10 Mar 2014 Derrick George RIVERS · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 7 Failure of the drugs administration policy to meet pharmacy requirements for patient and drug identification View source Failure of care home management to identify carers’ non-compliance with drugs administration protocols View source Failure of inspections to identify inadequacies in the drugs policy and drug administration protocol View source Failure to act upon all post-event recommendations in a timely manner View source Incomplete inspection of CQC Outcomes and the drugs administration system View source Lack of care home audit processes View source Failure of the drugs administration protocol to be fit for purpose and specific to the care home environment View source See 4 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
Derrick George RIVERS · 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
Derrick George Rivers, who had been admitted to full-time care after becoming frail and falling, was mistakenly given a 150mg dose of Clozapine intended for another resident. He was admitted to hospital with altered consciousness and confusion, initially improved, then deteriorated and died on 11 July 2013; the inquest found that he died from natural causes to which the Clozapine may have contributed. Concerns included inadequate medication policies and administration protocols, insufficient auditing and inspection, and incomplete implementation of recommendations intended to reduce the risk of medication errors.
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 drugs administration policy to meet pharmacy requirements for patient and drug identification
Wider context from the report “6) That the care home’s policy did not meet the pharmacy requirements in terms of patient and drug identification (pod system) .
” 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 care home management to identify carers’ non-compliance with drugs administration protocols
Wider context from the report “3) That the care home owner and/or manager were purportedly unaware of the fact that carers were not following drugs administration protocols .
” 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 inspections to identify inadequacies in the drugs policy and drug administration protocol
Wider context from the report “1) That the Local Authority and/or CQC, following their recent inspections of the care home, had not noted the inadequacies of the care home’s drugs policy/drug administration protocol .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to act upon all post-event recommendations in a timely manner
Wider context from the report “7) That the care home owner and/or manager did not act upon all recommendations made by ████████ after the event, in a timely manner . Risks therefore remain .
” 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 Incomplete inspection of CQC Outcomes and the drugs administration system
Wider context from the report “2) That not all CQC Outcomes were considered at the last inspection , purportedly because they did not have anyone available to inspect and review the drugs administration system at the material time .
” 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 care home audit processes
Wider context from the report “4) That the care home had little, if any, audit processes in place .
” 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 drugs administration protocol to be fit for purpose and specific to the care home environment
Wider context from the report “5) That the care home’s drugs administration protocol was not fit for purpose and was tantamount to a ‘hybrid’ of other policies i.e. it was not specific to the care home environment .
” Open source report
5 Mar 2014 Neil James Carter · Prevention of Future Deaths report London (West)
View report summary
Concerns raised 6 Failure of staff to accept the authority of the nurse in charge View source Deliberate falsification of nursing records View source Failure to perform basic nursing observations View source Inappropriate ward layout over two floors View source Inadequate staffing numbers and inappropriate staff skill mix View source Failure of management to listen or act on reported issues 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
Neil James Carter · 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
Neil James Carter took his own life on 20 November 2012 by jumping in front of a train while he was an inpatient at Priory Hospital Roehampton. The report identified repeated failures to perform basic nursing observations, inadequate staffing and skill mix, poor ward layout and discipline, management failures, and deliberate falsification of the nursing record. The inquest concluded that these failures led to missed opportunities to realise he was missing, search for him early, and offer life-saving interventions.
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 staff to accept the authority of the nurse in charge
Wider context from the report “(2) I heard evidence that indicated an enduring situation where the ward frequently had inadequate numbers of staff with an inappropriate skill mix and with an inappropriate layout over two floors. There was a lack of discipline with staff failing to accept a nurse in charge’s authority authority . Management was informed of some issues but failed to listen or act.
” 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 Deliberate falsification of nursing records
Wider context from the report “(3) There was a deliberate falsification of the nursing record .
” 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 basic nursing observations
Wider context from the report “(1) There were repeated failures to perform basic nursing observations
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Inappropriate ward layout over two floors
Wider context from the report “(2) I heard evidence that indicated an enduring situation where the ward frequently had inadequate numbers of staff with an inappropriate skill mix and with an inappropriate layout over two floors . There was a lack of discipline with staff failing to accept a nurse in charge’s authority authority. Management was informed of some issues but failed to listen or act.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Inadequate staffing numbers and inappropriate staff skill mix
Wider context from the report “(2) I heard evidence that indicated an enduring situation where the ward frequently had inadequate numbers of staff with an inappropriate skill mix and with an inappropriate layout over two floors. There was a lack of discipline with staff failing to accept a nurse in charge’s authority authority. Management was informed of some issues but failed to listen or act.
” 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 to listen or act on reported issues
Wider context from the report “(2) I heard evidence that indicated an enduring situation where the ward frequently had inadequate numbers of staff with an inappropriate skill mix and with an inappropriate layout over two floors. There was a lack of discipline with staff failing to accept a nurse in charge’s authority authority. Management was informed of some issues but failed to listen or act .
” 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 Incorporate ward staffing levels and skill mix into ongoing provider monitoring and the next inspection.
Verbatim wording from the response “• A Mental Health Act Commissioner made a further visit to the ward, where Mr Carter was a patient, on 19 March 2014. They found safe staffing levels were in place on that occasion. However, the Commission intends that ward staffing levels and, in particular, the skill-mix of staff be incorporated within our monitoring of the provider, as well as in the planning and focus of our next inspection of The Priory Hospital Roehampton.” Source location 2014-0103-Response-by-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 Conduct a joint unannounced inspection assessing medicines management and staffing compliance actions.
Verbatim wording from the response “3. 12 March 2014: The Commission carried out a joint unannounced inspection comprising a compliance inspector, a Mental Health Act Commissioner and a pharmacy inspector. The inspection focused on assessment against outcomes 9 and 13 to consider whether the compliance actions that were required following the inspections on 25 June and 3 July 2013 had been satisfactorily completed. We summarise the findings below:” Source location 2014-0103-Response-by-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 ward layout and its impact on patient care in planning and execution of the next hospital inspection.
Verbatim wording from the response “• The appropriateness of the ward layout over two floors and its impact on patient care has not been specifically looked at by the Commission to date in its inspections since the death of Mr Carter. Within the Commission’s regulatory methodology this concern relates to outcome 10 dealing with the safety and suitability of premises. Outcome 10 corresponds to regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We are grateful that this concern has been brought to our attention and we intend to incorporate the outcome specifically into the planning and execution of our next inspection of the hospital.” Source location 2014-0103-Response-by-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 Conduct an unannounced follow-up inspection assessing emergency procedures, observation policies, staff training and completion of earlier compliance actions.
Verbatim wording from the response “2. 24 October 2013: The Commission undertook a joint unannounced inspection in direct response to information that was received following a death of a patient at the hospital in September 2013. The inspection was conducted by compliance inspectors and a Mental Health Act Commissioner. The inspection focussed on outcome areas that related to some of the concerns raised including emergency procedures, observation policies and staff training and also assessed whether the actions required to achieve compliance with Outcomes 1 and 10, following the inspection on 25 June and 3 July 2013, had been completed. The Priory Hospital Roehampton was found to be compliant with all outcomes that were assessed. We set out a summary of those findings below:” Source location 2014-0103-Response-by-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 Conduct an unannounced joint compliance inspection of The Priory Hospital Roehampton and require remedial action for identified non-compliance.
Verbatim wording from the response “Since June 2013 the Commission have carried out the following compliance inspections of The Priory Hospital Roehampton:” Source location 2014-0103-Response-by-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 Assess observation training and continue monitoring observation information and policy implementation to inform future inspections.
Verbatim wording from the response “One of the steps that the Commission has undertaken in response to this has been to consider observation training as part of the follow-up inspection of staffing standards on 12 March 2014. The inspection on 12 March comprised a joint unannounced inspection comprising a compliance inspector, a Mental Health Act Commissioner and a pharmacy inspector. The inspection on 12 March focused on assessment against outcomes 9 (Medicines Management) and 13 (Staffing) to consider whether the compliance actions that were required following the inspections on 25 June and 3 July 2013 had been satisfactorily completed. During the inspection of 14 March the Commission found training on how to carry out” Source location 2014-0103-Response-by-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 Use information about alleged nursing-record falsification to inform planning and delivery of the next inspection.
Verbatim wording from the response “The Commission has seen no evidence of deliberate falsification during the course of our inspections. It is extremely worrying that such evidence was presented. It is also a very difficult thing for the Commission to identify either in regular monitoring or at an inspection visit unless it had been brought to our attention by staff, patients or relatives. Nevertheless, this information will inform the planning and delivery of the next inspection visit of The Priory Hospital Roehampton.” Source location 2014-0103-Response-by-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 Undertake an unannounced inspection within four months covering reported concerns, additional regulatory concerns and new intelligence, coordinated with Mental Health Act monitoring.
Verbatim wording from the response “The Commission plans to undertake the next inspection visit of The Priory Hospital Roehampton within the next four months. The precise date of the inspection has not been set and it is to be unannounced. It is also intended that that visit would consider not only the specific areas of concern highlighted in this report but also those highlighted in a separate Regulation 28 report that was addressed to the Commission following the inquest into the death of another service user at The Priory Hospital Roehampton. That visit would also take account of any further intelligence that is gathered or brought to the Commission’s attention before that inspection. The planning of that inspection is also being coordinated with the Mental Health Act Commissioners’ monitoring of the provider for the same purposes.” Source location 2014-0103-Response-by-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 of deliberate nursing-record falsification was identified during inspections.
Verbatim wording from the response “The Commission has seen no evidence of deliberate falsification during the course of our inspections. It is extremely worrying that such evidence was presented. It is also a very difficult thing for the Commission to identify either in regular monitoring or at an inspection visit unless it had been brought to our attention by staff, patients or relatives. Nevertheless, this information will inform the planning and delivery of the next inspection visit of The Priory Hospital Roehampton.” Source location 2014-0103-Response-by-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 Alleged deliberate record falsification may require referral to the relevant professional regulatory body, such as the NMC or GMC.
Verbatim wording from the response “The Commission would also respectfully suggest that if it has not been done so already this may be a matter which would require referral to the relevant professional regulatory body, whether NMC, GMC or otherwise.” Source location 2014-0103-Response-by-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 Deliberate record falsification is difficult to identify through routine monitoring or inspections unless reported by staff, patients or relatives.
Verbatim wording from the response “The Commission has seen no evidence of deliberate falsification during the course of our inspections. It is extremely worrying that such evidence was presented. It is also a very difficult thing for the Commission to identify either in regular monitoring or at an inspection visit unless it had been brought to our attention by staff, patients or relatives. Nevertheless, this information will inform the planning and delivery of the next inspection visit of The Priory Hospital Roehampton.” Source location 2014-0103-Response-by-Care-Quality-Commission
Open published response
4 Mar 2014 Ms. Kimberley Parsons · Prevention of Future Deaths report Avon
View report summary
Concerns raised 5 Lack of published evidence supporting assisted self-harming as a treatment approach View source Lack of proper procedures for introducing and using novel treatments View source Failure to discuss proposed treatment with the consultant in charge View source Failure to record proposed treatment discussions View source Failure to address identified patient-safety deficiencies at Hillview Lodge 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
Ms. Kimberley Parsons · 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. Kimberley Parsons, who had a history of mental health problems and suicidal ideation, was found hanging in her room at Sycamore Ward on 16 March 2014 after repeated self-harm during her admission. She was transferred to intensive care but died from her injuries on 24 March 2014. Concerns included serious patient-safety deficiencies at Hillview Lodge, including incomplete observation records, shortcomings in resuscitation equipment and training, and deficiencies in care planning and pathways for patients with emotionally unstable personality disorder.
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 published evidence supporting assisted self-harming as a treatment approach
Wider context from the report “(1) The suggestion made to Ms. Parsons, a person with a history of self-harming and who remained at high risk of self-harming, that she could be assisted with self-harming was not an approach to patient care and treatment which was supported by any reference to the results of any research published in a peer-reviewed professional journal . Therefore if this is a bona fide approach to treatment in a high risk patient then the Trust should be able to justify that this is a recognised and generally accepted practice by reference to the published literature and/or results of published research .
(2) If the Trust cannot provide evidence to support this treatment being a recognised and generally accepted practice then the Trust must establish proper procedures for the introduction and use of novel treatments including the obtaining of any necessary ethical approvals.
(3) This discussion with regard to ‘assisted self-harming’ was not discussed by the nurse with the consultant psychiatrist nor was any record made of the discussion. The Trust should undertake a proper review of any training with respect to these matters so as to ensure any discussions with regard to proposed treatment are had with the full knowledge and agreement of the consultant in charge and that those discussions are properly recorded.
” 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 proper procedures for introducing and using novel treatments
Wider context from the report “(1) The suggestion made to Ms. Parsons, a person with a history of self-harming and who remained at high risk of self-harming, that she could be assisted with self-harming was not an approach to patient care and treatment which was supported by any reference to the results of any research published in a peer-reviewed professional journal. Therefore if this is a bona fide approach to treatment in a high risk patient then the Trust should be able to justify that this is a recognised and generally accepted practice by reference to the published literature and/or results of published research.
(2) If the Trust cannot provide evidence to support this treatment being a recognised and generally accepted practice then the Trust must establish proper procedures for the introduction and use of novel treatments including the obtaining of any necessary ethical approvals .
(3) This discussion with regard to ‘assisted self-harming’ was not discussed by the nurse with the consultant psychiatrist nor was any record made of the discussion. The Trust should undertake a proper review of any training with respect to these matters so as to ensure any discussions with regard to proposed treatment are had with the full knowledge and agreement of the consultant in charge and that those discussions are properly recorded.
” 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 discuss proposed treatment with the consultant in charge
Wider context from the report “(1) The suggestion made to Ms. Parsons, a person with a history of self-harming and who remained at high risk of self-harming, that she could be assisted with self-harming was not an approach to patient care and treatment which was supported by any reference to the results of any research published in a peer-reviewed professional journal. Therefore if this is a bona fide approach to treatment in a high risk patient then the Trust should be able to justify that this is a recognised and generally accepted practice by reference to the published literature and/or results of published research.
(2) If the Trust cannot provide evidence to support this treatment being a recognised and generally accepted practice then the Trust must establish proper procedures for the introduction and use of novel treatments including the obtaining of any necessary ethical approvals.
(3) This discussion with regard to ‘assisted self-harming’ was not discussed by the nurse with the consultant psychiatrist nor was any record made of the discussion. The Trust should undertake a proper review of any training with respect to these matters so as to ensure any discussions with regard to proposed treatment are had with the full knowledge and agreement of the consultant in charge and that those discussions are properly recorded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to record proposed treatment discussions
Wider context from the report “(1) The suggestion made to Ms. Parsons, a person with a history of self-harming and who remained at high risk of self-harming, that she could be assisted with self-harming was not an approach to patient care and treatment which was supported by any reference to the results of any research published in a peer-reviewed professional journal. Therefore if this is a bona fide approach to treatment in a high risk patient then the Trust should be able to justify that this is a recognised and generally accepted practice by reference to the published literature and/or results of published research.
(2) If the Trust cannot provide evidence to support this treatment being a recognised and generally accepted practice then the Trust must establish proper procedures for the introduction and use of novel treatments including the obtaining of any necessary ethical approvals.
(3) This discussion with regard to ‘assisted self-harming’ was not discussed by the nurse with the consultant psychiatrist nor was any record made of the discussion . The Trust should undertake a proper review of any training with respect to these matters so as to ensure any discussions with regard to proposed treatment are had with the full knowledge and agreement of the consultant in charge and that those discussions are properly recorded .
” 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 address identified patient-safety deficiencies at Hillview Lodge
Wider context from the report “(1) That serious deficiencies affecting the safety of patients at Hillview Lodge which had been identified in March 2014 had not been addressed by the Trust by the time of the CQC inspection in June 2014.
” 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 Maintain regular contact with AWP to monitor progress against regulatory requirements.
Verbatim wording from the response “CQC maintained regular contact with AWP following the comprehensive inspection in order to monitor progress in meeting requirements and in addition, in December 2014 carried out a programme of unannounced inspections across AWP to establish whether the trust had complied with the warning notices.” Source location 2015-0077-Response-by-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 Conduct unannounced inspections across AWP to establish compliance with the warning notices.
Verbatim wording from the response “CQC maintained regular contact with AWP following the comprehensive inspection in order to monitor progress in meeting requirements and in addition, in December 2014 carried out a programme of unannounced inspections across AWP to establish whether the trust had complied with the warning notices.” Source location 2015-0077-Response-by-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 Complete a comprehensive inspection of AWP, including a focused review of Hillview Lodge and rating the organisation.
Verbatim wording from the response “You may be aware that the Care Quality Commission (CQC) carried out a comprehensive inspection of the Avon and Wiltshire Partnership NHS Trust (AWP) in June 2014. This was one of the ‘pilot’ new style comprehensive inspections of NHS and independent healthcare organisations. As such, whilst we provided a narrative in the report as to whether the trust was providing safe, effective care that was responsive to people’s needs, delivered by staff that were caring and whether the trust was well led we did not provide a rating (now rate organisations on a four point scale – outstanding, good, requires improvement and inadequate against these key areas).” Source location 2015-0077-Response-by-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 Issue enforcement warning notices addressing trust-wide incident learning and Hillview Lodge environmental safety deficiencies.
Verbatim wording from the response “As a consequence of the inspection enforcement action was taken and four warning notices were issued. The warning notices served to notify the provider (AWP) that CQC had judged that the quality of health care provided for the regulated activities required significant improvement. Two of the warning notices were relevant to Hillview.” Source location 2015-0077-Response-by-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 Make an unannounced Mental Health Act visit to Hillview Lodge to assess environmental and health-and-safety compliance.
Verbatim wording from the response “In addition, CQC undertakes focused visits to assess compliance with the the Mental Health Act. Whilst these visits look closely at issues surrounding patients detained under the Mental Health Act they also look at environmental issues and health and safety. An unannounced Mental Health Act visit will be made to Hillview Lodge in the next few months.” Source location 2015-0077-Response-by-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 Undertake a further comprehensive inspection of AWP before April 2016, including particular attention to Hillview’s compliance actions.
Verbatim wording from the response “As the inspection in June 2014 was part of the ‘pilot’ programme and not rated a further comprehensive inspection will be undertaken at some time in the future (before April 2016) when AWP will be rated. As part of the inspection Hillview Lodge will be visited and particular attention will be paid to progress made against the compliance actions.” Source location 2015-0077-Response-by-Care-Quality-Commission
Open published response
14 Jan 2014 Russell James Felstead · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Failure to access and read all relevant information across nursing and clinical records 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
Russell James Felstead · 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
Russell James Felstead, who had severe learning disabilities, epilepsy and a history of falls, was found unresponsive on the floor of his room on 7 January 2013 and died on 28 January 2013 after a subdural haematoma was identified and operated on. Relevant information about his falls and helmet was available in the hospital records from 7 January but was not noted by doctors until 11 January, when an urgent CT scan was requested.
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 access and read all relevant information across nursing and clinical records
Wider context from the report “Doctors must ensure that all relevant information is accessed and read even if this is in the Nursing notes as opposed to the Clinical records. It is clear that the information which prompted an urgent CT scan on the 11th January had been available in Mr Felstead’s medical records since the 7th January and his helmet had in fact been at the hospital.
” Open source report
10 Jan 2014 Mary WALDRON · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 9 Failure of nursing home staff to take appropriate action when aware of low blood pressure View source Inability of the nursing home to address future risks relating to a nurse's training View source Lack of clarity regarding the status of the Care Quality Commission investigation View source Failure of nursing home staff to recognise acutely unwell residents View source Failure of nursing home managers to take action to prevent recurrence View source Failure of nursing home managers to undertake effective incident investigations View source Failure to provide the non-driving paramedic with satellite navigation information for hospital transfer times View source Inaccurate reporting by nursing home managers to the Care Quality Commission View source Lack of ongoing training in recognition and treatment of acutely unwell residents View source See 6 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
Mary WALDRON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mary Waldron became unwell at St Mary's Nursing Home on 24 August 2013 and was transferred to University Hospital, Coventry, where she died after suffering a cardiac arrest during the transfer. Concerns included failures to recognise and appropriately respond to her acute illness and low blood pressure, inadequate ongoing staff training, shortcomings in the nursing home's investigation and reporting, uncertainty about the CQC investigation, and potential confusion between ambulance drivers and paramedics about transfer times.
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 nursing home staff to take appropriate action when aware of low blood pressure
Wider context from the report “(2) failure of the nursing home staff to undertake appropriate action when they were aware of the low blood pressure ;
” 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 Inability of the nursing home to address future risks relating to a nurse's training
Wider context from the report “(7) the nurse primarily involved in this incident is no longer an employee at St Mary's and is working elsewhere. St Mary's nursing home is therefore unable to take action to address potential future risks relating to the training of this nurse ;
” 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 clarity regarding the status of the Care Quality Commission investigation
Wider context from the report “(6) lack of clarity as to the investigation that is to be undertaken by the CQC . The nursing home gave evidence that the investigation is closed, whilst the family believe it is ongoing ;
” 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 nursing home staff to recognise acutely unwell residents
Wider context from the report “(1) failure of the nursing home staff to recognise an acutely unwell resident ;
” 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 nursing home managers to take action to prevent recurrence
Wider context from the report “(4) failure of the nursing home managers to undertake an effective investigation into this incident and to take action to prevent repetition;
” 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 nursing home managers to undertake effective incident investigations
Wider context from the report “(4) failure of the nursing home managers to undertake an effective investigation into this incident and to take action to prevent repetition;
” 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 non-driving paramedic with satellite navigation information for hospital transfer times
Wider context from the report “(8) the potential for further incidents of confusion between driver and paramedic with regard to hospital transfer times , with the possibility of significant adverse consequences. Evidence given was that satellite navigation information (including time to arrival) was only available directly to the ambulance driver . Direct visualisation of a satellite navigation console by the non-driving paramedic could address this risk.
” 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 reporting by nursing home managers to the Care Quality Commission
Wider context from the report “(5) inaccurate reporting by the nursing home managers to the Care Quality Commission (CQC) that internal protocols had been appropriately followed , when evidence given at the inquest was that this was not the case ;
” 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 ongoing training in recognition and treatment of acutely unwell residents
Wider context from the report “(3) a lack of ongoing training with regard to the recognition and treatment of acutely unwell residents ; with reliance solely on initial nursing training ;
” Open source report
17 Dec 2013 William Alfred Andrews · Prevention of Future Deaths report South Yorkshire (West)
View report summary
Concerns raised 4 Lack of a standard procedure for checking and counting syringe caps at the end of operations View source Failure to ensure that detachable syringe caps are visibly different in colour from the equipment View source Failure to implement recommended strategies to reduce recurrence of plastic obstruction incidents View source Failure to ensure operating staff are aware that bulb syringes are supplied with caps 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
William Alfred Andrews · 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
William Alfred Andrews, a 77-year-old man, underwent cardiac surgery and subsequently suffered repeated circulatory arrests after a bulb syringe cap entered and remained in his left ventricle. The cap was later removed during a second operation, but his condition deteriorated and he died. Concerns included the cap's lack of visibility, inadequate awareness of its presence, and the absence of a standard procedure to check and count syringe caps at the end of surgery.
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 standard procedure for checking and counting syringe caps at the end of operations
Wider context from the report “(1) If a simple precaution was taken in ensuring that the tip of a bulb syringe or similar was a different colour to the rest of the equipment then it is difficult to see how a surgeon could use a syringe with the tip still in place by error. As the attached photograph shows there is no significant difference between the syringe with the tip on or off.
(2) There is a further concern in respect of other information which is contained with the Trust’s SUI report as follows:
It is perhaps of some relevance that in 2001-2 a number of instances of items of anaesthetic airway equipment being blocked with extraneous pieces of plastic and causing harm to patients were the subject of a national police investigation (Operation Cordian). The police findings were examined by an Expert Group, which published a series of recommendations in 2004. Their conclusion was that there was no criminal intent but that the incidents had happened as a matter of chance. Strategies to reduce the chances of these events recurring were recommended. Recommendation 1 states “The MHRA should recommend to manufacturers and the relevant Standards Committees that ….. detachable caps (eg. On intravenous cannulae and giving sets) be manufactured in brightly coloured material, preferably red, to aid visibility”.
No action appears to have been taken in consequence of this.
(3) The SUI report goes on to indicate that none of the team undertaking the operation were aware that the bulb syringe came supplied with a cap. The previous brand used by the Trust was not supplied with a syringe cap. The current bulb syringes in use obviously do have a cap but this is normally removed by the scrub practitioner before the syringe is supplied to the operating surgeon. Thus there has been little opportunity for surgeons to appreciate that syringes now have caps. This underlines the importance of ensuring that such devices are manufactured with a brightly coloured cap, if one is to be used at all.
(4) There appears to be no standard procedure for checking for syringe caps (where used) at the end of the operation , such as there is with swabs. The evidence available to me suggests that items such as syringe caps are just discarded by the scrub practitioner without being retained for counting . Of course, the fact that some syringes are apparently manufactured with a cap and others without complicates the situation but is not actually a bar to counting the number of caps present at the outset of the operation.
” 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 that detachable syringe caps are visibly different in colour from the equipment
Wider context from the report “(1) If a simple precaution was taken in ensuring that the tip of a bulb syringe or similar was a different colour to the rest of the equipment then it is difficult to see how a surgeon could use a syringe with the tip still in place by error. As the attached photograph shows there is no significant difference between the syringe with the tip on or off .
(2) There is a further concern in respect of other information which is contained with the Trust’s SUI report as follows:
It is perhaps of some relevance that in 2001-2 a number of instances of items of anaesthetic airway equipment being blocked with extraneous pieces of plastic and causing harm to patients were the subject of a national police investigation (Operation Cordian). The police findings were examined by an Expert Group, which published a series of recommendations in 2004. Their conclusion was that there was no criminal intent but that the incidents had happened as a matter of chance. Strategies to reduce the chances of these events recurring were recommended. Recommendation 1 states “The MHRA should recommend to manufacturers and the relevant Standards Committees that ….. detachable caps (eg. On intravenous cannulae and giving sets) be manufactured in brightly coloured material, preferably red, to aid visibility”.
No action appears to have been taken in consequence of this.
(3) The SUI report goes on to indicate that none of the team undertaking the operation were aware that the bulb syringe came supplied with a cap. The previous brand used by the Trust was not supplied with a syringe cap. The current bulb syringes in use obviously do have a cap but this is normally removed by the scrub practitioner before the syringe is supplied to the operating surgeon. Thus there has been little opportunity for surgeons to appreciate that syringes now have caps. This underlines the importance of ensuring that such devices are manufactured with a brightly coloured cap, if one is to be used at all.
(4) There appears to be no standard procedure for checking for syringe caps (where used) at the end of the operation, such as there is with swabs. The evidence available to me suggests that items such as syringe caps are just discarded by the scrub practitioner without being retained for counting. Of course, the fact that some syringes are apparently manufactured with a cap and others without complicates the situation but is not actually a bar to counting the number of caps present at the outset of the operation.
” 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 implement recommended strategies to reduce recurrence of plastic obstruction incidents
Wider context from the report “(1) If a simple precaution was taken in ensuring that the tip of a bulb syringe or similar was a different colour to the rest of the equipment then it is difficult to see how a surgeon could use a syringe with the tip still in place by error. As the attached photograph shows there is no significant difference between the syringe with the tip on or off.
(2) There is a further concern in respect of other information which is contained with the Trust’s SUI report as follows:
It is perhaps of some relevance that in 2001-2 a number of instances of items of anaesthetic airway equipment being blocked with extraneous pieces of plastic and causing harm to patients were the subject of a national police investigation (Operation Cordian). The police findings were examined by an Expert Group, which published a series of recommendations in 2004. Their conclusion was that there was no criminal intent but that the incidents had happened as a matter of chance. Strategies to reduce the chances of these events recurring were recommended. Recommendation 1 states “The MHRA should recommend to manufacturers and the relevant Standards Committees that ….. detachable caps (eg. On intravenous cannulae and giving sets) be manufactured in brightly coloured material, preferably red, to aid visibility”.
No action appears to have been taken in consequence of this.
(3) The SUI report goes on to indicate that none of the team undertaking the operation were aware that the bulb syringe came supplied with a cap. The previous brand used by the Trust was not supplied with a syringe cap. The current bulb syringes in use obviously do have a cap but this is normally removed by the scrub practitioner before the syringe is supplied to the operating surgeon. Thus there has been little opportunity for surgeons to appreciate that syringes now have caps. This underlines the importance of ensuring that such devices are manufactured with a brightly coloured cap, if one is to be used at all.
(4) There appears to be no standard procedure for checking for syringe caps (where used) at the end of the operation, such as there is with swabs. The evidence available to me suggests that items such as syringe caps are just discarded by the scrub practitioner without being retained for counting. Of course, the fact that some syringes are apparently manufactured with a cap and others without complicates the situation but is not actually a bar to counting the number of caps present at the outset of the operation.
” 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 operating staff are aware that bulb syringes are supplied with caps
Wider context from the report “(1) If a simple precaution was taken in ensuring that the tip of a bulb syringe or similar was a different colour to the rest of the equipment then it is difficult to see how a surgeon could use a syringe with the tip still in place by error. As the attached photograph shows there is no significant difference between the syringe with the tip on or off.
(2) There is a further concern in respect of other information which is contained with the Trust’s SUI report as follows:
It is perhaps of some relevance that in 2001-2 a number of instances of items of anaesthetic airway equipment being blocked with extraneous pieces of plastic and causing harm to patients were the subject of a national police investigation (Operation Cordian). The police findings were examined by an Expert Group, which published a series of recommendations in 2004. Their conclusion was that there was no criminal intent but that the incidents had happened as a matter of chance. Strategies to reduce the chances of these events recurring were recommended. Recommendation 1 states “The MHRA should recommend to manufacturers and the relevant Standards Committees that ….. detachable caps (eg. On intravenous cannulae and giving sets) be manufactured in brightly coloured material, preferably red, to aid visibility”.
No action appears to have been taken in consequence of this.
(3) The SUI report goes on to indicate that none of the team undertaking the operation were aware that the bulb syringe came supplied with a cap . The previous brand used by the Trust was not supplied with a syringe cap. The current bulb syringes in use obviously do have a cap but this is normally removed by the scrub practitioner before the syringe is supplied to the operating surgeon. Thus there has been little opportunity for surgeons to appreciate that syringes now have caps . This underlines the importance of ensuring that such devices are manufactured with a brightly coloured cap, if one is to be used at all.
(4) There appears to be no standard procedure for checking for syringe caps (where used) at the end of the operation, such as there is with swabs. The evidence available to me suggests that items such as syringe caps are just discarded by the scrub practitioner without being retained for counting. Of course, the fact that some syringes are apparently manufactured with a cap and others without complicates the situation but is not actually a bar to counting the number of caps present at the outset of the operation.
” Open source report
13 Dec 2013 STEPHANIE DANIELS · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 9 Failure to complete and record patient observations View source Lack of nurse review of recent records during admission or transfer handover View source Delays in admission to an appropriate mental health bed View source Failure to properly clerk in mental health patients View source Failure to implement handover policies in practice View source Lack of clinical supervision and guidance for junior medical staff View source Failure to conduct prompt, thorough and independent investigations of serious patient deaths View source Failure of junior medical staff to review clinical records and history before prescribing medication View source Lack of a reliable method for notifying the responsible Consultant of patient admission View source See 6 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
STEPHANIE DANIELS · 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
Stephanie Daniels, who had a history of serious mental health problems and repeated self-harm, was admitted to the Safire unit on 22 March 2012 after a delay in securing an inpatient bed. She died there on 24 March 2012 after being found unconscious with a ligature around her neck. The principal concerns included inadequate observation and handover, failure to clerk her in, medication-recording and supervision problems, failures in the emergency response, and deficiencies in the subsequent internal investigation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and record patient observations
Wider context from the report “8. Performing and recording observations on other patients
I was concerned about the discovery of incomplete written observations for another patient where there are significant gaps in the records and may illustrate a systemic problem because the patient was transferred to a different ward. This was only discovered during the course of the inquest and was brought to the attention of MHSC so that they could carry out their own investigations.
” 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 nurse review of recent records during admission or transfer handover
Wider context from the report “2. Handover
All the evidence showed that the handover of information between nursing and clinical colleagues was a vital piece in the jigsaw of care. MHSC have introduced a new policy but I have a concern that simple issues may be overlooked. For new patients being admitted or transferred, there is no requirement for the nurse in charge to review their recent records . MHSC have produced new or updated policies/protocols but experience has shown that what may be delivered on paper is not being done in practice. Consequently, I am concerned that without appropriate audit and clinical/nursing leadership this may prove to be ineffective.
” 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 admission to an appropriate mental health bed
Wider context from the report “3. Bed Availability
MHSC say that following the death of the deceased, a new policy has been introduced so that there is no waiting time at all for the allocation of a bed in the case of a patient who is deemed clinically to require one. A bed will be found somewhere which will be appropriate to their needs. As I understood the evidence from the CCG in the case this should have occurred in any event. However, other NHS Trusts nationwide who do not have such a policy, may have patients whose delayed admission means that they are not having the appropriate nursing and clinical input, as well as medication review . In turn this means their condition may continue to deteriorate and when effective care does start, the patient may well be more ill than they should be. I am concerned that the importance of this is recognised not only by MHSC but nationally for all other NHS mental health trusts.
” 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 clerk in mental health patients
Wider context from the report “4. Clerking In
The failure to properly clerk in the patient is a matter of serious concern , especially as many such patients will have physical health problems. MHSC had clear policies requiring the clerking in of a patient, but these were simply not adhered to . It is very common for patients with mental health problems to have associated physical conditions which require appropriate monitoring and treatment. It seems that despite the existence of appropriate policies, in practice these were not being complied with . Whether or not any new or different policy or auditing of compliance is the way to achieve uniformity is a matter for MHSC. I repeat what I have said earlier. MHSC have produced new or updated policies/protocols but experience has shown that what may be delivered on paper is not being done in practice. Consequently, I am concerned that without appropriate audit and clinical/nursing leadership this may prove to be ineffective.
” 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 implement handover policies in practice
Wider context from the report “2. Handover
All the evidence showed that the handover of information between nursing and clinical colleagues was a vital piece in the jigsaw of care. MHSC have introduced a new policy but I have a concern that simple issues may be overlooked. For new patients being admitted or transferred, there is no requirement for the nurse in charge to review their recent records. MHSC have produced new or updated policies/protocols but experience has shown that what may be delivered on paper is not being done in practice . Consequently, I am concerned that without appropriate audit and clinical/nursing leadership this may prove to be ineffective .
” 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 clinical supervision and guidance for junior medical staff
Wider context from the report “5. Supervision of Junior Medical Staff
I am concerned about the lack of appropriate clinical supervision and guidance for junior medical staff . Two junior doctors were asked to attend the ward and made no appropriate clinical records of the reason for their attendance, reviewing the records, seeing the patient and explaining any clinical decision to prescribe medication. It is appreciated that they are busy with a number of duties but it is a matter of concern that they did not undertake basic clinical recording duties for a patient who clearly should have been seen. They did not notice that the patient had not been clerked in. Medication was being prescribed without adequate consideration of the relevant clinical history. They did not notice the named Consultant in charge of the patient was unaware of the admission. Appropriate clinical supervision would be expected to ensure an appropriate standard of performance. I understand that supervision may be delegated by the North West Deanery to the relevant NHS Trust but there has to be some basic accepted levels of interaction, communication and supervision between the junior Doctors and their Consultants to ensure an appropriate standard and continuity of care. This may be a joint responsibility between the Deanery and the NHS trust involved.
” 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 prompt, thorough and independent investigations of serious patient deaths
Wider context from the report “1. Internal NHS SUI Investigation v Independent Investigation
I am concerned that a death such as this of either a detained or voluntary patient (where Article 2 is arguably engaged) requires a prompt, thorough and robust investigation to be completed as soon as possible. Deficiencies in systems, protocols, policies, record keeping and individual actions need to be identified quickly and remedial action taken. This cannot wait for an inquest which may not take place for many months. This was not the first case of a poor or incomplete SUI investigation. The court was aware of and invited submissions about the recent case of R (Antoniou) v Central and North West London NHS Foundation Trust and others [2013] EWHC 3055 (Admin).
In this case there were significant errors and omissions in the SUI investigation . Important witnesses were not interviewed. The delay in finding the deceased a bed was not a central issue and no specific findings were made about it. The medication recording errors had not been noted and had the deceased been injected with PRN Haloperidol for severe agitation, then she should have been subject to physical observations for a continuous period of time immediately afterwards, as well as other steps in compliance with the Trust’s Rapid Tranquilisation Policy. It is accepted that SUI investigations are important and hope to learn lessons quickly to be implemented. Whilst the current law indicated that it is not a requirement for there to be an independent investigation at that stage, it is a matter of concern that very significant failures in the investigative process have occurred. The Trust investigation did not reveal at all the allegation of the commencement of discreet continuous observations on the morning of 24th March.
This is not the first time that the Trust SUI investigations have been found to be flawed and I have experience of other Trusts’ investigations also being significantly flawed. In conclusion in this sort of case I am concerned that without appropriately speedy and thorough independent investigation commissioned by the NHS Trust involved, flawed SUI investigation reports may continue to be produced . This is a policy decision for the NHS but I strongly urge consideration of this.
” 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 junior medical staff to review clinical records and history before prescribing medication
Wider context from the report “6. Prescribing of Medication by Junior Medical Staff
I am concerned by the circumstances in this case where medication came to be prescribed. There is an overlap of my concerns about supervision and my observations at paragraph 5 above should be regarded as repeated here. Both junior doctors had no recollection of attending the ward, speaking to the staff or seeing the patient. They simply prescribed the medication. They had no recollection of reviewing the deceased’s records and understood that was essential when considering prescribing any medication, and in particular PRN rapid tranquillisation. In this case, the patient was already taking a number of drugs which had sedative effects. Two further medications were introduced that have similar properties and that also could potentially affect heart function.
” 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 reliable method for notifying the responsible Consultant of patient admission
Wider context from the report “7. Mechanism by which the Consultant in charge of the patient would learn of the patient’s admission
It is of concern that there was apparently no simple method of ensuring that the Consultant in whose name the patient was admitted became aware of the admission and could therefore ensure appropriate clinical leadership and review was undertaken. It would seem that there could be a number of simple solutions for this problem.
” Open source report
28 Nov 2013 Doris Phoebe Miller · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 3 Unavailability of a pulse oximeter in the GP surgery View source Lack of an effective communication system between GP surgeries and district nurses View source Failure to provide the GP surgery with access to transferred patient records 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
Doris Phoebe Miller · 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
The circumstances of Doris Phoebe Miller’s death are not provided in the supplied text. Concerns included the GP surgery’s lack of access to her transferred medical records, ineffective communication about an urgent blood test, and the absence of a pulse oximeter at the surgery.
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 a pulse oximeter in the GP surgery
Wider context from the report “(3) During the inquest hearing it became apparent that the surgery at Broughton Gate did not have access to a pulse oximeter to measure Mrs Miller’s oxygenation . This is a relatively inexpensive item and should perhaps be available in every doctor’s surgery throughout the country.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective communication system between GP surgeries and district nurses
Wider context from the report “(2) On the 23rd July 2013 the GP had requested the district nurses to attend Mrs Miller to carry out an urgent blood test. The GP was dismayed to discover a week later that the call out sample had not been taken and that the results, therefore, were not available to her. There appears to be no system for effective communication between the GP surgery and the district nurses . Again this gives rise to a concern that lives may be at risk.
” 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 surgery with access to transferred patient records
Wider context from the report “(1) Mrs Miller’s notes and records were unavailable to the GP surgery at Broughton Gate despite having been transferred to the surgery , following the closure of the Willen practice in April 2013. Indeed I was informed by a GP who gave evidence before me that she was still, in November 2013, unable to access the patient records . Over 2000 patients were transferred to Broughton Gate and if the circumstance above continues there is a possibility that lives will be put at risk.
” Open source report
11 Nov 2013 Kathleen Rosemary Dixon · Prevention of Future Deaths report South and East Cumbria
View report summary
Concerns raised 1 Repetition of similar unsafe circumstances 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
Kathleen Rosemary Dixon · 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
Kathleen Rosemary Dixon was receiving treatment for mental illness that was escalating, but its severity was not recognised by those treating her, and she drowned in a river. The concern raised was that similar circumstances had occurred in previous inquests and that the Trust should be assessed independently.
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 Repetition of similar unsafe circumstances
Wider context from the report “(1) This is a repetition of similar circumstances in a number of previous Inquests and I think the Trust needs to be assessed independently.
” Open source report
Concerns raised 3 Failure of regular external inspections to recognize relevant physical safety matters View source Failure to cover or otherwise maintain safe temperatures for exposed heating pipes and valves View source Lack of risk assessment of room-specific physical safety for individual residents View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Walter Gordon Powley · 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
Walter Gordon Powley died after falling against uncovered radiator pipes and valves at a care and nursing home, sustaining burns to his legs. The report raised concerns about the high temperature of uncovered pipework, the absence of risk assessment of the room’s physical circumstances, and inspection bodies not identifying these issues. The inquest also identified inadequate ongoing risk assessments and failures to adhere to procedures for giving and recording medication as contributing factors.
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 regular external inspections to recognize relevant physical safety matters
Wider context from the report “3.Western Park View had been inspected by the Care Quality Commission and the Local Authority on a regular basis. Evidence indicated that these matters referred to had not been recognized by those bodies.
” 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 cover or otherwise maintain safe temperatures for exposed heating pipes and valves
Wider context from the report “1.Neither the pipes that he fell against nor the valves that connected those pipes to the radiator, were covered. HSE published guidance indicated that the maximum temperature of such pipes should be 43 degrees centigrade . Readings taken from uncovered pipes both in Mr Powley’s room and other rooms in the Home indicated that the temperatures ranged between 60 degrees centigrade and more than 70 degrees centigrade . Evidence was given at the Inquest that a number of other residential homes in this area did not have pipes and valves covered. It may well be therefore that this applies throughout the country.
” 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 risk assessment of room-specific physical safety for individual residents
Wider context from the report “2.It was therefore also apparent that there had not been a risk assessment of the physical circumstances in that room, and whether it was therefore safe for a particular resident .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the way adult social care inspections are conducted.
Verbatim wording from the response “Our local compliance inspector did inspect the location in May 2012 and reviewed seven outcomes or regulations. Unfortunately they did not inspect against Regulation 15, Outcome 10. We are currently reviewing the way in which we inspect in adult social care and are piloting a new methodology very soon. Instead of the current outcomes we will be assessing against five domains and ask five questions:” Source location 2013-0251-Response-by-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 Pilot a new adult social care inspection methodology using five assessment domains.
Verbatim wording from the response “Our local compliance inspector did inspect the location in May 2012 and reviewed seven outcomes or regulations. Unfortunately they did not inspect against Regulation 15, Outcome 10. We are currently reviewing the way in which we inspect in adult social care and are piloting a new methodology very soon. Instead of the current outcomes we will be assessing against five domains and ask five questions:” Source location 2013-0251-Response-by-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 Explore how the new inspection methodology can ensure inspectors check high-risk areas.
Verbatim wording from the response “I welcome the timeliness of your report and will share its findings within my organisation; there are definitely lessons to be learnt from this very sad situation, which includes exploring the ways in which we can work more closely with the HSE and how we can ensure, within our new methodology, that our inspectors are checking high-risk areas such as this.” Source location 2013-0251-Response-by-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 provider has ultimate responsibility for identifying and monitoring unsafe conditions and taking appropriate action.
Verbatim wording from the response “The provider has the ultimate responsibility for ensuring that they know and monitor any unsafe conditions in the service and take the correct action.” Source location 2013-0251-Response-by-Care-Quality-Commission
Open published response
23 Sep 2013 Yvonne Sydney Annie Perry · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 2 Lack of a robust process for tracking review of radiology reports by emergency department consultants View source Lack of access to electronic hospital notes and records for GPs attending the Windsor Intermediate Care Unit 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
Yvonne Sydney Annie Perry · 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
Yvonne Sydney Annie Perry fractured her left hip after a fall at home, and the possibility of the fracture identified on 19 December 2012 was not acted upon until early January 2013. She later developed a severe urinary tract infection and died of sepsis on 2 February 2013; concerns included the lack of a robust process for tracking radiology reports and the absence of GP access to electronic hospital notes and records.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of a robust process for tracking review of radiology reports by emergency department consultants
Wider context from the report “(1) That the x-ray taken of Mrs. Perry’s hip, reported on by the consultant radiologist on the 19th December 2012, was not acted upon until the 3rd January 2013. It was recognised that the Hospital “do not have a robust process for tracking that the emergency department consultants have looked at the radiology reports.” Without such a system I believe further deaths may occur in the future.
” 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 access to electronic hospital notes and records for GPs attending the Windsor Intermediate Care Unit
Wider context from the report “(2) The GPs who attend the Windsor Intermediate Care Unit do not have access to the electronic hospital notes and records and those witnesses from WICU who attended the inquest considered that such access would improve the care afforded to patients. Similarly without access to the patients notes further deaths may occur in the future.
” Open source report
23 Sep 2013 Sally King · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 3 Failure to provide Pain Team assessment during hospital admission View source Failure to provide care and treatment on the appropriate ward or department View source Lack of beds delaying transfer to the Respiratory Team 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
Sally King · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sally King was admitted to Milton Keynes Hospital after falling from her chairlift on 22 December 2012 and sustaining a fractured femur and ribs; the inquest concluded that she died as a result of an accident. Concerns included the failure of the Pain Team to see her during an admission of over three weeks and delays in transferring her to the Respiratory Team because of a lack of beds, with the transfer occurring on the day 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 provide Pain Team assessment during hospital admission
Wider context from the report “(1) Mrs. King was a patient in the hospital for over three weeks and despite numerous attempts to involve the Pain Team they proved unsuccessful and she was not seen by the team during her admission .
” 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 care and treatment on the appropriate ward or department
Wider context from the report “(2) ████████ a Consultant Orthopaedic Surgeon, in his evidence told me, “after three weeks of asking, the Respiratory Team eventually agreed to take over Mrs. King’s care. However her transfer was delayed due to lack of beds on ward 16.” Mrs. King was eventually transferred on the 6th February, the very day that she died. It would seem that she was not being cared for and treated on the appropriate ward or department .
” 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 beds delaying transfer to the Respiratory Team
Wider context from the report “(2) ████████ a Consultant Orthopaedic Surgeon, in his evidence told me, “after three weeks of asking, the Respiratory Team eventually agreed to take over Mrs. King’s care. However her transfer was delayed due to lack of beds on ward 16 .” Mrs. King was eventually transferred on the 6th February, the very day that she died. It would seem that she was not being cared for and treated on the appropriate ward or department.
” Open source report
19 Sep 2013 Daniel Onley · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 3 Insufficient supervision to safeguard safety and wellbeing View source Failure to manage risks associated with medication management View source Insufficient arrangements to support taking anti-convulsant medication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Daniel Onley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daniel Onley, a resident at Orchard House, was found face down in his bath on 22 June 2012 and was concluded to have died from sudden unexplained death in epilepsy. Concerns included insufficient support for taking anti-convulsant medication, inadequate management of medication-related risks, and insufficient evening supervision.
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 supervision to safeguard safety and wellbeing
Wider context from the report “(3) The supervision provided to Daniel during the evening of Thursday 21st June 2012 was not sufficient to safeguard Daniel’s safety and wellbeing .
” 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 manage risks associated with medication management
Wider context from the report “(2) There had been a failure to manage risks associated with Daniel’s management of his medication .
” 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 arrangements to support taking anti-convulsant medication
Wider context from the report “(1) That the arrangements in place to support Daniel to take his anti-convulsant medication were insufficient .
” Open source report
20 Aug 2013 Mohammed Mozammel Hussain CHAUDHURY · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 7 Failure to follow pressure sore prevention guidance View source Deficiencies in pressure sore care planning and specialist referral View source Failure to establish safe staffing levels for unconscious patients requiring regular turning View source Failure to turn patients at the required frequency View source Insufficient nursing staffing capacity View source Inconsistent pressure sore risk scoring View source Failure of nursing care to prevent and manage pressure sores View source See 4 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
Mohammed Mozammel Hussain CHAUDHURY · 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
Mohammed Chaudhury suffered multiple injuries in a traffic collision and later developed five severe, septic pressure sores while in hospital. The report raised concerns about inadequate turning, incomplete care planning and tissue-viability referrals, inconsistent risk scoring, shortages in nursing staff, and uncertainty about whether staffing levels for unconscious patients requiring regular turning were safe.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to follow pressure sore prevention guidance
Wider context from the report “(2) Professional evidence confirmed that this was due to failure to turn regularly. 2 hourly turning was required, although this was not prescribed by tissue viability nurses or doctors. There were missing care plans, gaps in plans and delays in referral to TVN. Waterlow scoring was not consistent. Days were recorded when there were only 2, 3, 4, 5 or 6 turns per day. NICE guidance was not being followed . Some improvements in training and reporting have been reported.
” 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 pressure sore care planning and specialist referral
Wider context from the report “(2) Professional evidence confirmed that this was due to failure to turn regularly. 2 hourly turning was required, although this was not prescribed by tissue viability nurses or doctors. There were missing care plans, gaps in plans and delays in referral to TVN . Waterlow scoring was not consistent. Days were recorded when there were only 2, 3, 4, 5 or 6 turns per day. NICE guidance was not being followed. Some improvements in training and reporting have been reported.
” 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 safe staffing levels for unconscious patients requiring regular turning
Wider context from the report “(4) Although the ward has since been restructured and takes different cases, it was not possible to conclude that current staffing levels in the hospital for unconscious patients requiring regular turning were safe , as comparisons were difficult and the judgement required professional and managerial opinion.
” 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 turn patients at the required frequency
Wider context from the report “(2) Professional evidence confirmed that this was due to failure to turn regularly . 2 hourly turning was required, although this was not prescribed by tissue viability nurses or doctors. There were missing care plans, gaps in plans and delays in referral to TVN. Waterlow scoring was not consistent. Days were recorded when there were only 2, 3, 4, 5 or 6 turns per day . NICE guidance was not being followed. Some improvements in training and reporting have been reported.
” 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 nursing staffing capacity
Wider context from the report “(3) Nursing rotas for the period were not available. Some days were reported as below establishment . (8 by day and 6 by night for 31 patients of which at least a ¼ were high dependency). Not all bank shifts were filled .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Inconsistent pressure sore risk scoring
Wider context from the report “(2) Professional evidence confirmed that this was due to failure to turn regularly. 2 hourly turning was required, although this was not prescribed by tissue viability nurses or doctors. There were missing care plans, gaps in plans and delays in referral to TVN. Waterlow scoring was not consistent . Days were recorded when there were only 2, 3, 4, 5 or 6 turns per day. NICE guidance was not being followed. Some improvements in training and reporting have been reported.
” 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 nursing care to prevent and manage pressure sores
Wider context from the report “(1) Infected pressure sores may have been a cause of death and they were unusual in extent and severity. Their development was prevented in ITU when he was most at risk and considerable improvement was achieved in the nursing home after discharge. Their development and deterioration related to nursing care on Murray Falconer ward in KCH between 27th September and 9th December.
” Open source report
13 Aug 2013 Vera Lillian STEEL · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Limited availability of fire-protective clothing for smokers in care homes 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
Vera Lillian STEEL · 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
Vera Lillian STEEL, a resident of Glebe Nursing Home, suffered severe burns after dropping a lit match into her lap while attempting to smoke on the garden terrace on 24 March 2012. She died later that evening despite treatment; the principal concern was the availability and use of fire-protective clothing for smokers in care homes and similar settings.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Limited availability of fire-protective clothing for smokers in care homes
Wider context from the report “The deceased who had full testamentary capacity, was either bedbound or in a wheel chair. She insisted on smoking. She was extremely frail and tried to light a cigarette using a match. She apparently managed to strike one but she then dropped it (the lit match) into her lap. Her cotton night dress caught fire and she received burns. In the course of evidence we received evidence how it is now possible to obtain a fire protective apron or smock that could be worn or draped over the smoker so that any such incident would result in the match (or a lit cigarette) burning out without any damage to the clothing or smoker. With many fatal domestic fires being caused by the “incautious disposal of smoking products” this sort of pro-active clothing could be more widely available and those places (such as care homes) who residents may include smokers should be encouraged to provide access to these protective measures .
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations