9 Oct 2018 Tom Cribley · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 12 Failure to document important clinical findings View source Insufficient clinical staff training in identifying and treating sepsis View source Failure to escalate monitoring and management after grossly abnormal blood results View source Failure of senior leadership ownership of training programme implementation and review View source Failure to maintain systematic and monitored ongoing sepsis training View source Failure to complete full PIT STOP reviews View source Failure to hand over clinical concerns to relevant clinical staff View source Failure to escalate and convey the severity of deterioration to the Critical Care Team View source Failure to review an initial diagnosis when the patient deteriorates View source Delays in escalating NEWS to medical staff View source Delays in administering antibiotic therapy during clinical deterioration View source Failure to repeat observations hourly in accordance with the NEWS policy View source See 9 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
Tom Cribley · 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
Tom Cribley attended Aintree hospital on 18 February 2017 with vomiting, diarrhoea and a rash, and was later diagnosed with meningococcal sepsis. The report identifies concerns including failures to document and escalate the rash and deteriorating observations, inadequate handovers and reassessment, delayed recognition of abnormal blood results, and delayed antibiotic treatment. Tom did not recover and died on 20 February 2017.
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 document important clinical findings
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage . The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” 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 clinical staff training in identifying and treating sepsis
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate monitoring and management after grossly abnormal blood results
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results , the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of senior leadership ownership of training programme implementation and review
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board . This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain systematic and monitored ongoing sepsis training
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness .
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to complete full PIT STOP reviews
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review , the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” 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 hand over clinical concerns to relevant clinical staff
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers , the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate and convey the severity of deterioration to the Critical Care Team
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team , who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” 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 review an initial diagnosis when the patient deteriorates
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate , the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” 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 escalating NEWS to medical staff
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” 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 administering antibiotic therapy during clinical deterioration
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” 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 repeat observations hourly in accordance with the NEWS policy
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy . The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report
19 Sep 2018 Hubert Kelly · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 4 Absence of permanent medically qualified staff in the waiting area View source Excessive waiting times for patients to be seen by clinicians in the emergency department View source Failure to provide meaningful interaction with patients awaiting further assessment View source Lack of suitable space or resources for patients awaiting further assessment 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
Hubert Kelly · 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
Hubert Kelly was taken to hospital on the evening of 13 November 2017 after his health deteriorated and waited for four hours in a wheelchair in the emergency department with his family. Nursing staff later found that he had died, and concerns included patients waiting in corridors without meaningful interaction or permanent medically qualified staff, with waits of up to seven hours for clinical assessment.
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 Absence of permanent medically qualified staff in the waiting area
Wider context from the report “1. Evidence emerged during the inquest that following triage assessment nursing staff lacked room or resources to allow patients to remain in the ambulance triage area or in a cubicle and consequently patients were left to wait in corridors;
2. There was no meaningful interaction with patients waiting for further assessment including no permanent medically qualified staff in the waiting area ;
3. Waiting times at the emergency department were frequently exceeding the four-hour waiting time set nationally, with patients waiting to be seen by clinicians for up to seven hours.
” 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 Excessive waiting times for patients to be seen by clinicians in the emergency department
Wider context from the report “1. Evidence emerged during the inquest that following triage assessment nursing staff lacked room or resources to allow patients to remain in the ambulance triage area or in a cubicle and consequently patients were left to wait in corridors;
2. There was no meaningful interaction with patients waiting for further assessment including no permanent medically qualified staff in the waiting area;
3. Waiting times at the emergency department were frequently exceeding the four-hour waiting time set nationally , with patients waiting to be seen by clinicians for up to seven hours .
” 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 meaningful interaction with patients awaiting further assessment
Wider context from the report “1. Evidence emerged during the inquest that following triage assessment nursing staff lacked room or resources to allow patients to remain in the ambulance triage area or in a cubicle and consequently patients were left to wait in corridors;
2. There was no meaningful interaction with patients waiting for further assessment including no permanent medically qualified staff in the waiting area;
3. Waiting times at the emergency department were frequently exceeding the four-hour waiting time set nationally, with patients waiting to be seen by clinicians for up to seven hours.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of suitable space or resources for patients awaiting further assessment
Wider context from the report “1. Evidence emerged during the inquest that following triage assessment nursing staff lacked room or resources to allow patients to remain in the ambulance triage area or in a cubicle and consequently patients were left to wait in corridors ;
2. There was no meaningful interaction with patients waiting for further assessment including no permanent medically qualified staff in the waiting area;
3. Waiting times at the emergency department were frequently exceeding the four-hour waiting time set nationally, with patients waiting to be seen by clinicians for up to seven hours.
” Open source report
27 Jul 2018 Mrs Natalie Billingham · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 4 Delays in assessing available blood results View source Failure to administer antibiotics at an earlier stage View source Failure to recognise the development of sepsis View source Inadequate communication 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
Mrs Natalie Billingham · 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
Mrs Natalie Billingham was admitted to hospital with worsening foot pain, later developed necrotising fasciitis, underwent emergency surgery including a through-knee amputation, and died on the evening of 2 March 2018. The report identified concerns about inadequate communication and delays in reviewing abnormal blood results, recognising sepsis, and administering antibiotics.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Delays in assessing available blood results
Wider context from the report “1. Evidence emerged during the inquest that there was inadequate communication and delays in assessing the blood results when available . There were also missed opportunities for administering antibiotics at an earlier stage and recognising the development of sepsis.
” 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 administer antibiotics at an earlier stage
Wider context from the report “1. Evidence emerged during the inquest that there was inadequate communication and delays in assessing the blood results when available. There were also missed opportunities for administering antibiotics at an earlier stage and recognising the development of sepsis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the development of sepsis
Wider context from the report “1. Evidence emerged during the inquest that there was inadequate communication and delays in assessing the blood results when available. There were also missed opportunities for administering antibiotics at an earlier stage and recognising the development of sepsis .
” 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 communication
Wider context from the report “1. Evidence emerged during the inquest that there was inadequate communication and delays in assessing the blood results when available. There were also missed opportunities for administering antibiotics at an earlier stage and recognising the development of sepsis.
” Open source report
25 Jul 2018 Jane Olive Parker · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure of the diet preparation system to provide food in the correct format before serving View source Lack of care assistant understanding of modified diets and adherence requirements View source Lack of regular kitchen sorting and marking of food for residents with specific dietary requirements View source Lack of care assistant understanding and systems for escalating choking episodes to SALT 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
Jane Olive Parker · 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
Jane Olive Parker, who had dementia and a history of choking episodes, was found unresponsive approximately 40 minutes after eating an inappropriate meal unobserved in her room on 24 August 2016. Post-mortem examination found un-chewed food in her airway, and the recorded conclusion was death from aspiration of food, contributed to by neglect. Concerns included poor understanding and preparation of modified diets, and failures to escalate choking episodes to the Speech and Language Team for reassessment.
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 diet preparation system to provide food in the correct format before serving
Wider context from the report “2. Within the care home the system for preparing the correct diets types was such that food would come up to be served and would then need to be put into the correct format by the care staff . There was no regular system of the kitchen sorting and marking food to be served for individual residents with specific dietary requirements such as Mrs Parker. Following Mrs Parker’s death both the Local Authority in question and the Care Home provider had taken steps to improve systems within their care homes but it was unclear if there was national work in place to ensure care homes and their kitchens ensured clearly marked food was provided for residents with modified diets;
” 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 assistant understanding of modified diets and adherence requirements
Wider context from the report “1. There was poor understanding by the care home assistants of what was meant by the types of modified diets that could be recommended by the SALT teams . Following Mrs Parker’s death both the Local Authority in question and the Care Home provider had taken steps to improve knowledge within their care homes but it was unclear if there were national programmes to ensure that care assistants understood modified diets and the importance of adherence to them ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of regular kitchen sorting and marking of food for residents with specific dietary requirements
Wider context from the report “2. Within the care home the system for preparing the correct diets types was such that food would come up to be served and would then need to be put into the correct format by the care staff. There was no regular system of the kitchen sorting and marking food to be served for individual residents with specific dietary requirements such as Mrs Parker . Following Mrs Parker’s death both the Local Authority in question and the Care Home provider had taken steps to improve systems within their care homes but it was unclear if there was national work in place to ensure care homes and their kitchens ensured clearly marked food was provided for residents with modified diets ;
” 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 assistant understanding and systems for escalating choking episodes to SALT
Wider context from the report “3. In Mrs Parker’s case the Inquest heard that there were opportunities to escalate her case back to SALT after choking episodes. However there was limited understanding within the care home assistants of the need to report and escalate choking episodes to ensure that the SALT team provided expert input and reduced risk. Following Mrs Parker’s death both the Local Authority in question and the Care Home provider had taken steps to improve systems within their care homes but it was unclear if there was national work in place to ensure that there were appropriate systems in place to ensure that there were appropriate escalations to SALT .
” Open source report
16 Jul 2018 Sheila Winifred Ridgway · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Lack of a system for communication between treating specialty consultants about potential ongoing risks of simultaneous specialty-specific treatments 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
Sheila Winifred Ridgway · 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
Sheila Winifred Ridgway was treated for arterial disease in both legs and later developed a painful, cold, pulseless right leg after stopping dual antiplatelet therapy before a planned loop ECG recorder procedure. She subsequently developed diarrhoea, deteriorating renal function, low blood pressure and multi-organ failure due to sepsis, and died after escalation of treatment was considered futile. The principal concern was inadequate communication between specialty consultants about ongoing risks and treatment requirements.
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 system for communication between treating specialty consultants about potential ongoing risks of simultaneous specialty-specific treatments
Wider context from the report “1) Communication between specialty consultants – lack of any system to ensure that communication occurs between the treating consultants as to the necessity for identifying and documenting any potential ongoing risks when specialty specific treatments are being contemplated or planned for the different specialities simultaneously
” Open source report
29 Jun 2018 ASHLEY ERNEST NOTSON · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 2 Lack of a legal requirement for care-home carers to carry a mobile or portable telephone for summoning assistance View source Lack of a requirement for care providers to ensure that care-home carers have first-aid training 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
ASHLEY ERNEST NOTSON · 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
Ashley Notson died at age 55 after choking on a piece of meat at the care home where he lived, later dying in hospital from hypoxic brain injury resulting from the choking episode. The inquest raised concerns that the law did not require care-home carers to have first-aid training or to have access to a mobile or portable telephone to summon assistance without leaving the person they were caring for.
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 legal requirement for care-home carers to carry a mobile or portable telephone for summoning assistance
Wider context from the report “The inquest heard that the law currently does not require care providers to ensure that carers in a care home have had first aid training. Fortunately, the carer on duty at the time of incident was trained in first aid and did what he could to assist Ashley, but a similar situation could clearly arise in another care home without such a suitably trained carer present.
The inquest also heard that, at this care home, all carers carry a mobile or portable telephone so that they can summon assistance if an incident occurs without having to leave the person they are looking after , but that this was not a legal requirement either .
” 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 requirement for care providers to ensure that care-home carers have first-aid training
Wider context from the report “The inquest heard that the law currently does not require care providers to ensure that carers in a care home have had first aid training . Fortunately, the carer on duty at the time of incident was trained in first aid and did what he could to assist Ashley, but a similar situation could clearly arise in another care home without such a suitably trained carer present .
The inquest also heard that, at this care home, all carers carry a mobile or portable telephone so that they can summon assistance if an incident occurs without having to leave the person they are looking after, but that this was not a legal requirement either.
” Open source report
12 Jun 2018 Rita Taylor · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 10 Inadequate clinical documentation for care continuity View source Lack of consultant understanding of appropriate hyponatraemia management View source Failure of the serious incident report to fulfil its learning and accuracy obligations View source Failure to obtain appropriate specialist assistance for hyponatraemia management View source Failure to complete specialist consultation for hyponatraemia management View source Failure to follow recommended hyponatraemia monitoring and treatment guidelines View source Failure to create a coherent plan for managing diabetes insipidus and related fluid balance View source Failure to apply appropriate treatment for increasing serum potassium levels View source Lack of meaningful documentation in hospital notes View source Failure to establish a management plan for hyponatraemia View source See 7 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
Rita Taylor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Rita Taylor was admitted to hospital with severe hyponatraemia in the context of diabetes insipidus and a pituitary adenoma, and died on 15 August 2017 after developing central pontine myelinolysis. The principal concerns were failures to appropriately monitor and manage her sodium levels and diabetes insipidus, including omission of desmopressin, inadequate fluid-balance assessment, insufficient documentation, and lack of a coherent management plan.
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 Inadequate clinical documentation for care continuity
Wider context from the report “6. The documentation throughout Mrs Taylor’s admission until transfer to the high dependency unit was inadequate with no record of assessment or a coherent management plan in place to ensure appropriate care and continuity of that care for succeeding physicians to consider or to follow .
” 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 consultant understanding of appropriate hyponatraemia management
Wider context from the report “4. The apparent lack of understanding of the appropriate management of hyponatraemia by consultants whose care Mrs Taylor was under , despite two emergency consultant physicians having a specialist interest in endocrinology. Whilst some attempt was made to contact St George’s hospital this was not successfully followed through to assist them in their management.
” 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 serious incident report to fulfil its learning and accuracy obligations
Wider context from the report “7. As was acknowledged in Court, the SI report did not fulfil its obligations and it was agreed that it would be extensively re-written and re-presented to HM Coroner’s Court to more accurately reflect the circumstances of Mrs Taylor’s death and the learning points required to assist in preventing any future deaths .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain appropriate specialist assistance for hyponatraemia management
Wider context from the report “1. The failure to appropriately manage Mrs Taylor’s hyponatraemia by the on call consultant physician on the 31st July 2017 on the grounds that it was not his sphere of expertise. No contact was considered or made to someone who may have been able to assist leaving Mrs Taylor to languish overnight with no management plan in place and a lack of any meaningful documentation in her hospital notes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to complete specialist consultation for hyponatraemia management
Wider context from the report “4. The apparent lack of understanding of the appropriate management of hyponatraemia by consultants whose care Mrs Taylor was under, despite two emergency consultant physicians having a specialist interest in endocrinology. Whilst some attempt was made to contact St George’s hospital this was not successfully followed through to assist them in their management .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to follow recommended hyponatraemia monitoring and treatment guidelines
Wider context from the report “2. The failure, at any time between the 31st July 2017 and 5th August 2017 to follow the national recommended guidelines for the management and treatment of hyponatraemia, in particular the need to measure serum sodium regularly and to limit the rate of rise of serum sodium to prevent complications.
” 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 create a coherent plan for managing diabetes insipidus and related fluid balance
Wider context from the report “3. The failure, at any time between the 31st July 2017 until the 6th August 2017 to create a coherent plan for the management of Mrs Taylors medical problems resulting in the failure to assess fluid balance or to reintroduce desmopressin , given a known diagnosis of diabetes insipidus on a background of a pituitary adenoma.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to apply appropriate treatment for increasing serum potassium levels
Wider context from the report “5. The failure of an emergency consultant physician with an interest in endocrinology to understand that giving intravenous fluids with potassium is not an appropriate method to increase serum potassium levels, more so as Mrs Taylor at that time could eat and drink normally.
” 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 meaningful documentation in hospital notes
Wider context from the report “1. The failure to appropriately manage Mrs Taylor’s hyponatraemia by the on call consultant physician on the 31st July 2017 on the grounds that it was not his sphere of expertise. No contact was considered or made to someone who may have been able to assist leaving Mrs Taylor to languish overnight with no management plan in place and a lack of any meaningful documentation in her hospital notes .
” 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 a management plan for hyponatraemia
Wider context from the report “1. The failure to appropriately manage Mrs Taylor’s hyponatraemia by the on call consultant physician on the 31st July 2017 on the grounds that it was not his sphere of expertise. No contact was considered or made to someone who may have been able to assist leaving Mrs Taylor to languish overnight with no management plan in place and a lack of any meaningful documentation in her hospital notes.
” Open source report
7 Jun 2018 Kevin Freely · Prevention of Future Deaths report London (West)
View report summary
Concerns raised 1 Failure by patients and care organisations to heed safety guidance on fire hazards from paraffin-based skin products 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
Kevin Freely · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kevin Freely, aged 61, died at home on 12 October 2016 after a lighted cigarette caused his bedclothes to catch fire while he was bedbound and unable to escape. The principal concern was that warnings about the fire hazard associated with paraffin-based emollient skin products were not being heeded by patients and care organisations providing care in people’s homes.
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 by patients and care organisations to heed safety guidance on fire hazards from paraffin-based skin products
Wider context from the report “The NHS National Patient Safety Agency brought out a Rapid Response Report 4 on 26th November 2007 entitled “Fire hazard with paraffin based skin products on dressings and clothing”. I am concerned that this message within the 2007 Safety Report is not being heeded by patients and Care Organisations responsible for caring for patients in their own homes .
” Open source report
15 May 2018 Doris Mary Ridgwell · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3 Delays in authorising abnormal results onto the Clinical Manager system View source Omission of blood test results from discharge summaries View source Insufficiently clear procedures for telephoning abnormal coagulation results 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 Mary Ridgwell · 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
Doris Mary Ridgwell was admitted to hospital with knee swelling and pain, with an INR of 8.1 that was not successfully communicated to the ward or acted upon before her discharge. She was later admitted with a large subdural haematoma and intraventricular bleed, and the inquest determined that she died as a consequence of over-anticoagulation. Concerns included unclear procedures for communicating abnormal coagulation results, delays in making results available to healthcare professionals, and discharge summaries that did not include blood test results.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Delays in authorising abnormal results onto the Clinical Manager system
Wider context from the report “Abnormal results are not authorised onto the Clinical Manager system to be viewed by Healthcare professionals by Laboratory staff until they have telephoned the results through to the ward , which can potentially cause a delay in these being available on the 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 Omission of blood test results from discharge summaries
Wider context from the report “The Discharge summaries provided to GPs following discharge from Hospital do not include blood tests results , meaning a potential safeguard to check these results is missed ;
” 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 Insufficiently clear procedures for telephoning abnormal coagulation results
Wider context from the report “The Trust’s Standard Operating Procedure for Telephoning of Coagulation Results is not sufficiently clear regarding what action should be taken by staff in the Blood Sciences Department to ensure abnormal coagulation results are made known to the treating Healthcare professionals ;
- A new Standard Operating Procedure has been prepared, but having had sight of this, I do not believe this clearly outlines for Laboratory staff the steps to be taken in telephoning through abnormal Coagulation Results ;
” Open source report
14 May 2018 Gladys Kathleen Rich · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 8 Lack of a mechanism to ensure safe delivery and discharge of Falls Prevention Service input View source Failure of the Falls Prevention Service to proactively follow up required input View source Failure to transmit and resubmit completed falls action plans through the required process View source Failure to use appropriate falls referral thresholds View source Unavailability of required falls prevention equipment View source Failure to consider and action falls risk action plan advice View source Failure to make new falls prevention referrals after further falls View source Failure to identify falls risks during pre-assessment View source See 5 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
Gladys Kathleen Rich · 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
Gladys Kathleen Rich suffered repeated falls after moving into Avenue House Nursing and Care Home, culminating in a fall on 28 December 2016 that caused traumatic subdural and subarachnoid haemorrhages and a skull fracture. She died on 3 March 2017; the medical cause of death included chest infection, intracranial haemorrhage and a fall, with rectal cancer and liver metastases also recorded. The principal concerns related to failures to identify and manage her falls risk, ineffective referral and follow-up by the care home and Falls Prevention Service, inadequate resources and equipment, and the absence of an effective system to ensure required falls-prevention input was delivered.
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 mechanism to ensure safe delivery and discharge of Falls Prevention Service input
Wider context from the report “3. There does not seem to be any mechanism for ensuring that Falls Prevention Service input is in fact delivered when it is required and that a patient is only ever discharged or that it is clear that the underlying symptoms causing the falls are resolved or that measures have been put in place to mitigate the falls 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 of the Falls Prevention Service to proactively follow up required input
Wider context from the report “2. In relation to the Falls Prevention Service.
a) Despite Mrs Rich having been referred to the Falls Prevention Service by her GP and the service being notified of a fall related hospitalisation in August 2016, the onus was placed on the patient and her family to make a further appointment . In the absence of any further contact, the service assumes that their input is no longer required . As is clear in the case of Mrs Rich, the prevention service was very much still required. Again, when the service was contacted in November 2016 the failure to receive a form or a response to the subsequent letter again led to an automatic assumption that input was no longer required despite the fact that this was the second referral to have been made in relation to Mrs Rich. It was explained in evidence that the reason the service cannot be more proactive is because they are inadequately resourced .
” 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 transmit and resubmit completed falls action plans through the required process
Wider context from the report “c) Once a referral was made, and a falls risk action plan was received the advice within does not appear to have been properly considered or actioned. Furthermore, the action plan was returned to the Falls Prevention Service by post rather than the required method of facsimile . Although the care home was notified that the Falls Prevention Service had not received the completed action plan, it was not resubmitted . Despite Mrs Rich then suffering a series of further falls, no new referrals were made to the Falls Prevention Service.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to use appropriate falls referral thresholds
Wider context from the report “b) The policy of waiting for 3 falls before making a referral seems to be arbitrary and also at odds with the Fall Prevention Service requirement of 1 fall within a 12 month period before a referral will be accepted .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Unavailability of required falls prevention equipment
Wider context from the report “d) The care home may not have some of the equipment that they require for patients such as Mrs Rich e.g. a bed sensor mat .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to consider and action falls risk action plan advice
Wider context from the report “c) Once a referral was made, and a falls risk action plan was received the advice within does not appear to have been properly considered or actioned . Furthermore, the action plan was returned to the Falls Prevention Service by post rather than the required method of facsimile. Although the care home was notified that the Falls Prevention Service had not received the completed action plan, it was not resubmitted. Despite Mrs Rich then suffering a series of further falls, no new referrals were made to the Falls Prevention Service.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to make new falls prevention referrals after further falls
Wider context from the report “c) Once a referral was made, and a falls risk action plan was received the advice within does not appear to have been properly considered or actioned. Furthermore, the action plan was returned to the Falls Prevention Service by post rather than the required method of facsimile. Although the care home was notified that the Falls Prevention Service had not received the completed action plan, it was not resubmitted. Despite Mrs Rich then suffering a series of further falls, no new referrals were made to the Falls Prevention Service .
” 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 identify falls risks during pre-assessment
Wider context from the report “a) Failure to identify Mrs Rich as a falls risk during a pre-assessment process , despite the fact that she had sustained a fall requiring hospitalisation 9 months before. The pre-assessment check may not therefore be sufficiently robust .
” Open source report
8 May 2018 WILLIAM DICKENS · Prevention of Future Deaths report London Inner (South)
View report summary
Concerns raised 2 Failure to make contemporaneous observation-log entries View source Failure to conduct required ward patient observations 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
WILLIAM DICKENS · 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 DICKENS, who was assessed as at high risk of repeat self-harm, died on 10 May 2017 after being discovered hanging by a belt from the bed in his room at a mental health unit. The report raises concerns that required intermittent observations were not carried out, that observation-log entries were made after the event, and that defects in the logging process could create a risk of future deaths.
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 make contemporaneous observation-log entries
Wider context from the report “(1) From 10 am on the morning of 10 May 2017 the observation regime for the ward was not complied with. While there are notes on the observation log suggesting that some patients had been seen in the period between 10 am and 11 am, Mr Dickens was not seen from 9.47 am until he was discovered hanging by a belt from the bed in his room just before 10.40 am. The observation log shows that several other patients were unaccounted for during the same period.
(2) During the inquest the nurse in charge of the ward gave evidence that the entries she had made on the observation log for the period between 10 am and 11 am were not made contemporaneously but after Mr Dickens had died . No note had been made on the log to indicate that the entries were being made after the event .
(3) While the observation log may have different purposes, it seems to me that two reasonable purposes of it are (i) to act as a prompt to make sure that the necessary checks on the patients were in fact conducted; and (ii) to ensure that there is a record that at a certain time, certain patients had been accounted for and were safe.
(4) Those purposes are plainly frustrated if entries are made on the log at times that are different to the actual observations, and after the event .
(5) Given that part of the purpose of the log is to ensure the safety of patients, particularly those such as Mr Dickens who are at high risk of self-harm or suicide, defects in the observation log process give rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, 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 Failure to conduct required ward patient observations
Wider context from the report “(1) From 10 am on the morning of 10 May 2017 the observation regime for the ward was not complied with . While there are notes on the observation log suggesting that some patients had been seen in the period between 10 am and 11 am, Mr Dickens was not seen from 9.47 am until he was discovered hanging by a belt from the bed in his room just before 10.40 am. The observation log shows that several other patients were unaccounted for during the same period .
(2) During the inquest the nurse in charge of the ward gave evidence that the entries she had made on the observation log for the period between 10 am and 11 am were not made contemporaneously but after Mr Dickens had died. No note had been made on the log to indicate that the entries were being made after the event.
(3) While the observation log may have different purposes, it seems to me that two reasonable purposes of it are (i) to act as a prompt to make sure that the necessary checks on the patients were in fact conducted ; and (ii) to ensure that there is a record that at a certain time, certain patients had been accounted for and were safe.
(4) Those purposes are plainly frustrated if entries are made on the log at times that are different to the actual observations, and after the event.
(5) Given that part of the purpose of the log is to ensure the safety of patients, particularly those such as Mr Dickens who are at high risk of self-harm or suicide, defects in the observation log process give rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future.
” Open source report
18 Apr 2018 Mr Colin Johns · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 3 Inadequate communication and history-taking during mental health assessment View source Failure to record significant self-harm and access-to-medication risks View source Failure to find a suitable bed for a high-risk patient 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
Mr Colin Johns · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Colin Johns, a 71-year-old man with a history of low mood, alcohol dependency and previous self-harm, was discharged home after presenting with suicidal thoughts and requesting psychiatric admission. He subsequently took an overdose of co-codamol and died after being found collapsed at home. Concerns included inadequate communication and history-taking about self-harm attempts and insufficient efforts to find a suitable inpatient bed.
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 Inadequate communication and history-taking during mental health assessment
Wider context from the report “1. Evidence emerged during the inquest that there was inadequate communication and history taken as part of the assessment process by the MHLS nurse . Specifically there were failures to record the fact he had attempted to strangle/suffocate himself whilst in the A and E department and gain entry to the drugs trolley.
” 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 significant self-harm and access-to-medication risks
Wider context from the report “1. Evidence emerged during the inquest that there was inadequate communication and history taken as part of the assessment process by the MHLS nurse. Specifically there were failures to record the fact he had attempted to strangle/suffocate himself whilst in the A and E department and gain entry to the drugs trolley .
” 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 find a suitable bed for a high-risk patient
Wider context from the report “2. Further efforts should have been made to find a suitable bed given his high level of risk and previous history .
” Open source report
3 Apr 2018 Barbara Haley · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Provision of food unsuitable for a soft diet View source Failure to supervise high-risk residents while eating 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
Barbara Haley · 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
Barbara Haley inhaled vomit, saliva, food or liquid while resident at Hilltop Court Care Home, developed a chest infection, and died at Stepping Hill Hospital on 13 October 2017 after suffering a cardiac arrest en route. Concerns included her being provided food unsuitable for her soft diet and being left alone to eat despite having been assessed as at high risk of choking.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Provision of food unsuitable for a soft diet
Wider context from the report “1. Mrs Haley was on a soft diet (described as a “fork-mashable diet” in evidence). Despite this, there was evidence that Mrs Haley had been provided with food items not suitable for her by staff . In particular, on one occasion toast was found in her room . On another occasion, staff had apparently suggested to a family member that chocolate could be given to Mrs Haley .
” 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 supervise high-risk residents while eating
Wider context from the report “2. During the course of her evidence, ████████ (Home Manager) explained that Mrs Haley was assessed as being at High Risk of choking and scored high on the risk assessment that had been carried out. Despite this, Mrs Haley would be left alone in her room to eat because ████████ stated she did not like to have staff present when she was eating; she would then refuse to eat. We heard evidence from a manager at another home that Mrs Haley would eat when she was in the dining room with other residents, where staff could also observe her. It was of concern that Mrs Haley was being left alone in her room to eat when she had been assessed as being at the high risk of choking .
” Open source report
1 Apr 2018 Julia Jane MacPherson · Prevention of Future Deaths report South London
View report summary
Concerns raised 6 Failure to follow NICE guidelines for prescribing off-licence medicines View source Failure to provide timely clinical review following reported deterioration View source Failure of hospital staff to regularly read clinical and nursing entries in patient medical records View source Failure to formally review mental capacity to consent to treatment View source Absence of a statutory process for recording informal patients' consent to medication View source Incomplete or missing records of consent discussions for off-licence mental health medication 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
Julia Jane MacPherson · 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
Julia Jane MacPherson, an informal patient of Oxleas NHS Foundation Trust, suffered swallowing difficulties and collapsed in the community with food bolus and vomitus in her throat; resuscitation was unsuccessful. Concerns included failure to arrange or undertake a timely medical review, failure to assess her mental capacity after concerns about confusion, incomplete clinical records, and prescribing and consent processes for off-licence medication. The inquest recorded the medical cause of death as upper airway obstruction associated with swallowing difficulties secondary to medication-related extrapyramidal symptoms.
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 NICE guidelines for prescribing off-licence medicines
Wider context from the report “(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however:
(a) This review did not take place and her Responsible Clinician did not see this note until the inquest.
(b) Julia was not reviewed on 16th May.
(c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May.
(2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records.
(3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised.
(4) NICE guidelines for the prescription of off licenced medicines was not followed.
(5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely clinical review following reported deterioration
Wider context from the report “(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however:
(a) This review did not take place and her Responsible Clinician did not see this note until the inquest.
(b) Julia was not reviewed on 16th May .
(c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May.
(2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records.
(3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised.
(4) NICE guidelines for the prescription of off licenced medicines was not followed.
(5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital staff to regularly read clinical and nursing entries in patient medical records
Wider context from the report “(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however:
(a) This review did not take place and her Responsible Clinician did not see this note until the inquest.
(b) Julia was not reviewed on 16th May.
(c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May.
(2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records .
(3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised.
(4) NICE guidelines for the prescription of off licenced medicines was not followed.
(5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to formally review mental capacity to consent to treatment
Wider context from the report “(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however:
(a) This review did not take place and her Responsible Clinician did not see this note until the inquest.
(b) Julia was not reviewed on 16th May.
(c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May.
(2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records.
(3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised.
(4) NICE guidelines for the prescription of off licenced medicines was not followed.
(5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Absence of a statutory process for recording informal patients' consent to medication
Wider context from the report “(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however:
(a) This review did not take place and her Responsible Clinician did not see this note until the inquest.
(b) Julia was not reviewed on 16th May.
(c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May.
(2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records.
(3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised.
(4) NICE guidelines for the prescription of off licenced medicines was not followed.
(5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Incomplete or missing records of consent discussions for off-licence mental health medication
Wider context from the report “(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however:
(a) This review did not take place and her Responsible Clinician did not see this note until the inquest.
(b) Julia was not reviewed on 16th May.
(c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May.
(2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records.
(3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised.
(4) NICE guidelines for the prescription of off licenced medicines was not followed.
(5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Return to inspect Oxleas NHS Foundation Trust and follow up the identified concerns to check that necessary improvements have been made.
Verbatim wording from the response “We will be returning to inspect Oxleas NHS Foundation Trust later in the year. We intend to follow through some of the areas of concern in more detail. This will be to ensure the trust has learnt from this and made the necessary improvements.” Source location 2018-0298-Response-by-CQC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conducted a follow-up inspection of Oxleas NHS Foundation Trust’s acute wards to assess whether specific improvements had been made.
Verbatim wording from the response “Since Julia Jane MacPherson's death in May 2016, we have inspected Oxleas NHS Foundation Trust once. This was a follow up inspection of the acute wards in the Trust, including Norman Ward, in February 2017 to see if some specific improvements had taken place since the comprehensive inspection in April 2016. We also carried out regular visits by our Mental Health Act reviewers, and the last one took place on Norman Ward in March 2017.” Source location 2018-0298-Response-by-CQC
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Specific circumstances of Julia MacPherson’s individual care and treatment fall outside the regulator’s remit for comment.
Verbatim wording from the response “We note our legal responsibility to submit a written response to you, however some of the matters of concern relate to the very specific circumstances of Julia MacPherson's individual care and treatment, so we are unable as a regulator to comment on this.” Source location 2018-0298-Response-by-CQC
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The inspection concluded that prescribing followed NICE guidance and raised no concerns about managing medicines prescribed outside usual levels.
Verbatim wording from the response “The inspection in April 2016 looked at 105 medicine administration records and concluded that NICE guidance was being followed when prescribing medicines. We did record that three patients were being prescribed medicines outside of the usual levels, but do not raise any concerns about how that was being managed.” Source location 2018-0298-Response-by-CQC
Open published response
26 Jan 2018 Vanessa Ferkova · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 5 Difference in commissioned services between primary and secondary care settings for similar unscreened patient populations View source Failure to include clinical observations in walk-in centre triage View source Confusion among the public about the roles of walk-in centres, urgent care centres and GP services attached to Emergency Departments View source Failure to maintain equivalent triage systems for unscreened patients across walk-in centres and emergency departments View source Unavailability of timely clinical triage including assessment of clinical observations at walk-in centre services View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Vanessa Ferkova · 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
Vanessa Ferkova, aged 2, attended a GP walk-in centre with fever and vomiting and later developed a rash. She was subsequently recognised as very unwell and likely suffering from meningococcal septicaemia, went into cardiac arrest in an ambulance, and died after unsuccessful resuscitation. The principal concern was that the walk-in centre did not provide clinical triage or a required timeframe for initial assessment, despite concerns that earlier observations could have identified and treated shock.
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 Difference in commissioned services between primary and secondary care settings for similar unscreened patient populations
Wider context from the report “I am concerned that there is a difference in the services commissioned between primary and secondary care settings, where the potential population of patients is similar; that being unscreened members of the public, including children .
I heard evidence that there is a confusion amongst the general public as to the roles of walk-in centres, urgent care centres and GP services attached to Emergency Departments. In this case it was likely that, had Vanessa presented to a GP service attached to an Emergency Department, she would have had a clinical triage within 15 minutes of arriving (including an assessment of clinical observations) and that she would not have died from septicaemia. I am concerned that she did not receive this care because of the service from which her parents (understandably) sought treatment.
The walk-in centre provider is currently investigating whether it should/could provide a triage service which includes an assessment of clinical observations. I am to be provided the outcome of this investigation at the end of February 2018. As such, I have not written a prevention of future deaths report to this provider but I am concerned that this is a nationwide issue which warrants consideration by NHS England as the commissioner of primary care services.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to include clinical observations in walk-in centre triage
Wider context from the report “I heard evidence from the CQC that the walk-in centre had been inspected for the first time in the June following Vanessa’s death. It was judged to have ‘triage process whereby patients were assessed so they were seen according to clinical need...’ but also that ‘Patients arriving at the service were seen generally according to arrival time’. The report also states that ‘Screening, prioritising and navigation of patients was completed by an appropriate clinician’. These conclusions were based on the process of receptionists documenting the presence/absence of ‘red flags’ and clinicians reviewing the waiting list when considering which patient was next to be seen.
I am concerned that the CQC judged the centre to have a triage process that was based on clinical need when that assessment does not include taking clinical observations which, in secondary care hospitals, was stated to be a vital patient safety tool . Given that walk-in centres and emergency departments both accept ‘unscreened’ patients, it is concerning that such differing triage systems should be in place; a situation which is seeming accepted by the regulator. I heard evidence that, should this circumstance repeat itself, then it is likely that the same outcome would occur. As such, my duty to raise these concerns is engaged.
” 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 Confusion among the public about the roles of walk-in centres, urgent care centres and GP services attached to Emergency Departments
Wider context from the report “I am concerned that there is a difference in the services commissioned between primary and secondary care settings, where the potential population of patients is similar; that being unscreened members of the public, including children.
I heard evidence that there is a confusion amongst the general public as to the roles of walk-in centres, urgent care centres and GP services attached to Emergency Departments . In this case it was likely that, had Vanessa presented to a GP service attached to an Emergency Department, she would have had a clinical triage within 15 minutes of arriving (including an assessment of clinical observations) and that she would not have died from septicaemia. I am concerned that she did not receive this care because of the service from which her parents (understandably) sought treatment.
The walk-in centre provider is currently investigating whether it should/could provide a triage service which includes an assessment of clinical observations. I am to be provided the outcome of this investigation at the end of February 2018. As such, I have not written a prevention of future deaths report to this provider but I am concerned that this is a nationwide issue which warrants consideration by NHS England as the commissioner of primary care services.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain equivalent triage systems for unscreened patients across walk-in centres and emergency departments
Wider context from the report “I heard evidence from the CQC that the walk-in centre had been inspected for the first time in the June following Vanessa’s death. It was judged to have ‘triage process whereby patients were assessed so they were seen according to clinical need...’ but also that ‘Patients arriving at the service were seen generally according to arrival time’. The report also states that ‘Screening, prioritising and navigation of patients was completed by an appropriate clinician’. These conclusions were based on the process of receptionists documenting the presence/absence of ‘red flags’ and clinicians reviewing the waiting list when considering which patient was next to be seen.
I am concerned that the CQC judged the centre to have a triage process that was based on clinical need when that assessment does not include taking clinical observations which, in secondary care hospitals, was stated to be a vital patient safety tool. Given that walk-in centres and emergency departments both accept ‘unscreened’ patients, it is concerning that such differing triage systems should be in place ; a situation which is seeming accepted by the regulator . I heard evidence that, should this circumstance repeat itself, then it is likely that the same outcome would occur. As such, my duty to raise these concerns is engaged.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Unavailability of timely clinical triage including assessment of clinical observations at walk-in centre services
Wider context from the report “I am concerned that there is a difference in the services commissioned between primary and secondary care settings, where the potential population of patients is similar; that being unscreened members of the public, including children.
I heard evidence that there is a confusion amongst the general public as to the roles of walk-in centres, urgent care centres and GP services attached to Emergency Departments. In this case it was likely that, had Vanessa presented to a GP service attached to an Emergency Department, she would have had a clinical triage within 15 minutes of arriving (including an assessment of clinical observations) and that she would not have died from septicaemia. I am concerned that she did not receive this care because of the service from which her parents (understandably) sought treatment.
The walk-in centre provider is currently investigating whether it should/could provide a triage service which includes an assessment of clinical observations. I am to be provided the outcome of this investigation at the end of February 2018. As such, I have not written a prevention of future deaths report to this provider but I am concerned that this is a nationwide issue which warrants consideration by NHS England as the commissioner of primary care services.
” Open source report
22 Dec 2017 Ronald Arthur Farrington · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 12 Failure to conduct an adequate safeguarding enquiry View source Failure to inform family about CQC enquiries View source Failure to obtain independent evidence about care View source Failure to refer infected pressure sores to a general practitioner View source Failure to keep accurate care records View source Inadequate tissue viability nurse service capacity View source Failure to incorporate tissue viability advice into care plans View source Failure to involve family in safeguarding review View source Failure to produce an adequate s42 report View source Failure to provide accurate information about tissue viability nurse involvement View source Failure to follow tissue viability advice on turning and dressing sores View source Failure to inform family about developed pressure sores View source See 9 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
Ronald Arthur Farrington · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ronald Arthur Farrington, who had dementia and Parkinson’s disease and was resident in a nursing home, developed infected sacral pressure sores. He was admitted to hospital with sepsis and died on 21 June 2016; the inquest recorded sepsis caused by infection in the pressure sore, with pneumonia contributing. The substantive concerns included failures to follow and record tissue-viability advice, failure to refer the infection to his general practitioner, inadequate tissue-viability nurse availability, and insufficient independent investigation by the CQC and safeguarding review.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct an adequate safeguarding enquiry
Wider context from the report “5. A large scale review has been convened as a result of the safeguarding alert raised by East Surrey Hospital. It is now being conducted by Surrey Adult Safeguarding. As at the date of the resumed inquest no adequate s42 report has been written. The family have not been invited to take part in the review. No adequate enquiry has been made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to inform family about CQC enquiries
Wider context from the report “4. Mr Farrington’s family who visited him on a very regular basis and could have provided information about his care were not made aware that he had developed pressure sores, nor that the CQC were conducting any enquiries.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain independent evidence about care
Wider context from the report “3. The CQC did not obtain independent evidence about Mr Farrington’s care having received 2 notifications that he had developed pressure sores.
” 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 refer infected pressure sores to a general practitioner
Wider context from the report “1. Nuffield Care Centre:
a.) Failed to incorporate all the advice given by the tissue viability nurses in Mr Farrington’s care plans.
b.) Failed to keep accurate records.
c.) Informed the CQC that the tissue viability nurses were still involved with Mr Farrington when they weren’t.
d.) Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr Farrington’s sores
e.) Failed to refer Mr Farrington to his General Practitioner when he developed an infection in the sacral pressure sore on the 1st June 2016.
” 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 keep accurate care records
Wider context from the report “1. Nuffield Care Centre:
a.) Failed to incorporate all the advice given by the tissue viability nurses in Mr Farrington’s care plans.
b.) Failed to keep accurate records.
c.) Informed the CQC that the tissue viability nurses were still involved with Mr Farrington when they weren’t.
d.) Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr Farrington’s sores
e.) Failed to refer Mr Farrington to his General Practitioner when he developed an infection in the sacral pressure sore on the 1st June 2016.
” 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 tissue viability nurse service capacity
Wider context from the report “2. Only one tissue viability nurse was employed by First Community Care from March 2016 onwards. They were on annual leave for 6 weeks between the 18th March and the 15th June 2016. This was not an adequate level of service.
” 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 incorporate tissue viability advice into care plans
Wider context from the report “1. Nuffield Care Centre:
a.) Failed to incorporate all the advice given by the tissue viability nurses in Mr Farrington’s care plans.
b.) Failed to keep accurate records.
c.) Informed the CQC that the tissue viability nurses were still involved with Mr Farrington when they weren’t.
d.) Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr Farrington’s sores
e.) Failed to refer Mr Farrington to his General Practitioner when he developed an infection in the sacral pressure sore on the 1st June 2016.
” 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 involve family in safeguarding review
Wider context from the report “5. A large scale review has been convened as a result of the safeguarding alert raised by East Surrey Hospital. It is now being conducted by Surrey Adult Safeguarding. As at the date of the resumed inquest no adequate s42 report has been written. The family have not been invited to take part in the review. No adequate enquiry has been made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to produce an adequate s42 report
Wider context from the report “5. A large scale review has been convened as a result of the safeguarding alert raised by East Surrey Hospital. It is now being conducted by Surrey Adult Safeguarding. As at the date of the resumed inquest no adequate s42 report has been written. The family have not been invited to take part in the review. No adequate enquiry has been made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accurate information about tissue viability nurse involvement
Wider context from the report “1. Nuffield Care Centre:
a.) Failed to incorporate all the advice given by the tissue viability nurses in Mr Farrington’s care plans.
b.) Failed to keep accurate records.
c.) Informed the CQC that the tissue viability nurses were still involved with Mr Farrington when they weren’t.
d.) Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr Farrington’s sores
e.) Failed to refer Mr Farrington to his General Practitioner when he developed an infection in the sacral pressure sore on the 1st June 2016.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to follow tissue viability advice on turning and dressing sores
Wider context from the report “1. Nuffield Care Centre:
a.) Failed to incorporate all the advice given by the tissue viability nurses in Mr Farrington’s care plans.
b.) Failed to keep accurate records.
c.) Informed the CQC that the tissue viability nurses were still involved with Mr Farrington when they weren’t.
d.) Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr Farrington’s sores
e.) Failed to refer Mr Farrington to his General Practitioner when he developed an infection in the sacral pressure sore on the 1st June 2016.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to inform family about developed pressure sores
Wider context from the report “4. Mr Farrington’s family who visited him on a very regular basis and could have provided information about his care were not made aware that he had developed pressure sores , nor that the CQC were conducting any enquiries.
” Open source report
18 Dec 2017 Anne Morris · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 7 Failure of the HTT to obtain a written discharge plan from the hospital View source Failure to liaise with the HTT before discharge View source Failure to formulate a written discharge plan identifying the responsible community HTT View source Failure of the HTT to establish the patient's consent to contact a support person View source Failure to identify a responsible HTT for the discharge address View source Failure to inform the relevant HTT of consent to contact support persons View source Failure to contact consented friends and relatives regarding community support 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
Anne Morris · 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
Anne Morris died by suicide after hanging herself while alone in a friend’s house on 26 June 2017. The principal concerns were that the Priory Hospital did not contact consented friends or relatives, did not establish a written discharge and follow-up plan, and did not liaise adequately with the relevant Oxleas Home Treatment Team before discharge. Concerns were also raised that the Oxleas team did not obtain a discharge plan or know that Anne had agreed to contact with a friend regarding community support and suicide risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of the HTT to obtain a written discharge plan from the hospital
Wider context from the report “(4) The Oxleas HTT do not appear to have proactively contacted the Priory Hospital for a written discharge plan prior to, or at the time, of the home visit on the 25/6/17. Had the HTT made contact with the Priory Hospital it would still have been possible to formulate a plan (including the availability of collateral assistance from Messrs ████████).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to liaise with the HTT before discharge
Wider context from the report “(3) The Priory Hospital did not identify a responsible HTT for the discharge address in Eltham and there was no liaison with an HTT prior to discharge .
” 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 formulate a written discharge plan identifying the responsible community HTT
Wider context from the report “(2) The Priory Hospital did not formulate a written plan, before discharge from hospital, identifying the HTT who would be responsible for onward care in the community and, in particular making the relevant HTT aware that Anne was agreeable to health care professionals speaking to Peter Forester and Bernard Bakes regarding support with her mental health issues.
” 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 HTT to establish the patient's consent to contact a support person
Wider context from the report “(5) The Oxleas HTT do not appear to have been aware of Anne’s willingness for mental health professionals to contact her friend ████████ regarding community support with her suicide risk . Had Oxleas HTT proactively made contact with the Priory Hospital they could have been made aware of this arrangement.
” 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 identify a responsible HTT for the discharge address
Wider context from the report “(3) The Priory Hospital did not identify a responsible HTT for the discharge address in Eltham and there was no liaison with an HTT prior to discharge.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the relevant HTT of consent to contact support persons
Wider context from the report “(2) The Priory Hospital did not formulate a written plan, before discharge from hospital, identifying the HTT who would be responsible for onward care in the community and, in particular making the relevant HTT aware that Anne was agreeable to health care professionals speaking to Peter Forester and Bernard Bakes regarding support with her mental health issues .
” 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 contact consented friends and relatives regarding community support
Wider context from the report “(1) I am concerned that the staff at the Priory Hospital did not make contact with friends and relatives after Anne had consented to them being contacted .
” Open source report
12 Dec 2017 Joseph Peter Dunne · Prevention of Future Deaths report Isle of Wight
View report summary
Concerns raised 2 Failure to prevent incorrectly authenticated or attributed access to and alteration of patient medical records View source Failure to make medical-record edits visible to treating clinicians 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
Joseph Peter Dunne · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joseph Peter Dunne, aged 58, was discharged from hospital on 14 July 2015 after presenting with pain and feeling unwell, and was later found collapsed at home on 16 July 2015. He became unresponsive while using the toilet and was pronounced dead at 3.20 p.m.; the medical cause of death was peritonitis due to a perforated duodenal ulcer. The report raises concerns about Information Governance breaches that allowed clinical records, including an abnormal D-dimer result, to be deleted or altered and not seen by treating clinicians.
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 prevent incorrectly authenticated or attributed access to and alteration of patient medical records
Wider context from the report “1. I am concerned that there are clear breaches in Information Governance protocols . It is clear that there are IG issues which allow one Clinician to make entries or delete information from a patient’s medical records, when they are not correctly logged in to the database , or are doing so under a colleague’s log-in (which remains live after they've walked away from the computer terminal) . Matters are compounded inasmuch as these edits are then found to be invisible to those clinicians who are actually treating the patient, and are only ascertainable when an IT audit trail is undertaken. It should not be possible for Doctor A to be able to access records made by Doctor B and to alter those medical records .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to make medical-record edits visible to treating clinicians
Wider context from the report “1. I am concerned that there are clear breaches in Information Governance protocols. It is clear that there are IG issues which allow one Clinician to make entries or delete information from a patient’s medical records, when they are not correctly logged in to the database, or are doing so under a colleague’s log-in (which remains live after they've walked away from the computer terminal). Matters are compounded inasmuch as these edits are then found to be invisible to those clinicians who are actually treating the patient , and are only ascertainable when an IT audit trail is undertaken . It should not be possible for Doctor A to be able to access records made by Doctor B and to alter those medical records.
” Open source report
27 Oct 2017 Stephen George Coulson · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 5 Failure of the system for audit of controlled-drug processes View source Failure of the system for documentation of controlled drugs View source Lack of escalation for admission of patients requiring continued observation or review View source Failure of high-level investigations to identify lessons View source Failure of the system for administration of controlled drugs 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
Stephen George Coulson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen George Coulson was discharged from Manchester Royal Infirmary after an increased Fentanyl patch was applied, with no record that the previous patch had been removed and despite confusion and agitation requiring further observation under hospital policy. He was found in cardiac arrest at home in the early hours of 1 January 2016 and died in intensive care later that day. The principal concerns were controlled-drug administration and documentation, failure to escalate the need for observation and review before discharge, and the Trust’s investigation failing to identify lessons.
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 system for audit of controlled-drug processes
Wider context from the report “1) Controlled drugs – the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs
” 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 system for documentation of controlled drugs
Wider context from the report “1) Controlled drugs – the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs
” 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 escalation for admission of patients requiring continued observation or review
Wider context from the report “2) Observation policy – the lack of escalation of the need to admit patients for observation and review should they fulfil the criteria to require continued observation / review prior to discharge
” 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 high-level investigations to identify lessons
Wider context from the report “3) High Level Investigation – the witness did not accept that any lessons could be learnt from the investigation surrounding the death of the deceased.
” 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 system for administration of controlled drugs
Wider context from the report “1) Controlled drugs – the system in place for the administration , documentation and audit of processes associated with the use of controlled drugs
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain the revised action plan for the incident, identifying lessons for the Trust.
Verbatim wording from the response “In light of the Regulation 28 report, the Commission obtained the revised action plan regarding this tragic incident, which has been submitted directly to you. This does now identify a number of lessons for the Trust.” Source location 2017-0307-Response-by-CQC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor the Trust’s audit of opioid patch monitoring form implementation through quarterly engagement and consider it at the next inspection.
Verbatim wording from the response “The policy was updated in November 2017 to include reference to an opioid patch monitoring form. The use of the form should minimise the risk of a similar incident experienced by Mr Coulson being repeated. The trust managers have informed the Commission that they plan to audit implementation of the form. We will monitor this through our quarterly engagement meetings and subsequently consider this at the next inspection, which is likely to take place between October and December 2018.” Source location 2017-0307-Response-by-CQC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Trust’s controlled drugs policy and share proposed improvements with the Trust.
Verbatim wording from the response “As you are aware, the Trust have a controlled drugs policy in place. The pharmacy team within the Commission has reviewed this policy. The policy is of an acceptable standard, with some suggestions for improvements, such as making it clear who has responsibility for investigating medicines incidents, which occur outside of pharmacy. We will share these with the trust.” Source location 2017-0307-Response-by-CQC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share suggestions clarifying responsibility for investigating medicines incidents occurring outside pharmacy.
Verbatim wording from the response “As you are aware, the Trust have a controlled drugs policy in place. The pharmacy team within the Commission has reviewed this policy. The policy is of an acceptable standard, with some suggestions for improvements, such as making it clear who has responsibility for investigating medicines incidents, which occur outside of pharmacy. We will share these with the trust.” Source location 2017-0307-Response-by-CQC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess early warning score use and escalation at the next inspection.
Verbatim wording from the response “That said, we will ensure that the use of the early warning score and escalation is considered at the next inspection. We will also continue to monitor through our quarterly engagement with the Trust.” Source location 2017-0307-Response-by-CQC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue monitoring early warning score use and escalation through quarterly engagement with the Trust.
Verbatim wording from the response “That said, we will ensure that the use of the early warning score and escalation is considered at the next inspection. We will also continue to monitor through our quarterly engagement with the Trust.” Source location 2017-0307-Response-by-CQC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Trust’s controlled drug standard operating procedures through ongoing engagement.
Verbatim wording from the response “The trust must also have in place a controlled drug Standard Operating Procedures (SOPs). We will review these as part of our ongoing engagement with the trust. For your information, we have recently implemented a system of having a named pharmacist inspector who has responsibility for the Trust and who meets with the head pharmacist. They are aware of this Regulation 28 report and will include this as part of their next meeting.” Source location 2017-0307-Response-by-CQC
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The information currently held provides no evidence that the concerns reflect a systemic issue.
Verbatim wording from the response “In addition, in light of the Regulation 28 report, we have also considered whether there is sufficient evidence to take further regulatory action regarding this matter. We have concluded, based on the information we currently hold, that there is no evidence there is a systemic issue. However, please be assured we will continue to monitor the issues you have raised from a regulatory perspective and use the information to inform future regulatory activity at the Trust.” Source location 2017-0307-Response-by-CQC
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No further regulatory action is considered necessary regarding this matter based on the information currently held.
Verbatim wording from the response “In addition, in light of the Regulation 28 report, we have also considered whether there is sufficient evidence to take further regulatory action regarding this matter. We have concluded, based on the information we currently hold, that there is no evidence there is a systemic issue. However, please be assured we will continue to monitor the issues you have raised from a regulatory perspective and use the information to inform future regulatory activity at the Trust.” Source location 2017-0307-Response-by-CQC
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The controlled drugs policy is of an acceptable standard, although improvements to incident-investigation responsibilities have been suggested.
Verbatim wording from the response “As you are aware, the Trust have a controlled drugs policy in place. The pharmacy team within the Commission has reviewed this policy. The policy is of an acceptable standard, with some suggestions for improvements, such as making it clear who has responsibility for investigating medicines incidents, which occur outside of pharmacy. We will share these with the trust.” Source location 2017-0307-Response-by-CQC
Open published response
Concerns raised 6 Failure to conduct a serious incident report into a preventable death View source Failure of neuroradiological review to identify and flag critical intracranial pressure indicators View source Delay in availability of neuroradiological reports for key neurosurgical consultations View source Failure to seek specialist ophthalmic advice View source Failure to obtain the outcome of external ophthalmic assessments View source Risk of fatal respiratory depression and further intracranial pressure elevation from opioid analgesia in raised intracranial pressure View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Sam Antony Crick · 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
Sam Antony Crick, aged 24, developed recurrent hydrocephalus and progressively raised intracranial pressure before a catastrophic collapse on 29 February 2016. He underwent emergency neurosurgical intervention but died at Addenbrookes Hospital on 4 March 2016. The concerns included missed radiological and ophthalmological signs of rising intracranial pressure, delays in obtaining and considering important imaging information, and the absence of a serious incident investigation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct a serious incident report into a preventable death
Wider context from the report “(A).This was a significant adverse event and the death was preventable. However, there have been no serious incident report (SIR) into the death . The importance of the SIR process is to consider root causes and importantly, to make recommendations and implement an action plan. Learning lessons is a key feature of the process.
” 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 neuroradiological review to identify and flag critical intracranial pressure indicators
Wider context from the report “(B). The neuroradiological review of the CT scan in November 2015 and early December 2015 did not highlight the obvious brain parenchymal herniation through the pre-existing burr hole as well as other interval change and this was a missed opportunity of flagging a clear indicator of rising intracranial pressure . Furthermore, there is now a separate investigation on the death of another person (SP) where involvement of the neuroradiology department at the Queens hospital is a central issue.
” 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 Delay in availability of neuroradiological reports for key neurosurgical consultations
Wider context from the report “(C). The last face to face consultation between the Neurosurgeon and the deceased was on the 3rd February 2016 but the written neuroradiological report of the January 26th CT scan was not available until the 4th February 2016 and so this report was not considered by the Neurosurgeon as it was not available for this key consultation . This report did highlight some alarming features of herniation but this vital information was therefore not considered.
” 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 seek specialist ophthalmic advice
Wider context from the report “(D). The consultant neurosurgeons examination on the 2nd December 2015 did not find frank papilledema and yet an examination by a consultant ophthalmologist at the Luton and Dunstable hospital on the 18th November 2015 and 24th December 2015 had found papilledema at both appointments. The consultant neurologist’s referral letter from Luton and Dunstable indicated a finding of papilledema also and stated an ophthalmic review was being sought but there appears to have been no attempt to find the outcome of the Luton assessments. Further, and in the alternative, no specialist ophthalmic advice was sought by the neurosurgeon even though there had been lengthy ophthalmic follow up over a number of years after the third ventriculostomy in 2007 and also given the recorded findings of the consultant neurologist in Luton.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain the outcome of external ophthalmic assessments
Wider context from the report “(D). The consultant neurosurgeons examination on the 2nd December 2015 did not find frank papilledema and yet an examination by a consultant ophthalmologist at the Luton and Dunstable hospital on the 18th November 2015 and 24th December 2015 had found papilledema at both appointments. The consultant neurologist’s referral letter from Luton and Dunstable indicated a finding of papilledema also and stated an ophthalmic review was being sought but there appears to have been no attempt to find the outcome of the Luton assessments . Further, and in the alternative, no specialist ophthalmic advice was sought by the neurosurgeon even though there had been lengthy ophthalmic follow up over a number of years after the third ventriculostomy in 2007 and also given the recorded findings of the consultant neurologist in Luton.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Risk of fatal respiratory depression and further intracranial pressure elevation from opioid analgesia in raised intracranial pressure
Wider context from the report “(F). A point explored in the investigation was the administration of opioid analgesia in someone who has raised intracranial pressure . This was looking at an opiate acting as a respiratory depressant with a consequent rise in the level of carbon dioxide in the blood which in turn could further raise ICP provoked by hypercapnia . This could cause a fatality . Luton and Dunstable hospital have designed a standard operating procedure to address this and it raises a question of whether this should be distributed nationally so as to achieve consistency of approach.
” Open source report
21 Aug 2017 Francesca Whyatt · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 4 Failure to automatically treat ligature incidents as SIUs View source Lack of clear guidance or criteria for treating ligature or other self-harming incidents as SUIs to trigger investigation View source Lack of risk assessment of the East Wing ward configuration over four floors View source Lack of formal guidance on the frequency of observation competency checklist completion by ad-hoc agency staff 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
Francesca Whyatt · 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
Francesca Whyatt, who was at known risk from ligatures, was found unconscious with tights around her neck at the Priory Hospital on 25 September 2013 and died in hospital on 28 September 2013. The report identifies concerns about the ward’s four-floor configuration, observation arrangements, control of ligature items, staffing and training, and the lack of clear criteria for investigating ligature and other self-harming incidents as serious untoward incidents.
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 automatically treat ligature incidents as SIUs
Wider context from the report “(3) Ligature incidents are not automatically treated as SIUs (though the evidence suggests that death can occur within seconds of a ligature being applied).
” 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 clear guidance or criteria for treating ligature or other self-harming incidents as SUIs to trigger investigation
Wider context from the report “(4) There is no clear guidance or criteria on the circumstances in which a ligature incident/s (or other self-harming incident/s) should be treated as an SUI such as to trigger an SUI investigation .
” 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 the East Wing ward configuration over four floors
Wider context from the report “(1) There has been no risk assessment of the configuration of the East Wing ward over four floors .
” 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 formal guidance on the frequency of observation competency checklist completion by ad-hoc agency staff
Wider context from the report “(2) There is no written or other formal guidance on the frequency with which ad-hoc agency staff should complete the observation competency checklist .
” Open source report
16 Aug 2017 Helen Theresa Cannon · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 3 Failure to ensure understanding of the meaning of countersigning risk assessment checklists View source Failure to seek medical or paramedic assistance when warranted by a person's condition View source Failure to address inaccuracies in moving and handling risk assessment checklists during investigations 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
Helen Theresa Cannon · 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
Helen Theresa Cannon fell at home on 2 April 2017 and was assisted from the floor by Eldercare emergency responders without medical or paramedic assistance being sought. She had suffered internal haemorrhage from a pelvic fracture sustained in the fall and died two days later; concerns were also identified about inaccuracies in the moving and handling risk assessment and flaws in Eldercare’s subsequent 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 ensure understanding of the meaning of countersigning risk assessment checklists
Wider context from the report “2. Following Mrs Cannon’s death Eldercare carried out an investigation. The investigation was flawed in that it did not address clear inaccuracies in the Moving and Handling Risk assessment checklist completed by one of the Emergency Responders, nor did it discover that the other Emergency Responder attending did not understand that he was agreeing with the accuracy of the information recorded on the checklist when he countersigned it . It was his belief that he signed the checklist simply to agree that he had been present .
” 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 seek medical or paramedic assistance when warranted by a person's condition
Wider context from the report “1. The emergency responders did not seek medical or paramedic assistance for Mrs Cannon because she was complaining of suffering aching rather than pain . It transpired that Mrs Cannon had suffered internal haemorrhage as a result of a pelvic fracture sustained in her fall, and this led to her death two days later. Evidence was heard at the Inquest from a Consultant Trauma and Orthopaedic Surgeon that in the circumstances it would have been good practice to have obtained medical or paramedic assistance for Mrs Cannon .
” 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 inaccuracies in moving and handling risk assessment checklists during investigations
Wider context from the report “2. Following Mrs Cannon’s death Eldercare carried out an investigation. The investigation was flawed in that it did not address clear inaccuracies in the Moving and Handling Risk assessment checklist completed by one of the Emergency Responders, nor did it discover that the other Emergency Responder attending did not understand that he was agreeing with the accuracy of the information recorded on the checklist when he countersigned it. It was his belief that he signed the checklist simply to agree that he had been present.
” Open source report
31 Jul 2017 Michael Bingham · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Lack of clarity and consistency in head and neck injury guidelines for considering CT scans in older people with dementia or cognitive impairment View source Lack of consistent regulatory or guidance requirements for assessing fall risks from emergency door release panels View source Failure to provide alarms indicating when internal secure doors become insecure across the service View source Inadequate inspection procedures for Registered Persons’ compliance with internal secure door safety and security requirements View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Bingham · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Bingham fell down stairs at Hilltop Court Care Home on 22 September 2016 after an emergency door release caused internal secure doors to open. He sustained C1/C2 fractures, was not diagnosed with a CT scan, later developed aspiration pneumonia, and died on 24 September 2016; concerns included door security alarms, guidance and inspection procedures, clarity about CT scans for older people with cognitive impairment, and the resulting risk of further deaths.
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 clarity and consistency in head and neck injury guidelines for considering CT scans in older people with dementia or cognitive impairment
Wider context from the report “I am concerned that the current Guidelines for Head/neck injuries (as amended) may continue to provide a lack of clarity as to when CT scans should be considered in those over 65 and with dementia or other cognitive impairment . The word ‘confusion’ remains under the general guidance (bullet point 5) but has been changed to ‘dementia’ under the guidance for those who are already being subject to a head scan . I ask that you consider reviewing your guidelines to ensure clarity and consistency of their clinical application.
” 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 consistent regulatory or guidance requirements for assessing fall risks from emergency door release panels
Wider context from the report “I accept that on the present Regulations it is for the Registered Person to make a risk assessment in relation to internal secure doors and the safety and security that they provide to service users. However, I ask you to review, in light of the evidence I have received in the course of this investigation whether there should be a further issue of regulations or guidance to ensure a consistent approach in respect of the assessment of any safety risk due to falls posed by the use of an emergency door release panel . I also ask you to review your inspection procedures in respect of a Registered Person’s compliance with the Regulations in respect of the safety and security of internal secure doors.
” 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 alarms indicating when internal secure doors become insecure across the service
Wider context from the report “It was accepted by you during the inquest that there was a ‘blind spot’ in the risk assessment of the internal secure doors , in that you were not required by any regulatory body to have an alarm to alert staff when secure doors became insecure by virtue of the use of the green emergency door release or otherwise.
I accept that you have now implemented an alarm system in Hilltop Court Care home that will indicate when the internal doors become insecure and have fitted auditory alarms in relation to the external doors. You indicated that you are in the process of implementing similar systems in the other care homes owned by Harbour Healthcare. I am concerned that without the implementation of these alarms across your service provision there would continue to be circumstances that create a risk of other deaths . I would be grateful for an indication of when you expect this implementation to be completed by way of response.
” 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 inspection procedures for Registered Persons’ compliance with internal secure door safety and security requirements
Wider context from the report “I accept that on the present Regulations it is for the Registered Person to make a risk assessment in relation to internal secure doors and the safety and security that they provide to service users. However, I ask you to review, in light of the evidence I have received in the course of this investigation whether there should be a further issue of regulations or guidance to ensure a consistent approach in respect of the assessment of any safety risk due to falls posed by the use of an emergency door release panel. I also ask you to review your inspection procedures in respect of a Registered Person’s compliance with the Regulations in respect of the safety and security of internal secure doors .
” 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 Regulation 28 lessons in regional regulatory-risk meetings and explore how to better inform inspectors about risks identified by the incident.
Verbatim wording from the response “However, we do recognise that there are lessons to be learnt from this sad death. We always consider and learn from Regulation 28 reports and their recommendations in our Regional Regulatory Risk Meetings. Within that forum we will explore how we can better inform our inspectors about the risks and issues identified as a result of this incident, and discuss how best to do so in our internal Continuous Improvement, Quality and Evaluation Group. We will also consider whether associated changes are needed when we begin planned work on the next iteration of our assessment framework, which is due to commence later this year. We will also explore how they can inform a planned checklist for use by inspectors when inspecting the safety of care homes premises.” Source location 2017-0322-Responses
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 further inspections to verify internal-door alarms or key-box panels at Hilltop Court and screech-alarm installation across Harbour Healthcare locations.
Verbatim wording from the response “The registered provider Harbour Healthcare has copied CQC into correspondence sent to yourself confirming the action they have taken following the death of Mr Bingham and the additional action they have taken in response to your Regulation 28 Report.” Source location 2017-0322-Responses
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 Discuss internally how lessons from the incident should inform inspection practice and consider associated changes for the next assessment-framework iteration.
Verbatim wording from the response “However, we do recognise that there are lessons to be learnt from this sad death. We always consider and learn from Regulation 28 reports and their recommendations in our Regional Regulatory Risk Meetings. Within that forum we will explore how we can better inform our inspectors about the risks and issues identified as a result of this incident, and discuss how best to do so in our internal Continuous Improvement, Quality and Evaluation Group. We will also consider whether associated changes are needed when we begin planned work on the next iteration of our assessment framework, which is due to commence later this year. We will also explore how they can inform a planned checklist for use by inspectors when inspecting the safety of care homes premises.” Source location 2017-0322-Responses
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 incident lessons can inform a planned premises-safety checklist for care-home inspectors.
Verbatim wording from the response “However, we do recognise that there are lessons to be learnt from this sad death. We always consider and learn from Regulation 28 reports and their recommendations in our Regional Regulatory Risk Meetings. Within that forum we will explore how we can better inform our inspectors about the risks and issues identified as a result of this incident, and discuss how best to do so in our internal Continuous Improvement, Quality and Evaluation Group. We will also consider whether associated changes are needed when we begin planned work on the next iteration of our assessment framework, which is due to commence later this year. We will also explore how they can inform a planned checklist for use by inspectors when inspecting the safety of care homes premises.” Source location 2017-0322-Responses
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Specific legislative change was not considered a priority because the issue was technical and lacked multiple similar incidents.
Verbatim wording from the response “CQC proposing the amendment of the regulations is unlikely to be the most timely and effective mechanism for change or improvement in this area. The issue at hand is highly technical and specific; regulations are usually set at a higher level, with detailed risks and issues addressed through codes and practice and guidance. In addition, door release mechanisms have not so far been identified as a key safety issue through multiple incident similar to those involved in this incident; it is very unlikely, despite this latest tragedy, to be seen as a priority for specific legislative change at this time.” Source location 2017-0322-Responses
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 existing guidelines and action plan were considered to mitigate the identified risk, with compliance monitored through quality meetings.
Verbatim wording from the response “To be clear however the existing guidelines meet National Institute for Health and Care Excellence guidance but contains an additional chart. During our inspection we identified a risk that staff were not following guidelines and the trust has received a Requirement Notice in that regard.” Source location 2017-0322-Responses
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 Providers or registered managers, rather than the regulator, decide how to comply with regulations and manage day-to-day safety work.
Verbatim wording from the response “In doing all of this we must however have regard to the fact that as with most regulators (and in accordance with our regulatory remit) CQC highlights breaches of the regulations to a Provider and requires compliance, but does not tell them how they” Source location 2017-0322-Responses
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing non-prescriptive inspection arrangements were considered appropriate because providers and service users have differing circumstances and risks.
Verbatim wording from the response “Premises safety forms part of the assessment we make of care home providers when we ask our key question ‘Is the service safe?’ There is a Key Line of Enquiry in our inspection assessment framework that asks: How are risks to people assessed and their safety monitored and managed so they are supported to stay safe and their freedom is respected? Inspectors explore how premises and the safety of communal and personal spaces are checked and managed to support people to stay safe when following this line of enquiry. As noted in your report, neither the regulations nor our assessment frameworks are prescriptive on how providers who are registered with us should do this. This is because each service is different and the needs of the people they care for and support can and do vary substantially.” Source location 2017-0322-Responses
Open published response
27 Jul 2017 Percy Jacks · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 6 Reliance of GP prescribing on receipt of hospital scan-result notification View source Haphazard DVT management system View source Failure of the hospital-to-GP DVT result communication system View source Failure to reliably communicate medication and clinical plans from hospital to care home View source Lack of medication review for correct Rivaroxaban dosage and duration View source Fragile communication system between GP, hospital and care home 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
Percy Jacks · 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
Percy Jacks died from a pulmonary embolus after being found unresponsive the morning following treatment for chest pain. The report identified failings in the management of his anticoagulation medication, including poor communication between the hospital, GP surgery and care home, and inadequate systems for ensuring the medication continued for the intended period.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Reliance of GP prescribing on receipt of hospital scan-result notification
Wider context from the report “(2) The system within the GP surgery for prescribing Rivaroxaban was poor and relied solely on receiving the notification of the results of the scan from the hospital . There was no facility to review the medication to ensure that the correct dosage for the correct period of time continued to be prescribed.
” 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 Haphazard DVT management system
Wider context from the report “(3) The evidence revealed a view from one of the hospital doctors to the effect that DVT management should be undertaken within the hospital setting rather than by the GP’s to ensure that a comprehensive and failsafe system operated rather than the somewhat haphazard one revealed by the evidence .
” 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 hospital-to-GP DVT result communication system
Wider context from the report “(1) The investigation revealed that the system for the Bronglais Hospital contacting the GP was poor. The result of the DVT scan which took place on 6 February was sent to the incorrect GP surgery and despite an explanation as to why that happened no satisfactory explanation could be found.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably communicate medication and clinical plans from hospital to care home
Wider context from the report “(4) The evidence further revealed a practice of sending details of the medication and clinical plan back with the driver of the patient who had taken the patient back from hospital to the care home.
” 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 medication review for correct Rivaroxaban dosage and duration
Wider context from the report “(2) The system within the GP surgery for prescribing Rivaroxaban was poor and relied solely on receiving the notification of the results of the scan from the hospital. There was no facility to review the medication to ensure that the correct dosage for the correct period of time continued to be prescribed .
” 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 Fragile communication system between GP, hospital and care home
Wider context from the report “(5) Overall the evidence revealed a very fragile system of communication between GP hospital and care home in circumstances in which the deceased had moved between three care homes in a short period of time.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Have inspectors use two specific information-sharing questions when reviewing practice safety from November 2017.
Verbatim wording from the response “We have revised and improved the wording of our Key Lines of Enquiry and from November 2017 inspectors will be considering the following two specific questions when they are reviewing the safety of a practice, instead of one being a prompt supporting the other: ‘When people move between teams, services and organisations (which may include at referral, discharge, transfer and transition), is all the information needed for their ongoing care shared appropriately, in a timely way and in line with relevant protocols?’ and ‘How well do the systems that manage information about people who use services support staff, carers and partner agencies to deliver safe care and treatment? (This includes coordination between different electronic and paper-based systems and appropriate access for staff to records.)’” Source location 2017-0329-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 Revise and improve the wording of the Key Lines of Enquiry on information sharing during transfers between services.
Verbatim wording from the response “We have revised and improved the wording of our Key Lines of Enquiry and from November 2017 inspectors will be considering the following two specific questions when they are reviewing the safety of a practice, instead of one being a prompt supporting the other: ‘When people move between teams, services and organisations (which may include at referral, discharge, transfer and transition), is all the information needed for their ongoing care shared appropriately, in a timely way and in line with relevant protocols?’ and ‘How well do the systems that manage information about people who use services support staff, carers and partner agencies to deliver safe care and treatment? (This includes coordination between different electronic and paper-based systems and appropriate access for staff to records.)’” Source location 2017-0329-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 Review how inspections assess timely information transfer between services, using policy, medicines and clinical expertise.
Verbatim wording from the response “As a result of the concerns being brought to our attention we have taken the opportunity to review how CQC checks that information about patients being transferred between services happens in a timely manner and whether there is any more we as a regulator can do to prevent an incident such as this from happening in future.” Source location 2017-0329-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 DVT management in primary care is accepted practice; hospital-only management was not considered necessary where appropriate safeguards are followed.
Verbatim wording from the response “3. The evidence revealed a view from one of the hospital doctors to the effect that DVT management should be undertaken within the hospital setting rather than by the GPs to ensure that a comprehensive and failsafe system operated rather than the somewhat haphazard one revealed by the evidence.” Source location 2017-0329-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 Including scan results with transferred patient records was considered sufficient, so no additional regulatory input was required.
Verbatim wording from the response “Cantilupe Surgery has informed CQC that hard copies of Mr Jacks’ notes, along with the scan results which were sent in error to the surgery by Bronglais General Hospital were collected by Capita on 10 February 2017. While Cantilupe Surgery did not contact the Bronglais Hospital to inform them of the error, they considered that the action of including the scan results along with Mr Jacks’ patient records were sufficient to ensure the information would reach the new practice promptly. The practice have informed us that in the event of a repetition of this kind of error they would inform the hospital in the light of Mr Jacks’ case. We do not consider that there is cause for additional input from CQC here.” Source location 2017-0329-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 Current inspection methodology was considered to cover the relevant care elements, so no additional policy change was required.
Verbatim wording from the response “As a result of the concerns being brought to our attention we have taken the opportunity to review how CQC checks that information about patients being transferred between services happens in a timely manner and whether there is any more we as a regulator can do to prevent an incident such as this from happening in future.” Source location 2017-0329-Response-by-Care-Quality-Commission
Open published response
27 Jul 2017 Sheila Margaret Gaskin · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 2 Failure to prohibit carers assisting the service user to smoke in bed View source Lack of effective day-to-day oversight of care provision View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sheila Margaret Gaskin · 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
Sheila Margaret Gaskin was bedbound and living at home with support from carers. After a carer assisted her to light a cigarette in bed on the evening of 20 March 2017, she was found the following morning with burns and soot markings after a fire; concerns included the absence of a prohibition on carers assisting her to smoke in bed and ineffective day-to-day oversight by care management.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to prohibit carers assisting the service user to smoke in bed
Wider context from the report “(1) The evidence revealed that there was an identified risk in the deceased's Care Plan of her smoking in bed. The Fire Service had been involved in risk assessing the situation and have provided flame retardant bedding and linen. Despite this obvious risk having been identified and implemented into the Care Plan there was nothing prohibiting carers assisting the deceased to smoke in bed which, the evidence revealed, was a regular occurrence.
(2) Management of the care provided accepted that there was no effective oversight by them on a day-to-day basis and they were unaware that carers were assisting the deceased in this way . They agreed that what was required was a blanket prohibition on carers assisting the service user in smoking which would have given greater degree of clarity.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of effective day-to-day oversight of care provision
Wider context from the report “(1) The evidence revealed that there was an identified risk in the deceased's Care Plan of her smoking in bed. The Fire Service had been involved in risk assessing the situation and have provided flame retardant bedding and linen. Despite this obvious risk having been identified and implemented into the Care Plan there was nothing prohibiting carers assisting the deceased to smoke in bed which, the evidence revealed, was a regular occurrence.
(2) Management of the care provided accepted that there was no effective oversight by them on a day-to-day basis and they were unaware that carers were assisting the deceased in this way . They agreed that what was required was a blanket prohibition on carers assisting the service user in smoking which would have given greater degree of clarity.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue reviewing regulated providers’ risk-management systems through inspections to identify unsafe care and care-plan breaches.
Verbatim wording from the response “However, that does not remove the requirement placed on providers and registered managers to ensure that they are delivering care in a safe way and doing all that is practicable to mitigate any risks. CQC will continue to review through its inspection processes the systems and processes being operated by those services it regulates and will challenge and if appropriate take enforcement action against the registered person where it finds that care is being provided in an unsafe way and is being provided contrary to the care plan.” Source location 2017-0328-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 A blanket prohibition on assisting smoking is not considered appropriate because person-centred care requires case-by-case risk assessment.
Verbatim wording from the response “With regard to the suggestion of a blanket prohibition on care workers assisting service users smoking, we are concerned that this approach is not consistent with the person-centred approach to care planning that we would expect to see. A blanket ban on this activity could inadvertently lead to a person’s care and support needs not being met in a way that promotes their needs and preferences; we would prefer that prohibition is risk assessed as appropriate on a case-by-case basis.” Source location 2017-0328-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 Existing inspection, governance and oversight processes are considered sufficient to identify key risks and ensure appropriate mitigation when operated effectively.
Verbatim wording from the response “Part of our current methodology includes inspectors making an assessment of the provider’s governance systems and how these are used to ensure that risks are managed and mitigated and the quality of assessment is under appropriate scrutiny by the registered person. Governance systems should include “spot checks” by the registered manager or delegated person to ensure that staff in the field are working in accordance with individuals’ care plans. This also enables the registered person to assess specific risks and offer guidance and support to their staff.” Source location 2017-0328-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 service was not CQC-regulated, so notification and oversight fell under CSSIW rather than CQC.
Verbatim wording from the response “We can confirm that we did not receive any statutory notification regarding Ms Gaskin’s death but we would not have expected to do so. This is because Ms Gaskin was being provided with care from Affinity Homecare Newtown, a service which is not regulated by CQC, rather falling under the jurisdiction of the Care and Social Services Inspectorate Wales (CSSIW). There would, therefore, have been no requirement placed on the service provider Affinity Homecare Newtown to inform CQC in this instance.” Source location 2017-0328-Response-by-Care-Quality-Commission
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations