only one of six homes he covers that requires this level of support. He said it was a struggle to provide good quality care and felt this report would be helpful -as I stated at inquest it is not intended in any way to be punitive but to put focus on areas that may be improved. A particular concern was clear evidence that examinations entered into Reg's notes were made at times when this was impossible because he was in hospital -this puts into question the reliability of notes generally .
” 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 perform and respond appropriately to basic checks and signs of life during resuscitation
Wider context from the report “(3) To Nursing and Midwifery Council. A Registered nurse was in charge of the home on the night of Reg's injury. Her statement told us that she forgot her basic training and had never had to attempt CPR before. Despite clear signs of breathing and resistance to her efforts she continued to be guided by the call handler at NWAS who had been confused by her inconsistent responses to his questions . Basic checks and signs of life were ignored. I was told at inquest that after being stepped down from nursing duty for a while she had had further training and was back in position. I was told that a referral to yourselves had been made and acknowledged but nothing further had been heard, has the referral been closed?
” 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 a defibrillator for attempted resuscitation in the care home
Wider context from the report “(2) To Care Quality Commission. You requested a note of the outcome of this case and please accept this report as such. I imagine you will be making further enquiries. There was no defibrillator in the home at the time of this incident although I am told one has now been installed. I was told that it is not a requirement for care homes to have one. If staff in these homes are expected to attempt resuscitation should provision be required?
” 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 retain and apply basic resuscitation training
Wider context from the report “(3) To Nursing and Midwifery Council. A Registered nurse was in charge of the home on the night of Reg's injury. Her statement told us that she forgot her basic training and had never had to attempt CPR before . Despite clear signs of breathing and resistance to her efforts she continued to be guided by the call handler at NWAS who had been confused by her inconsistent responses to his questions. Basic checks and signs of life were ignored. I was told at inquest that after being stepped down from nursing duty for a while she had had further training and was back in position. I was told that a referral to yourselves had been made and acknowledged but nothing further had been heard, has the referral been closed?
” 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 Followed up the provider’s actions addressing the CPR incident, including staff refresher training and action concerning the involved nurse.
Verbatim wording from the response “CQC were informed of the outcome of the local authority safeguarding investigation into the use of CPR on 1 December 2021 including actions to be taken to prevent further incidents. Actions included internal investigation by the provider, audit of the incident, a refresher of basic life support training for all staff, and a referral to the NMC regarding the individual nurse’s conduct. CQC followed up these actions and were reassured that staff had received refresher training in basic life support and that the provider had taken appropriate actions in relation to the registered nurse involved in the incident.” Source location Response from CQC
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 safeguarding alert and undertake further enquiries to assess whether additional regulatory activity is required.
Verbatim wording from the response “On 30 September 2022 CQC were notified of an allegation of abuse made by ambulance staff relating to concerns of neglect in relation to Mr Capstick whilst a resident at Westmorland Court Residential and Nursing Home. The concerns were identified by ambulance staff on 13 September 2022 when called to transport Mr Capstick to hospital. CQC are in the process of reviewing information related to this” 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 Without defibrillators, suitable resuscitation policies, procedures and trained staff are considered an appropriate alternative.
Verbatim wording from the response “Where equipment such as defibrillators are not installed, we would expect a provider to be able to demonstrate that they have suitable policies and procedures in place to ensure appropriate resuscitation methods can be carried out if required by suitably trained staff.” 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 Requiring care homes to install defibrillators falls outside the regulator’s role and remit.
Verbatim wording from the response “We have given careful consideration to the concerns raised in relation to whether it should be a requirement for care homes to have a defibrillator however this falls outside of the role and remit of CQC. We should clarify that the role and remit of CQC does not extend to prescribing how providers must meet the regulations stipulated, we place the onus and responsibility on providers themselves to make decisions around how best to deliver care safely and assure us of the same. There is no legal requirement for care homes to install equipment such as defibrillators but if they were to do so then there would be an expectation that staff are appropriately trained in how to use such equipment safely.” 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 Care providers are responsible for deciding how to deliver care safely and demonstrating compliance to the regulator.
Verbatim wording from the response “We have given careful consideration to the concerns raised in relation to whether it should be a requirement for care homes to have a defibrillator however this falls outside of the role and remit of CQC. We should clarify that the role and remit of CQC does not extend to prescribing how providers must meet the regulations stipulated, we place the onus and responsibility on providers themselves to make decisions around how best to deliver care safely and assure us of the same. There is no legal requirement for care homes to install equipment such as defibrillators but if they were to do so then there would be an expectation that staff are appropriately trained in how to use such equipment safely.” Source location Response from CQC
Open published response
Concerns raised 2 Failure of window restrictor standards to address deliberate attempts to defeat restrictors View source Lack of reliable, up-to-date guidance on the limitations of window restrictor standards View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Terrence Roy Hubert Taylor · 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
Terrence Roy Hubert Taylor, an 82-year-old short-term resident of a residential care home, overcame a window restrictor, climbed out of a first-floor window and fell during the early hours of 11 December 2020, sustaining injuries from which he died. The principal concern was that current British Standards for window restrictors address accidental falls but not deliberate attempts to defeat them, and that this limitation and subsequent guidance on stronger restrictors were not generally known or understood by residential care home operators, manufacturers or suppliers.
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 window restrictor standards to address deliberate attempts to defeat restrictors
Wider context from the report “1. The concern relates to the guidance provided to operators of residential care homes in respect of window restrictors and the standard they are required to meet. The current standards have been developed to prevent accidental falling from windows. They do not deal with deliberate attempts to defeat the restrictor , which may well be the situation encountered residential care homes, as in fact occurred in this case. This limitation is not known or understood by operators of residential care homes.
2. In December 2013 the Department of Health published Health Building Note 00-10 Part D: Windows and associated hardware. That guidance was not directed to residential care home provides. The Guidance was updated following an earlier Coroner’s report to prevent future deaths addressed to the Chief Medical Officer. That Guidance Note provides that
“... window restrictors tested to current British Standards may be inadequate in preventing a determined effort to force a window open beyond 100mm ...”.
It also noted that:
“... The relevant tests for restrictors cited in BS EN 14351-1 and BS EN 13126-5 have been developed to prevent accidental falling from windows ... None of the British and European Standards deal with deliberate attempts to defeat the restrictor using impact forces , which may be the situation encountered in hospitals and care homes”.
3. The evidence was that this Guidance was not generally known or understood by operators of residential care homes or manufactures or suppliers of window restrictors.
4. In 2019 the Health and Safety Executive published Research Report RR1150 Review of Window Restrictors use in Health and Social Care. The outcome of that research was that in order to protect vulnerable people in health and social care premises:
“... it is suggested that window restrictors (and their fixings) are capable of withstanding push forces of at least 850N ...”.
5. Thus the HSE’s research suggests that window restrictors in health and social care premises should be able to withstand forces very much greater than that of the British Standards .
6. The evidence was that this research was not generally known or understood by operators of residential care homes or manufactures or suppliers of window restrictors.
7. Operators of care homes are likely to consider they are taking reasonable steps to secure windows by fitting restrictors that meet the British Standards, whereas the 2013 Department of Health Guidance and the 2019 Health and Safety Executive research indicates that is not so.
8. Action is required to ensure operators of care homes are provided with reliable, up to date guidance and to ensure that the limitations of the British Standard are widely known and understood by operators of residential care homes.
9. Action is required to review the British Standard relating to window restrictors to consider whether some different standard or qualification to the existing standard is required in respect of residential care homes and/or deliberate acts to disable window restrictors.
” 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 reliable, up-to-date guidance on the limitations of window restrictor standards
Wider context from the report “1. The concern relates to the guidance provided to operators of residential care homes in respect of window restrictors and the standard they are required to meet. The current standards have been developed to prevent accidental falling from windows. They do not deal with deliberate attempts to defeat the restrictor, which may well be the situation encountered residential care homes, as in fact occurred in this case. This limitation is not known or understood by operators of residential care homes .
2. In December 2013 the Department of Health published Health Building Note 00-10 Part D: Windows and associated hardware. That guidance was not directed to residential care home provides . The Guidance was updated following an earlier Coroner’s report to prevent future deaths addressed to the Chief Medical Officer. That Guidance Note provides that
“... window restrictors tested to current British Standards may be inadequate in preventing a determined effort to force a window open beyond 100mm ...”.
It also noted that:
“... The relevant tests for restrictors cited in BS EN 14351-1 and BS EN 13126-5 have been developed to prevent accidental falling from windows ... None of the British and European Standards deal with deliberate attempts to defeat the restrictor using impact forces, which may be the situation encountered in hospitals and care homes”.
3. The evidence was that this Guidance was not generally known or understood by operators of residential care homes or manufactures or suppliers of window restrictors .
4. In 2019 the Health and Safety Executive published Research Report RR1150 Review of Window Restrictors use in Health and Social Care. The outcome of that research was that in order to protect vulnerable people in health and social care premises:
“... it is suggested that window restrictors (and their fixings) are capable of withstanding push forces of at least 850N ...”.
5. Thus the HSE’s research suggests that window restrictors in health and social care premises should be able to withstand forces very much greater than that of the British Standards.
6. The evidence was that this research was not generally known or understood by operators of residential care homes or manufactures or suppliers of window restrictors .
7. Operators of care homes are likely to consider they are taking reasonable steps to secure windows by fitting restrictors that meet the British Standards, whereas the 2013 Department of Health Guidance and the 2019 Health and Safety Executive research indicates that is not so.
8. Action is required to ensure operators of care homes are provided with reliable, up to date guidance and to ensure that the limitations of the British Standard are widely known and understood by operators of residential care homes.
9. Action is required to review the British Standard relating to window restrictors to consider whether some different standard or qualification to the existing standard is required in respect of residential care homes and/or deliberate acts to disable window restrictors.
” 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 Publish provider bulletin content highlighting the deliberate bypass risk and directing providers to the window-restrictor safety guidance.
Verbatim wording from the response “In August 2024 we published a note in our bulletin to providers (a regular update for providers and professionals working in adult social care) highlighting the tragic loss of life following a deliberate attempt to bypass a window restrictor and to remind providers of the CQC’s ‘Learning From Safety Incidents’ webpage. This publication has been updated on the CQC website to reflect the Health Building Note published” Source location Response from CQC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish and maintain web guidance on window restrictors, including links to relevant HSE guidance and safety incident learning.
Verbatim wording from the response “It sets out control measures that may be taken by care homes to ensure that people are kept safe. In 2022, CQC published a ‘Learning From Safety Incidents’ page on our website on the use of window restrictors. This can be found, alongside relevant, up to date guidance on complying with the relevant health and safety precautions, here: www.cqc.org.uk/guidance-providers/learning-safety-incidents/issue-7-falls-windows. This webpage also has links to the latest HSE guidance on risks to vulnerable members of the public from falling from height from windows; www.hse.gov.uk/safetybulletins/windowrestrictors.htm.” Source location Response from CQC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the website publication to reflect NHS England guidance that British Standards do not address deliberate impact-force attempts to defeat window restrictors.
Verbatim wording from the response “In August 2024 we published a note in our bulletin to providers (a regular update for providers and professionals working in adult social care) highlighting the tragic loss of life following a deliberate attempt to bypass a window restrictor and to remind providers of the CQC’s ‘Learning From Safety Incidents’ webpage. This publication has been updated on the CQC website to reflect the Health Building Note published” Source location Response from CQC
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 Supplement existing signposting with guidance tailored to specific sectors and service types.
Verbatim wording from the response “We are currently undertaking work to improve how we signpost providers to sources of good practice, to support our Single Assessment Framework. Good practice that is applicable across all sectors is already available, and we signpost to the HSE 2012 information sheet on Falls from windows or balconies in health and social care under the Quality Statement on ‘safe environments’, under the Safe key question. In time this will be supplemented by guidance that is applicable to specific sectors (such as ASC or health), or to specific service types (such as care home).” Source location Response from CQC
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 Improve signposting to sources of good practice through the Single Assessment Framework.
Verbatim wording from the response “We are currently undertaking work to improve how we signpost providers to sources of good practice, to support our Single Assessment Framework. Good practice that is applicable across all sectors is already available, and we signpost to the HSE 2012 information sheet on Falls from windows or balconies in health and social care under the Quality Statement on ‘safe environments’, under the Safe key question. In time this will be supplemented by guidance that is applicable to specific sectors (such as ASC or health), or to specific service types (such as care home).” 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 Updates to British safety guidance on window restrictors depend on the Health and Safety Executive or British Standards Institution.
Verbatim wording from the response “Whilst the CQC will publish and expect providers and registered managers to be aware of, and follow, best practice when it comes to British safety standards, the CQC relies upon guidance issued. If either HSE or The British Standards Institution update their guidance around window restrictors, the CQC will take steps to ensure providers are signposted to it both through our website and published bulletins to providers.” Source location Response from CQC
Open published response
2 May 2024 Frederick Martin Gerard Boyd · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Lack of a clear system or expectation for the quality of checks on unwell residents View source Limited documentation of key periods View source Limited senior-manager oversight of documentation quality View source Unclear and poorly understood escalation system for unwell patients View source Limited staff understanding of the level of detail required in documentation 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
Frederick Martin Gerard Boyd · 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
Frederick Martin Gerard Boyd, a resident of Lakes Care Home with a long-term catheter, complained of severe abdominal pain on 10 September 2023 and was found unresponsive in bed at about 6am the following day. A postmortem found that he died from peritonitis due to a bladder perforation caused by long-term catheterisation. Concerns included the lack of clear systems for monitoring and escalating care when a resident was unwell, limited documentation, and limited managerial oversight of documentation quality.
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 a clear system or expectation for the quality of checks on unwell residents
Wider context from the report “1. The inquest heard evidence that there was no clear system or expectation regarding the quality of checks on a resident who exhibited signs of being unwell .
” 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 documentation of key periods
Wider context from the report “2. The evidence before the inquest was that the documentation in relation to the key period was limited and that there appeared to be a limited understanding by staff of the level of detail required and that oversight of the quality of documentation by senior managers was limited.
” 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 senior-manager oversight of documentation quality
Wider context from the report “2. The evidence before the inquest was that the documentation in relation to the key period was limited and that there appeared to be a limited understanding by staff of the level of detail required and that oversight of the quality of documentation by senior managers was limited .
” 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 and poorly understood escalation system for unwell patients
Wider context from the report “3. The evidence before the inquest indicated that the system for escalation where a patient was unwell was unclear and not understood by staff .
” 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 staff understanding of the level of detail required in documentation
Wider context from the report “2. The evidence before the inquest was that the documentation in relation to the key period was limited and that there appeared to be a limited understanding by staff of the level of detail required and that oversight of the quality of documentation by senior managers was limited.
” Open source report
15 Mar 2024 Sydney Alex Piper · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Lack of policing of homeless encampments in wooded areas View source Lack of monitoring of homeless encampments in wooded areas View source Failure to adequately supervise vulnerable persons View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sydney Alex Piper · 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
Sydney Alex Piper, a 69-year-old man living in supported accommodation, left a mental health clinic while inadequately supervised on 23 February 2023 and was discovered deceased in a tent in Epping Forest on 24 March 2023. His death was caused by morphine toxicity, although it was not possible to determine how he was administered morphine or came to be at the site. The concerns were inadequate supervision of a vulnerable person and insufficient monitoring and policing of encampments, which increased the risk of fatal harm.
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 policing of homeless encampments in wooded areas
Wider context from the report “2. Mr Piper’s death was the latest in a series of deaths investigated by this court in which homeless persons have died in tents and encampments in wooded areas along the A406 and the periphery of Epping Forest due to high risk behaviours including, but not limited to, crush injuries, fire, third party assaults and drug misuse. The monitoring and policing of such encampments is, in the view of the court, lacking which increases the risk of fatal harm.
” 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 monitoring of homeless encampments in wooded areas
Wider context from the report “2. Mr Piper’s death was the latest in a series of deaths investigated by this court in which homeless persons have died in tents and encampments in wooded areas along the A406 and the periphery of Epping Forest due to high risk behaviours including, but not limited to, crush injuries, fire, third party assaults and drug misuse. The monitoring and policing of such encampments is, in the view of the court, lacking which increases the risk of fatal harm.
” 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 adequately supervise vulnerable persons
Wider context from the report “1. The support worker who accompanied Mr Piper on the day of his disappearance claimed that she did not constantly supervise Mr Piper as alternatively; she did not wish to crowd him, she was allergic to cigarette smoke, and finally that she needed to rest her legs. The witness accepted that she had neither read Mr Piper’s support plan, nor the relevant policies and procedures relevant to her duties that day.
I am concerned that there is no clear evidence before me that the risk of a similar incident of inadequate supervision of a vulnerable person has been effectively mitigated.
” 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 Request and review evidence that Outlook Care completed its stated safety changes across remaining locations.
Verbatim wording from the response “We have reviewed the information we hold regarding Waterside Lodge Recovery Centre and asked Outlook Care to provide us with a copy of their response to H.M Senior Coroner. We note that although Outlook Care are not able to take action at Waterside Lodge due to its closure, they have committed to changes across their remaining nine locations to prevent such a sad event as this happening again. The changes include review of missing person policy, training for staff, additional risk assessments for supporting people using the service in the community and spot checks on one to one community visit support. We further note that the majority of these changes are due to be completed by the end of June 2024. Working with the CQC team covering the area where Outlook Care’s head office is located, we will request and review evidence of completion of these actions to ensure this has taken place.” 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 Metropolitan Police Service is best placed to address monitoring and policing of high-risk homeless encampments.
Verbatim wording from the response “With reference to the report’s second area of concern, while CQC shares this concern, I note that the Metropolitan Police Service are also a named respondent and trust that they will be best placed to address this.” Source location Response from CQC
Open published response
9 Mar 2024 Linda Heath · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 4 Insufficient inquiry into the parameters of care provided by private domiciliary carers View source Failure of immediate discharge summaries to include relevant and sufficient community treatment and nursing information View source Absence of GP follow-up triggers for recently discharged patients with worsening conditions and missed routine appointments View source Failure to make post-discharge referrals for patients needing district nursing care 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
Linda Heath · 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
Linda Heath was discharged from hospital with a sacral sore, but the discharge information did not include a required district nursing referral and no referral was made. Her condition worsened, she was admitted to hospital, and she died on 31 March 2022 from sepsis caused by an infected sacral sore. The substantive concerns included inadequate discharge information, failure to arrange district nursing care, insufficient follow-up after discharge, and over-reliance on private domiciliary carers without sufficient enquiry into their remit.
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 Insufficient inquiry into the parameters of care provided by private domiciliary carers
Wider context from the report “(4) An over reliance upon private hygiene care packages with insufficient inquiry into the parameters of care provided by the private domiciliary carers .
” 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 immediate discharge summaries to include relevant and sufficient community treatment and nursing information
Wider context from the report “(1) The Immediate Discharge Summary did not include relevant or sufficient information about treatment in the community needs or a nursing summary .
” 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 GP follow-up triggers for recently discharged patients with worsening conditions and missed routine appointments
Wider context from the report “(3) No trigger appears to exist whereby GPs conduct follow up enquiries or visits to patients who have recently been discharged from hospital and who are complaining of a condition which may worsen and failing to attend routine appointments due to a worsening of their 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 make post-discharge referrals for patients needing district nursing care
Wider context from the report “(2) Despite the presence of a difficult sacral sore which would have benefitted from district nursing care, no referral was made post discharge by the GP surgery .
” 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 Share the review findings with CQC’s Primary and Community Care operations team for consideration in its regulatory response.
Verbatim wording from the response “A national professional advisor and senior specialist for Primary and Community Care at CQC have reviewed the coroner’s letter, evidence bundle, the clinical records and practice response to the integrated care board who would cover the oversight of this GP practice. The findings will be shared with the operations team for Primary and Community Care to consider alongside other information held by CQC. This will inform our regulatory response.” 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 Routine monitoring and risk-based inspections are considered sufficient to identify and address further concerns about the services.
Verbatim wording from the response “During the inspection process we routinely review correspondence, tasks and referrals. We will use the regulation 28 report to remind colleagues of the importance of this process.” 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 Oversight of the GP practice is assigned to the integrated care board, while findings inform CQC’s regulatory response.
Verbatim wording from the response “A national professional advisor and senior specialist for Primary and Community Care at CQC have reviewed the coroner’s letter, evidence bundle, the clinical records and practice response to the integrated care board who would cover the oversight of this GP practice. The findings will be shared with the operations team for Primary and Community Care to consider alongside other information held by CQC. This will inform our regulatory response.” Source location Response from CQC
Open published response
8 Mar 2024 Rose Mary Hollingworth · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Failure to properly complete Care & Support plans without significant errors View source Failure to properly monitor, review, manage and check care agency performance View source Failure to provide suitably trained, experienced and competent carers View source Failure to properly supervise and manage carers 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
Rose Mary Hollingworth · 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 Mary Hollingworth, a frail woman with significant co-morbidities, was found unresponsive at home on 3 January 2022 after a carer left without carrying out welfare checks or providing care. She was admitted to hospital and died the following day from a spontaneous intracerebral haemorrhage. The concerns included failures to provide suitably trained and competent carers, supervise and manage carers, maintain an accurate care and support plan, and monitor the care agency.
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 properly complete Care & Support plans without significant errors
Wider context from the report “(3) The Care & Support plan was not properly completed and contained significant errors .
” 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 properly monitor, review, manage and check care agency performance
Wider context from the report “(4) There was a failure to properly monitor, review, manage and check the performance of the care agency .
” 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 suitably trained, experienced and competent carers
Wider context from the report “(1) There was a failure to provide suitably trained, experienced and competent carers for a vulnerable person dependent on a package of 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 Failure to properly supervise and manage carers
Wider context from the report “(2) There was a failure to properly supervise and manage the carers .
” 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 a comprehensive inspection of HomeDotCare Limited and publish the inspection report.
Verbatim wording from the response “In response to the death of Rosie Hollingworth, the Commission carried out a comprehensive inspection of HomeDotCare Limited in November 2022 with the attached report published in February 2023. The service was rated ‘Good’ overall.” 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 No evidence was found that the concerns identified in the prevention of future death report remain.
Verbatim wording from the response “Given the action already taken by the Commission, we are reassured that HomeDotCare Limited have responded appropriately in response to the death of Rose Hollingworth. We have not seen evidence to suggest the concerns mentioned in section 5 of the regulation 28 report remain.” Source location Response from Care Quality Commission
Open published response
13 Feb 2024 Blanche Audrey Knowles · Prevention of Future Deaths report West Yorkshire (Eastern)
View report summary
Concerns raised 1 Failure to adequately convey and proactively flag the importance of cooling burns by running water to nursing staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Blanche Audrey Knowles · 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
Blanche Audrey Knowles, who had multiple health conditions and was receiving nursing care, suffered burns when an inadequately checked hot drink spilled into her lap. She later became frail and died on 1 September 2023; the burns contributed to her death. The principal concern was that staff had not been adequately informed or trained about cooling burns under running water.
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 adequately convey and proactively flag the importance of cooling burns by running water to nursing staff
Wider context from the report “Whilst it was clear from the written and oral evidence provided to the inquest that measures had been implemented to address the risks from hot drinks, for example by the purchase and use of thermometers, upon questioning, the matter of the importance of assisting an individual who has suffered burns by way of ‘cooling by running water’ as noted by the Ambulance staff did not appear to have been adequately conveyed to staff , be that through training or by way of clear communication as operational matters/requirements in the nursing care context.
The burns suffered by Blanche contributed to the cause of her death and whilst it was not established that the recorded failure to apply ‘cooling by running water’ to her injuries would have made a material difference, I remain concerned that the clear importance of applying ‘cooling by running water’ does not appear to be proactively flagged in relevant policies/procedures or by active practical/operational communications to staff .
” Open source report
8 Feb 2024 Jake Brian BAKER · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 8 Failure to ensure mandatory and adequately assured training for personal advisers View source Opaque process for obtaining learning disability diagnoses View source Failure to ensure adequately informed and recorded internal and formal review meetings View source Lack of audit of the effectiveness and practical use of Mental Capacity Act training in adult services View source Confusing and delayed access to adult social care assessments for care leavers View source Inadequacy of pathway plans for care leavers View source Lack of practice standards for risk assessments of care leavers View source Non-mandatory Mental Capacity Act training in children’s services View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jake Brian BAKER · 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
Jake Baker, who had learning disability and type 1 diabetes, developed diabetic ketoacidosis while staying with his family and died at home on 31 December 2019. The report identified concerns about inadequate pathway planning, risk assessment, information-sharing, diabetes support and advice to his family, as well as failures to assess his capacity and ensure appropriate care-leaver support.
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 ensure mandatory and adequately assured training for personal advisers
Wider context from the report “a.) The issues surrounding the inadequacy of Jake’s pathway plan have not been addressed comprehensively in the last 4 years. Training for personal advisers is not mandatory and is only now being rolled out . The court was not provided with copies of the training or any protocol in relation to it so as to be assured of the adequacy of the training and its implementation .
” 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 Opaque process for obtaining learning disability diagnoses
Wider context from the report “b.) The process by which diagnoses of learning disabilities can be obtained remains opaque . There is no protocol in relation to this . The current situation leaves those making decisions in relation to young people struggling to obtain this vital information .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure adequately informed and recorded internal and formal review meetings
Wider context from the report “d.) How internal meetings and formal review meetings with other interested parties are informed and recorded is not subject to a protocol and the risk remains that decisions will be taken without adequate information and inquiry as to the risks inherent in those decisions .
” 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 audit of the effectiveness and practical use of Mental Capacity Act training in adult services
Wider context from the report “f.) Mental Capacity Act training is not mandatory in children’s services and the adult services have no audit of the effectiveness of the mandatory training provided and how it is being used in practice . There is therefore a risk that erroneous assumptions as to capacity will continue to be made .
” 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 Confusing and delayed access to adult social care assessments for care leavers
Wider context from the report “c.) The issue of how the numerous adult social care teams are accessed to obtain adult social care assessments for care leavers leads to confusion and delays . Vulnerable care leavers are at risk of being denied necessary support .
” 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 Inadequacy of pathway plans for care leavers
Wider context from the report “a.) The issues surrounding the inadequacy of Jake’s pathway plan have not been addressed comprehensively in the last 4 years . Training for personal advisers is not mandatory and is only now being rolled out. The court was not provided with copies of the training or any protocol in relation to it so as to be assured of the adequacy of the training and its implementation.
” 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 practice standards for risk assessments of care leavers
Wider context from the report “e.) Practice standards have not been put in place in relation to risk assessments of care leavers to inform their needs .
” 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 Non-mandatory Mental Capacity Act training in children’s services
Wider context from the report “f.) Mental Capacity Act training is not mandatory in children’s services and the adult services have no audit of the effectiveness of the mandatory training provided and how it is being used in practice. There is therefore a risk that erroneous assumptions as to capacity will continue to be made.
” 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 Roll out the formal local-authority assessment programme, including assessing Surrey County Council and using reported concerns to inform that assessment.
Verbatim wording from the response “Between May and November 2023, CQC completed 5 pilot local authority assessments, to test the associated assessment framework, methods and processes. In December 2023, CQC commenced a rollout of its formal local authority assessment programme.” 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 At the time of Mr Baker’s death, CQC lacked statutory powers to assess Surrey County Council or other local authorities.
Verbatim wording from the response “At the time of Mr. Baker’s death, CQC did not have any statutory powers in relation to the assessment of Surrey County Council or any other local authority.” Source location Response from Care Quality Commission
Open published response
8 Feb 2024 Ethel Doreen Reed · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 5 Failure of the electronic patient record system to identify authors of changes to finalised discharge letters View source Risk of cross infection from misallocated patients’ personal effects View source Lack of continuity of nursing staff on winter-pressure wards View source Lack of visible ward leadership and a clear escalation pathway View source Paucity of personal care on the ward View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ethel Doreen Reed · 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
Ethel Doreen Reed fell at home, sustaining rib fractures that caused a pneumothorax and chest infection, and later developed pneumonia and Covid-19 while in hospital. She was discharged to a community rehabilitation centre while described as not medically fit for discharge and died there on 2 March 2023. The report raises concerns about staffing, continuity of care, personal care, leadership and escalation arrangements on a winter-pressure ward, as well as an electronic record system issue affecting identification of authors of discharge-letter changes.
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 the electronic patient record system to identify authors of changes to finalised discharge letters
Wider context from the report “(2) An issue with the Lorenzo electronic patient record keeping system has been identified in respect of the system not auto populating the identification of the author of any changes made in the immediate discharge letter (IDL) after it has been finalised . This could lead to miscommunication of critical issues and difficulties in establishing who made what decisions which could lead to delays in treatment in the next post discharge setting which in turn could lead to 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 Risk of cross infection from misallocated patients’ personal effects
Wider context from the report “(1) H130 is on the 13th floor of Hull Royal Infirmary. It has an East and a West wing and spans the full floor. It was opened in response to winter pressures. At that time, in January 2023, Hull Royal Infirmary was placed under significant pressure in terms of admissions and staffing. The ward been open only a matter of some two weeks by the time Mrs Reed was transferred to that ward. Despite being medically fit for discharge upon arrival on that ward Mrs Reed’s condition worsened and family raised concerns as best they could but they reported that the ward was chaotic and that staff would tell them they had only just found out they were working on the ward before their shift started and there was no consistency of nursing staff on the ward.
Mrs Reed was dehydrated and family report that there was a paucity of personal care afforded on that ward. There was a risk of cross infection as patients’ personal effects such as toiletries were not with the right patients and had to be located by family. There was no established cohort of permanent staff on the ward at that time and no signposting to the ward sister or matron and therefore no way of patients, their friends, or their families being able to have a clear escalation pathway to ventilate concerns. Although HUTH now have an established team and leadership chain on Ward H130 there is a real concern that wards opened in response to winter pressures in the future in any busy hospital may give rise to the same peripatetic staffing regime, that is to say, agency staff and no fixed team in place and a lack of visible leadership. This could lead to the deterioration of patients not being recognised if there is no continuity of care by the same team of nursing staff.
” 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 continuity of nursing staff on winter-pressure wards
Wider context from the report “(1) H130 is on the 13th floor of Hull Royal Infirmary. It has an East and a West wing and spans the full floor. It was opened in response to winter pressures. At that time, in January 2023, Hull Royal Infirmary was placed under significant pressure in terms of admissions and staffing. The ward been open only a matter of some two weeks by the time Mrs Reed was transferred to that ward. Despite being medically fit for discharge upon arrival on that ward Mrs Reed’s condition worsened and family raised concerns as best they could but they reported that the ward was chaotic and that staff would tell them they had only just found out they were working on the ward before their shift started and there was no consistency of nursing staff on the ward .
Mrs Reed was dehydrated and family report that there was a paucity of personal care afforded on that ward. There was a risk of cross infection as patients’ personal effects such as toiletries were not with the right patients and had to be located by family. There was no established cohort of permanent staff on the ward at that time and no signposting to the ward sister or matron and therefore no way of patients, their friends, or their families being able to have a clear escalation pathway to ventilate concerns. Although HUTH now have an established team and leadership chain on Ward H130 there is a real concern that wards opened in response to winter pressures in the future in any busy hospital may give rise to the same peripatetic staffing regime, that is to say, agency staff and no fixed team in place and a lack of visible leadership. This could lead to the deterioration of patients not being recognised if there is no continuity of care by the same team of nursing staff.
” 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 visible ward leadership and a clear escalation pathway
Wider context from the report “(1) H130 is on the 13th floor of Hull Royal Infirmary. It has an East and a West wing and spans the full floor. It was opened in response to winter pressures. At that time, in January 2023, Hull Royal Infirmary was placed under significant pressure in terms of admissions and staffing. The ward been open only a matter of some two weeks by the time Mrs Reed was transferred to that ward. Despite being medically fit for discharge upon arrival on that ward Mrs Reed’s condition worsened and family raised concerns as best they could but they reported that the ward was chaotic and that staff would tell them they had only just found out they were working on the ward before their shift started and there was no consistency of nursing staff on the ward.
Mrs Reed was dehydrated and family report that there was a paucity of personal care afforded on that ward. There was a risk of cross infection as patients’ personal effects such as toiletries were not with the right patients and had to be located by family. There was no established cohort of permanent staff on the ward at that time and no signposting to the ward sister or matron and therefore no way of patients, their friends, or their families being able to have a clear escalation pathway to ventilate concerns . Although HUTH now have an established team and leadership chain on Ward H130 there is a real concern that wards opened in response to winter pressures in the future in any busy hospital may give rise to the same peripatetic staffing regime, that is to say, agency staff and no fixed team in place and a lack of visible leadership . This could lead to the deterioration of patients not being recognised if there is no continuity of care by the same team of nursing staff.
” 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 Paucity of personal care on the ward
Wider context from the report “(1) H130 is on the 13th floor of Hull Royal Infirmary. It has an East and a West wing and spans the full floor. It was opened in response to winter pressures. At that time, in January 2023, Hull Royal Infirmary was placed under significant pressure in terms of admissions and staffing. The ward been open only a matter of some two weeks by the time Mrs Reed was transferred to that ward. Despite being medically fit for discharge upon arrival on that ward Mrs Reed’s condition worsened and family raised concerns as best they could but they reported that the ward was chaotic and that staff would tell them they had only just found out they were working on the ward before their shift started and there was no consistency of nursing staff on the ward.
Mrs Reed was dehydrated and family report that there was a paucity of personal care afforded on that ward. There was a risk of cross infection as patients’ personal effects such as toiletries were not with the right patients and had to be located by family. There was no established cohort of permanent staff on the ward at that time and no signposting to the ward sister or matron and therefore no way of patients, their friends, or their families being able to have a clear escalation pathway to ventilate concerns. Although HUTH now have an established team and leadership chain on Ward H130 there is a real concern that wards opened in response to winter pressures in the future in any busy hospital may give rise to the same peripatetic staffing regime, that is to say, agency staff and no fixed team in place and a lack of visible leadership. This could lead to the deterioration of patients not being recognised if there is no continuity of care by the same team of nursing staff.
” 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 Monitor medicine-ward staffing levels and associated improvement actions until they are fully implemented, embedded, and sustained.
Verbatim wording from the response “Since the last inspection, the trust made improvements to their staffing on medicine wards. All associated post inspection action plans for staffing have been completed. CQC regularly monitors staffing in terms of fill rates (planned vs actual), reduction in the number of vacancies, improved turnover rates and improved sickness rates. CQC continues to monitor staffing levels to ensure these actions are fully implemented, embedded, and sustained.” Source location Response from Care Quality Commission
Open published response
2 Feb 2024 Susan Wendy Bracegirdle · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Failure to obtain input from key people involved in care during safeguarding reviews View source Failure to share pressure-ulcer care plans with the care team View source Lack of a communication strategy supporting joint working and family involvement in pressure-ulcer care View source Failure to upload updated images for Tissue Viability review of deteriorating pressure ulcers View source Failure to provide the GP with sufficient information about pressure-ulcer deterioration View source Failure to share and discuss internal pressure-ulcer reviews with the family 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
Susan Wendy Bracegirdle · 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 Wendy Bracegirdle, who had limited mobility and lived in a care home, developed a stage 3 pressure ulcer that deteriorated and was associated with osteomyelitis and sepsis. She died in hospital on 9 February 2023 after treatment was unsuccessful. Concerns included inadequate information sharing and joint working between district nurses, care staff, the GP, the family and the Tissue Viability team, which increased the risk that deterioration would not be recognised or managed promptly.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain input from key people involved in care during safeguarding reviews
Wider context from the report “4. There had been a safeguarding review undertaken. However key people involved in her care had not provided input to the review which meant there was no clear holistic assessment of what lessons could be learnt to reduce the risk of deaths from pressure ulcers in the future . It was unclear why such an approach had been 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 Failure to share pressure-ulcer care plans with the care team
Wider context from the report “1. The inquest heard evidence that because Mrs Bracegirdle was in a care home setting the District Nurses were responsible for management of her pressure ulcers. The care home was asked to ensure pressure relieving processes were followed. However, the District Nurses did not share care plans with the care team on the basis that they were digital documents and were care plans for the use of District Nurses. As a consequence, the care home management were not fully sighted, and joint care was more difficult to deliver increasing the risk of the pressure ulcers deteriorating.
” 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 communication strategy supporting joint working and family involvement in pressure-ulcer care
Wider context from the report “2. There was no communication strategy in place as a consequence of an approach that did not promote team /joint working . The inquest heard that as a consequence the family were unsighted on the condition of Mrs Bracegirdle until shortly before her admission to hospital . This meant that the family could not support the work to reduce the risk of the pressure ulcers deteriorating further and were not able to be a proactive about the care she was receiving increasing the risk of her pressure ulcers deteriorating
” 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 upload updated images for Tissue Viability review of deteriorating pressure ulcers
Wider context from the report “6. The Tissue Viability team had been asked by the District Nurses for input. This was provided remotely via access to photos taken by the District Nursing Team. Whilst it was clear that remote review could be effective it was not in this case because the review was based on an older image and an updated image showing a deteriorating picture in relation to the pressure ulcers was not uploaded . This was as a result of lack of joint working and effective communication. The impact was that what would have been helpful expert input from the TVN was not provided to a deteriorating picture.
” 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 the GP with sufficient information about pressure-ulcer deterioration
Wider context from the report “3. The GP was asked to provide input. Due to a lack of information sharing the GP who dealt with Mrs Bracegirdle does not seem to have appreciated the extent of the issue and as a consequence there was no face-to-face examination and antibiotics were not started.
” 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 share and discuss internal pressure-ulcer reviews with the family
Wider context from the report “5. An earlier internal review by the District Nursing team when Mrs Bracegirdle’s pressure ulcer became a category 3 was not shared or discussed with the family and they were unsighted on the issue .
” 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 Follow up actions establishing clear responsibility for escalating wound-care concerns to GPs.
Verbatim wording from the response “The district nursing notes dated 09 December 2022 refer to the wound having a strong malodour and heavy grey-yellow exudate. It was recorded “follow up with the GP as I suspect the wound is infected”. However, it is not clear whether the district nurses or care home staff had the responsibility for doing this. The second rapid review undertaken by the district nurse team leader on 16 December 2022 identified that there was no evidence that the concerns were escalated to the GP and a referral to the GP was only made on 13 December 2022, at which time antibiotics were commenced for a wound infection. Action arising from the rapid review was to discuss with the district nursing team the importance of following up any concerns or actions with the GP and not relying on the care staff to ensure this is done.” 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 Include joint-working Quality Statements in the service’s next assessment and follow up actions addressing previously identified communication shortfalls.
Verbatim wording from the response “At our last inspection of Stable Steps Care Centre on 8 and 19 June 2023 we found that improvements were needed to ensure communication worked effectively within the home. Feedback from people living at the home and their families was mixed with some people feeling staff were responsive to their needs, whilst others gave examples of where they felt there had been delays in receiving treatment. Families also told us communication between healthcare services and the home could be difficult, staff were not always able to identify deterioration in people and that liaison and referrals with external services could be improved.” 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 Follow up the registered manager’s investigation into failures to keep families informed and seek assurance that resulting actions mitigate communication risks.
Verbatim wording from the response “We would expect, as parties to general reviews of care whilst at the home, a person’s family to be involved and informed, with the consent of the individual, regarding their care, treatment and progress. We note that the registered manager in her statement, advised that she had apologised to the family for the failure to keep them informed regarding Mrs Bracegirdle’s pressure ulcers and that she had committed to investigating this shortfall. We will follow up on the outcome of the investigation to seek assurance that any actions arising from the investigation will mitigate further risks that families are not kept informed where appropriate within acceptable timeframes.” 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 CQC previously had no remit over local authorities’ safeguarding reviews, although it now assesses local authorities’ safety duties.
Verbatim wording from the response “4. There had been a safeguarding review undertaken. However key people involved in her care had not provided input to the review which meant there was no clear holistic assessment of what lessons could be learnt to reduce the risk of deaths from pressure ulcers in the future. It was unclear why such an approach had been taken.” 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 It is unclear whether updated tissue-viability advice would have altered treatment, although providing an updated image would have been helpful.
Verbatim wording from the response “an updated image showing a deteriorating picture in relation to the pressure ulcers was not uploaded. This was as a result of lack of joint working and effective communication. The impact was that what would have been helpful expert input from the TVN was not provided to a deteriorating picture.” 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 GP could reasonably expect tissue viability specialists to lead pressure-ulcer treatment and advise the GP if treatment became ineffective.
Verbatim wording from the response “3. The GP was asked to provide input. Due to a lack of information sharing the GP who dealt with Mrs Bracegirdle does not seem to have appreciated the extent of the issue and as a consequence there was no face-to-face examination and antibiotics were not started.” Source location Response from Care Quality Commission
Open published response
Concerns raised 1 Lack of guidelines for anaesthetic and/or Intensive Care management of a flanged tracheostomy tube View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Bryan Moore · 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 Bryan Moore sustained burns to 32% of his body in an industrial electrical accident and later underwent tracheostomy surgery during treatment. His tracheostomy became dislodged while he was being turned, causing hypoxic cardiac arrest and a non-survivable hypoxic brain injury; he died after care was withdrawn. The substantive concern identified was the absence of guidelines for the anaesthetic and/or Intensive Care management of a flanged tracheostomy tube.
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 guidelines for anaesthetic and/or Intensive Care management of a flanged tracheostomy tube
Wider context from the report “1. Guidelines for the anaesthetic and/or Intensive Care management of a flanged tracheostomy tube
” 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 Specific guidance may be written by the Association of Anaesthetists, Royal College of Anaesthetists, or Health Education England.
Verbatim wording from the response “Other bodies who may be able to assist with the writing of specific guidance could include the Association of Anaesthetists Great Britain and Ireland, the Royal College of Anaesthetists or Health Education, England, all of whom I note have been included in your report.” 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 Writing national guidance on adjustable flanged tracheostomy care falls outside the regulator’s remit.
Verbatim wording from the response “We have given careful consideration to the concerns raised and have come to the conclusion the concerns identified, namely; ‘that there is a lack of guidance for the anaesthetic and/or Intensive Care management of a flanged tracheostomy tube’ regretfully sits outside of CQC remit.” Source location Response from CQC
Open published response
15 Nov 2023 Lauren Page Smith · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 8 Gap in fitness-to-practise oversight for unregistered technicians View source Failure to assess and manage staff fitness to practise after identified deficiencies View source Failure of the ambulance service to implement collective learning from identified ECG training gaps View source Failure to correctly interpret 12 lead ECGs View source Failure to note or act upon auto-diagnostic ECG reports View source Failure to provide accurate information about observations and ECG findings View source Lack of qualitative assessment of ECG training View source Lack of further ECG training after identified incorrect interpretation View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lauren Page Smith · 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
Lauren Page Smith died at home on 6 January 2023 after paramedics attended to reported vomiting, chest pain and arm pain. An abnormal ECG, including an automated report of an anterior infarct, was interpreted as normal, and she declined hospital attendance after being given that incorrect information. The report raises concerns about ECG interpretation, training and assessment, and the absence of further action or safeguards addressing identified competency and patient-safety risks.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Gap in fitness-to-practise oversight for unregistered technicians
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████ . ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time . I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 and manage staff fitness to practise after identified deficiencies
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles . I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 ambulance service to implement collective learning from identified ECG training gaps
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████ . There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician . Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 correctly interpret 12 lead ECGs
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience .
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 note or act upon auto-diagnostic ECG reports
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report .
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 accurate information about observations and ECG findings
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct , and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 qualitative assessment of ECG training
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training . I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time .
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 further ECG training after identified incorrect interpretation
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg . I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 monitoring improvements to serious incident management and learning from deaths through ongoing monitoring and engagement.
Verbatim wording from the response “We will continue to monitor WMAS’s progress in making improvements to their serious incident management and learning from deaths through our ongoing monitoring activities and engagement.” 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 There was no evidence of provider-level failure in relation to Miss Lauren Page Smith’s death.
Verbatim wording from the response “Having carefully reviewed the information the trust has provided, we have concluded there is no evidence of provider level failing in relation to Miss Lauren Page Smith’s death. However, we did identify concerns that supported our inspection findings in relation to the serious incident investigation process, and in particular, the timeliness around addressing the training needs of the staff involved with Miss Lauren Page Smith’s care.” Source location Response from Care Quality Commission
Open published response
6 Nov 2023 Ms. Madeleine Lawrence · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Serious deficiencies affecting patient safety at Southmead Hospital, Bristol View source Failure to ensure training of current staff and ongoing training for new staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ms. Madeleine Lawrence · 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
Ms. Madeleine Lawrence suffered a traumatic hip dislocation while playing rugby and later developed sepsis and necrotising myositis after her hospital admission. Her condition deteriorated, but observations were not performed or escalated in a timely manner, and prompt treatment for presumed sepsis was not initiated; she died in hospital on 25 March 2022. The concerns identified included serious deficiencies affecting patient safety and the adequacy of staff training on recognising and treating deteriorating patients and sepsis.
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 Serious deficiencies affecting patient safety at Southmead Hospital, Bristol
Wider context from the report “(1) That serious deficiencies affecting the safety of patients at Southmead Hospital, Bristol which had been identified following the death of Ms. Lawrence
” 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 training of current staff and ongoing training for new staff
Wider context from the report “(2) The CQC should confirm that it is now satisfied that the Trust has addressed the training of current staff and has in place appropriate measures to ensure ongoing training for new staff .
” 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 Conduct an on-site assessment of staffing, learning culture, systems, pathways and transitions, including deteriorating-patient escalation and training practices.
Verbatim wording from the response “The CQC have contacted the provider North Bristol Trust to request written confirmation and evidence of the action they have taken to date, and intend to take, following the tragic death of Madeleine Lawrence. CQC also conducted an on-site assessment under the new single assessment framework on 22 January 2024 at Southmead Hospital with the focus on:” 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 the trust’s training and measures for ongoing training of new staff during ongoing regulatory engagement.
Verbatim wording from the response “We at the Care Quality Commission (CQC), have seen evidence of significant improvements at the trust and will continue to monitor this area.” Source location Response from Care Quality Commission
Open published response
31 Oct 2023 Evelyn Ann Burcham · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 4 Unavailability of riser-recliner chairs with controls that limit unauthorised use View source Failure to assess and mitigate the risk of cognitively impaired residents accessing riser-recliner chair controls View source Health and safety risk from disabling riser-recliner chair controls at the mains View source Risk of death to other residents from cognitively impaired residents operating riser-recliner chair 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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Evelyn Ann Burcham · 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
Evelyn Ann Burcham, who had dementia and required full care, was tipped from a riser-recliner chair after another resident accessed and operated its remote control while it was unattended. She sustained a severe brain bleed and died ten days later. The principal concern was that the risk of cognitively impaired residents accessing and operating chair controls had not been foreseen, and that the chairs lacked a suitable safety feature to restrict access to the controls.
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 Unavailability of riser-recliner chairs with controls that limit unauthorised use
Wider context from the report “I am concerned that these chairs are common place in care home settings where residents suffer from cognitive impairment. The risks of another resident with dementia accessing the controls of the riser-recliner chair(s) was not foreseen by the Home and so was not factored into any operative risk assessment at the time; hence no measures were in place to minimise the risk. There remains a real and immediate risk that those with a cognitive impairment that manifests itself in a compulsion to fiddle and/or press buttons, can create a risk of death to other residents in the same care facility or setting. If this particular care home group did not foresee the risk then it is likely that others have not foreseen it either.
I was told at the Home had made enquiries with manufacturers of these standard riser-recliner chairs about the ability to ‘lock’ the remote control and/or find a safe was of storing it so that it is not accessible to anyone who does not have the authority, training or appropriate cognitive function to be able to use it safely. It would appear that a chair with a ‘safe’ remote cannot be purchased by the Home and there do not appear to be any regulatory or manufacturing standards (over and above manufacturing standards for consumers) that require these types of chairs to have this, or some alternative, safety feature that limits the use of the controls. I was told that the only way to render the remote ‘safe’ was to turn the power off at the mains, which in itself could create health and safety issues if the chair needed to be operated quickly.
” 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 and mitigate the risk of cognitively impaired residents accessing riser-recliner chair controls
Wider context from the report “I am concerned that these chairs are common place in care home settings where residents suffer from cognitive impairment. The risks of another resident with dementia accessing the controls of the riser-recliner chair(s) was not foreseen by the Home and so was not factored into any operative risk assessment at the time; hence no measures were in place to minimise the risk. There remains a real and immediate risk that those with a cognitive impairment that manifests itself in a compulsion to fiddle and/or press buttons, can create a risk of death to other residents in the same care facility or setting. If this particular care home group did not foresee the risk then it is likely that others have not foreseen it either.
I was told at the Home had made enquiries with manufacturers of these standard riser-recliner chairs about the ability to ‘lock’ the remote control and/or find a safe was of storing it so that it is not accessible to anyone who does not have the authority, training or appropriate cognitive function to be able to use it safely. It would appear that a chair with a ‘safe’ remote cannot be purchased by the Home and there do not appear to be any regulatory or manufacturing standards (over and above manufacturing standards for consumers) that require these types of chairs to have this, or some alternative, safety feature that limits the use of the controls. I was told that the only way to render the remote ‘safe’ was to turn the power off at the mains, which in itself could create health and safety issues if the chair needed to be operated quickly.
” 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 Health and safety risk from disabling riser-recliner chair controls at the mains
Wider context from the report “I am concerned that these chairs are common place in care home settings where residents suffer from cognitive impairment. The risks of another resident with dementia accessing the controls of the riser-recliner chair(s) was not foreseen by the Home and so was not factored into any operative risk assessment at the time; hence no measures were in place to minimise the risk. There remains a real and immediate risk that those with a cognitive impairment that manifests itself in a compulsion to fiddle and/or press buttons, can create a risk of death to other residents in the same care facility or setting. If this particular care home group did not foresee the risk then it is likely that others have not foreseen it either.
I was told at the Home had made enquiries with manufacturers of these standard riser-recliner chairs about the ability to ‘lock’ the remote control and/or find a safe was of storing it so that it is not accessible to anyone who does not have the authority, training or appropriate cognitive function to be able to use it safely. It would appear that a chair with a ‘safe’ remote cannot be purchased by the Home and there do not appear to be any regulatory or manufacturing standards (over and above manufacturing standards for consumers) that require these types of chairs to have this, or some alternative, safety feature that limits the use of the controls. I was told that the only way to render the remote ‘safe’ was to turn the power off at the mains, which in itself could create health and safety issues if the chair needed to be operated quickly.
” 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 of death to other residents from cognitively impaired residents operating riser-recliner chair controls
Wider context from the report “I am concerned that these chairs are common place in care home settings where residents suffer from cognitive impairment. The risks of another resident with dementia accessing the controls of the riser-recliner chair(s) was not foreseen by the Home and so was not factored into any operative risk assessment at the time; hence no measures were in place to minimise the risk. There remains a real and immediate risk that those with a cognitive impairment that manifests itself in a compulsion to fiddle and/or press buttons, can create a risk of death to other residents in the same care facility or setting. If this particular care home group did not foresee the risk then it is likely that others have not foreseen it either.
I was told at the Home had made enquiries with manufacturers of these standard riser-recliner chairs about the ability to ‘lock’ the remote control and/or find a safe was of storing it so that it is not accessible to anyone who does not have the authority, training or appropriate cognitive function to be able to use it safely. It would appear that a chair with a ‘safe’ remote cannot be purchased by the Home and there do not appear to be any regulatory or manufacturing standards (over and above manufacturing standards for consumers) that require these types of chairs to have this, or some alternative, safety feature that limits the use of the controls. I was told that the only way to render the remote ‘safe’ was to turn the power off at the mains, which in itself could create health and safety issues if the chair needed to be operated quickly.
” Open source report
Concerns raised 1 Failure to ensure care residents keep their pendant close to them at all times View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jill BRICE · 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
Jill Brice died on 23 December 2022 at Royal Sussex County Hospital after suffering burn injuries and smoke inhalation when an extractor fan in her sheltered housing caught fire. The substantive concern was that care residents should be reminded to keep their emergency pendants close to them, as Jill Brice was not wearing hers when she died.
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 ensure care residents keep their pendant close to them at all times
Wider context from the report “The Fire Safety Report recommended that care residents be reminded to have their pendant close to them at all times . I would like reassurance that this be actioned.
” 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 accommodation provider is not regulated by the respondent, so it cannot provide reassurance about reminding residents to keep pendants nearby.
Verbatim wording from the response “Unfortunately, we are unable to provide reassurance required regarding this concern or to comment upon it. The accommodation where Jill Brice resided was sheltered accommodation managed by the Teachers Housing Association, a not-for-profit charitable organisation. This organisation is not registered with us and therefore not regulated by us. The Teachers Association would not be required to register with us unless it was providing a regulated activity, as defined in section 8 of the Health and Social Care Act 2008 and Part 1 paragraph 2 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014.” Source location Response from Care Quality Comission
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 Provisionally, the location falls outside registration requirements and therefore outside the scope of regulation.
Verbatim wording from the response “We have undertaken a rapid review of the concerns raised in your Regulation 28 report and established that the location where Mrs Brice was residing at the time of her death, namely the Dene, the Green, Rottingdean, Brighton, was not registered with us.” Source location Response from Care Quality Commission
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations