1 Oct 2021 Stephen Martin Verrall · Prevention of Future Deaths report South London
View report summary
Concerns raised 3 Failure to routinely check window restrictors during regulatory inspections View source Unavailability of weekend reception monitoring to prevent residents following visitors through the exit door View source Failure to prevent unaccompanied exit by residents without capacity or ability to assess risk View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Stephen Martin Verrall · 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 Martin Verrall fell from the window of his first-floor room at St John’s Nursing Home and died from his injuries two days later. Concerns included an inadequate window restrictor, lack of a window-maintenance risk assessment, unrestricted windows remaining years later, and risks of residents leaving the home unaccompanied.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely check window restrictors during regulatory inspections
Wider context from the report “(1) Care Quality Commission – I was informed that CQC did not routinely check window restrictors on inspections . I was told that it was the responsibility of providers to comply with regulatory requirements in this regard. Whilst that is uncontroversial, the death in this case, and the fact that there remained unrestricted windows in August 2021 nearly four years after this death, demonstrated that checks by the regulator are required . Responsive checks after incidents are not sufficient to prevent 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 Unavailability of weekend reception monitoring to prevent residents following visitors through the exit door
Wider context from the report “(2) St John’s Nursing Home – I heard that Stephen had managed to leave the home unaccompanied on several occasions. The opportunity to do so for those without capacity and without the ability to assess risk poses a risk to their lives. I was told that the reception is not manned on the weekends and there is a risk that residents may follow visitors through the door when they leave .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 unaccompanied exit by residents without capacity or ability to assess risk
Wider context from the report “(2) St John’s Nursing Home – I heard that Stephen had managed to leave the home unaccompanied on several occasions . The opportunity to do so for those without capacity and without the ability to assess risk poses a risk to their lives . I was told that the reception is not manned on the weekends and there is a risk that residents may follow visitors through the door when they leave.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a targeted inspection of St John’s Nursing Home and follow up the Warning Notice to assess window safety and compliance.
Verbatim wording from the response “Following the inquest we carried out a responsive “targeted” inspection of St John’s Nursing Home. “Targeted” inspections do not change the rating from the previous inspection but allow us to identify areas requiring action from the provider. This is because they do not assess all areas of a key question.” Source location 2021-0336-Response-from-Care-Quality-Commission_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Check at the next inspection that St John’s Nursing Home has embedded its premises-security changes and is effectively minimising identified risks.
Verbatim wording from the response “In addition to inspecting St John’s Nursing Home on 13 October 2021, we also wrote to the registered provider on 21 October 2021 and asked them to provide any further information and supporting evidence about the action they have taken or intend to take in response to your report. We received a response from the registered provider on 22 October 2021.” Source location 2021-0336-Response-from-Care-Quality-Commission_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CQC will not introduce routine window-restrictor checks because provider risk management remains within its existing assessment framework.
Verbatim wording from the response “Following the hearing we have met with the CQC Policy team to discuss your specific concerns and how they relate to the regulatory requirements, in particular, Regulation 12, Safe Care and Treatment | Care Quality Commission (cqc.org.uk), Regulation 15, Premises and equipment Regulation 15: Premises and equipment | Care Quality Commission (cqc.org.uk) and Regulation 17, Good governance Regulation 17: Good governance | Care Quality Commission (cqc.org.uk).” Source location 2021-0336-Response-from-Care-Quality-Commission_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Providers remain responsible for ensuring adequate window restrictors and checking their robustness and compliance with relevant guidance.
Verbatim wording from the response ““During our inspections, inspectors do not routinely check window restrictors as part of an inspection. However, inspectors may check some restrictors where observations on the day or information we receive prior to inspection identifies concerns. However, inspectors will check the systems and processes are in place to enable the provider to assess and monitor the quality of services and to identify, assess and manage risks to ensure people are protected against the risks of receiving inappropriate or unsafe care or treatment. It is care providers responsibility to ensure there are adequate window restrictors in place. It is also the provider’s responsibility to carry out adequate checks on the window restrictors to confirm that they are sufficiently robust and complied with the relevant guidance.”” Source location 2021-0336-Response-from-Care-Quality-Commission_Published
Open published response
28 Jul 2021 Jacob · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Lack of a system for recording child-related discussions in radiology meetings View source Absence of an alert and review system for ICE results across the paediatric team View source Lack of named or responsible consultant review before child discharge View source Low compliance with the paediatric sepsis screening tool View source Login issues for locum doctors working at the Trust View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Jacob · 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
Jacob died at eleven months from acute pyelonephritis, following earlier urinary tract sepsis and severe obstruction of both ureters. Investigations identifying the obstruction were not reviewed during his life, and the seriousness of a later infection was not recognised. The report identified concerns including low compliance with paediatric sepsis screening, lack of consultant review before discharge, and inadequate systems for reviewing investigation 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 Lack of a system for recording child-related discussions in radiology meetings
Wider context from the report “4. No current system for recording a discussion about a child, in the Radiology meetings (where important investigations are planned)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 an alert and review system for ICE results across the paediatric team
Wider context from the report “3. No alert/review system for ICE results yet in place for all the Paediatric team
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of named or responsible consultant review before child discharge
Wider context from the report “2. Lack of Named/Responsible Consultant review prior to a child’s 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 Low compliance with the paediatric sepsis screening tool
Wider context from the report “1. Continuing low compliance with the Paediatric sepsis screening tool
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Login issues for locum doctors working at the Trust
Wider context from the report “5. The risk of continuing Login issues when Locum doctors are working at the Trust
” Open source report
22 Jul 2021 John Dickinson · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 7 Failure to check food records before assessing food refusal View source Inconsistent and insufficiently detailed recording of general wellbeing View source Failure to create a plan for monitoring fluid and food intake View source Delay in assessing deterioration View source Failure to record GP advice communicated at handover View source Failure to place an instruction in the room to prompt monitoring View source Lack of a single document providing a holistic view of the person View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
John Dickinson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Dickinson was admitted to hospital after falls and treatment for a gall bladder infection, then moved to a care home. He later developed poor nutritional and fluid intake, dehydration, acute kidney impairment and a urinary tract infection, and died on 9 August 2020 while receiving palliative care. Concerns included inconsistent and insufficiently detailed record keeping, failures to document or act on advice about monitoring food and fluid intake, and delayed recognition of deterioration.
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 check food records before assessing food refusal
Wider context from the report “(1) The record keeping was inconsistent and lacked detail on general wellbeing.
(2) The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained.
(3) Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020.
(4) Advice from the GP on 15th July 2020 were handed over orally at a ‘huddle’ and no record was kept as to this being mentioned.
(5) Following the GP’s visit, no action planned regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring.
(6) The inconsistent and sometimes non-existent record keeping meant that Mr Dickinson was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before he began refusing lunch and evening meal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Inconsistent and insufficiently detailed recording of general wellbeing
Wider context from the report “(1) The record keeping was inconsistent and lacked detail on general wellbeing .
(2) The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained.
(3) Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020.
(4) Advice from the GP on 15th July 2020 were handed over orally at a ‘huddle’ and no record was kept as to this being mentioned.
(5) Following the GP’s visit, no action planned regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring.
(6) The inconsistent and sometimes non-existent record keeping meant that Mr Dickinson was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before he began refusing lunch and evening meal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 plan for monitoring fluid and food intake
Wider context from the report “(1) The record keeping was inconsistent and lacked detail on general wellbeing.
(2) The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained.
(3) Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020.
(4) Advice from the GP on 15th July 2020 were handed over orally at a ‘huddle’ and no record was kept as to this being mentioned.
(5) Following the GP’s visit, no action planned regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring.
(6) The inconsistent and sometimes non-existent record keeping meant that Mr Dickinson was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before he began refusing lunch and evening meal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 assessing deterioration
Wider context from the report “(1) The record keeping was inconsistent and lacked detail on general wellbeing.
(2) The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained.
(3) Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020.
(4) Advice from the GP on 15th July 2020 were handed over orally at a ‘huddle’ and no record was kept as to this being mentioned.
(5) Following the GP’s visit, no action planned regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring.
(6) The inconsistent and sometimes non-existent record keeping meant that Mr Dickinson was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before he began refusing lunch and evening meal .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 GP advice communicated at handover
Wider context from the report “(1) The record keeping was inconsistent and lacked detail on general wellbeing.
(2) The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained.
(3) Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020.
(4) Advice from the GP on 15th July 2020 were handed over orally at a ‘huddle’ and no record was kept as to this being mentioned .
(5) Following the GP’s visit, no action planned regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring.
(6) The inconsistent and sometimes non-existent record keeping meant that Mr Dickinson was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before he began refusing lunch and evening meal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 place an instruction in the room to prompt monitoring
Wider context from the report “(1) The record keeping was inconsistent and lacked detail on general wellbeing.
(2) The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained.
(3) Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020.
(4) Advice from the GP on 15th July 2020 were handed over orally at a ‘huddle’ and no record was kept as to this being mentioned.
(5) Following the GP’s visit, no action planned regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring.
(6) The inconsistent and sometimes non-existent record keeping meant that Mr Dickinson was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before he began refusing lunch and evening meal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 single document providing a holistic view of the person
Wider context from the report “(1) The record keeping was inconsistent and lacked detail on general wellbeing.
(2) The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained .
(3) Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020.
(4) Advice from the GP on 15th July 2020 were handed over orally at a ‘huddle’ and no record was kept as to this being mentioned.
(5) Following the GP’s visit, no action planned regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring.
(6) The inconsistent and sometimes non-existent record keeping meant that Mr Dickinson was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before he began refusing lunch and evening meal.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A formal investigation was not commenced because the apparent recording failures were individual and likely concerned people outside enforcement powers.
Verbatim wording from the response “In line with CQC’s regulatory responsibilities, we continue to monitor statutory notifications and enquiries related with this service. Having considered the evidence and information available in this case, we have made the decision not to commence a formal Registered Provider investigation into Mr Dickinson’s death. Whilst we acknowledge there were some apparent failures in the recording of care,” Source location 2021-0310-Response-from-CQC_Published
Open published response
7 Jul 2021 Dorothy Seekings · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 3 Failure to record resident aggression incidents in care plans View source Failure of staff to be aware of care plan contents View source Failure to raise safeguarding alerts with the local authority 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
Dorothy Seekings · 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
Dorothy Seekings, a resident of Clifton Court Nursing Home, was found dead in her room on 8 August 2019 after another resident entered the room; a post-mortem examination showed blunt force injuries, which were probably caused by that resident. Concerns included care plans not recording the other resident’s aggressive incidents towards staff, failure to raise a safeguarding alert, and staff appearing unaware of the care plan contents.
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 record resident aggression incidents in care plans
Wider context from the report “(1) the care plans for ████████ did not record incidents where ████████ had acted aggressively to staff members including an occasion when a staff member was kicked in the mouth by ████████.
(2) the failure to raise a safeguarding alert with the local authority regarding the above incident.
(3) The staff did not appear to be aware of the contents of the care plan for ████████ or other resident
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to be aware of care plan contents
Wider context from the report “(1) the care plans for ████████ did not record incidents where ████████ had acted aggressively to staff members including an occasion when a staff member was kicked in the mouth by ████████.
(2) the failure to raise a safeguarding alert with the local authority regarding the above incident.
(3) The staff did not appear to be aware of the contents of the care plan for ████████ or other resident
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to raise safeguarding alerts with the local authority
Wider context from the report “(1) the care plans for ████████ did not record incidents where ████████ had acted aggressively to staff members including an occasion when a staff member was kicked in the mouth by ████████.
(2) the failure to raise a safeguarding alert with the local authority regarding the above incident .
(3) The staff did not appear to be aware of the contents of the care plan for ████████ or other resident
” Open source report
Concerns raised 1 Failure to physically inspect accommodation suitability before placement View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Glenn Macmartin · 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
Glenn Macmartin had Bipolar Disorder and an Acquired Brain Injury and required specific care and accommodation. He was placed in a privately owned care home, where concerns were raised about care and suboptimal note keeping; the home later closed. He was admitted to hospital and died there on 1 April 2019.
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 physically inspect accommodation suitability before placement
Wider context from the report “(1) The deceased was accommodated in a Care Home that was subsequently formally closed due to poor service.
The selection of the accommodation was made without a physical inspection of its suitability for the deceased by the organisation with responsibility for providing the accommodation before the deceased took up residence.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The local authority has a role in selecting and monitoring care services, including safeguarding, and is expected to address that role.
Verbatim wording from the response “We recognise that the Local Authority also has a role in selection and monitoring of a service, as well as in relation to safeguarding. We anticipate the Local Authority will summarise this role in their response to the Regulation 28 report.” Source location Response from CQC
Open published response
26 Apr 2021 Alan Massam · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Limited understanding of when and how to use s.9 assessments for vulnerable adults View source Lack of clear inter-agency information-sharing arrangements for complex care View source Lack of a defined escalation process for refusal of medication and fluids View source Shortage of suitable adult care beds for complex cases View source Continuation of care in a home unable to safely meet complex care needs View source Lack of guidance on ensuring a care home can accept a person back after discharge View source Lack of guidance on acute trust action when attempts to contact a care home are unsuccessful View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alan Massam · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alan Massam, a resident with dementia, had repeated falls after moving to a dementia residential home and was twice admitted to hospital. After a traumatic brain bleed and rib fractures were identified, he deteriorated and died in hospital on 24 October 2019. Concerns included inadequate information-sharing between agencies, discharge without effective communication or confirmation that the care home could meet his needs, and the absence of a clear escalation process when he refused medication and fluids.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Limited understanding of when and how to use s.9 assessments for vulnerable adults
Wider context from the report “1. The inquest heard that the care of Mr Massam was complex due to his needs but there was no clear agreement or arrangement between agencies as to how to effectively share information in complex cases.in his case mental health services were involved as was the acute trust, GP and the care home but there was limited evidence of a joint approach to ensure his care was optimised. This included a limited understanding by those involved of when and how to use of s.9 assessments to reduce the risk to a vulnerable adult such as Mr Massam.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 inter-agency information-sharing arrangements for complex care
Wider context from the report “1. The inquest heard that the care of Mr Massam was complex due to his needs but there was no clear agreement or arrangement between agencies as to how to effectively share information in complex cases .in his case mental health services were involved as was the acute trust, GP and the care home but there was limited evidence of a joint approach to ensure his care was optimised . This included a limited understanding by those involved of when and how to use of s.9 assessments to reduce the risk to a vulnerable adult such as Mr Massam.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 defined escalation process for refusal of medication and fluids
Wider context from the report “3. The staff at the home were aware of the prescribing of medication including antibiotics. However when he refused them and fluids there was no defined escalation process which would ensure that the risk this presented was recognised and acted on .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Shortage of suitable adult care beds for complex cases
Wider context from the report “4. Once the initial home could not manage Mr Massam and served a notice on the family there was a significant pressure to find another home that would accept him. Whilst the search was undertaken he remained in a home where staff felt they could no longer safely meet his care needs. The inquest heard that this search was exacerbated by a national shortage of suitable beds within the adult care sector for complex cases such as Mr Massam .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Continuation of care in a home unable to safely meet complex care needs
Wider context from the report “4. Once the initial home could not manage Mr Massam and served a notice on the family there was a significant pressure to find another home that would accept him. Whilst the search was undertaken he remained in a home where staff felt they could no longer safely meet his care needs . The inquest heard that this search was exacerbated by a national shortage of suitable beds within the adult care sector for complex cases such as Mr Massam.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on ensuring a care home can accept a person back after discharge
Wider context from the report “2. Mr Massam was discharged back to the care home by the acute trust. The inquest heard that the home would not have accepted him back if they had been spoken to as they did not feel they could meet his needs. The inquest heard that there is no national guidance/protocol about what an acute trust should do if attempts to contact a home are unsuccessful or about the obligation to ensure the home can accept him back in such circumstances as these.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on acute trust action when attempts to contact a care home are unsuccessful
Wider context from the report “2. Mr Massam was discharged back to the care home by the acute trust. The inquest heard that the home would not have accepted him back if they had been spoken to as they did not feel they could meet his needs. The inquest heard that there is no national guidance/protocol about what an acute trust should do if attempts to contact a home are unsuccessful or about the obligation to ensure the home can accept him back in such circumstances as these.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake an unannounced targeted inspection of Lisburne Court covering the concerns raised in the prevention of future death report.
Verbatim wording from the response “Upon receipt of the concerns raised within the Regulation 28 report issued to CQC by the Coroner on 26 April 2021 a decision was made to undertake an unannounced targeted inspection of Lisburne Court. The findings of this inspection will be shared with the Coroner. This will be completed to ensure that the circumstances of Mr Massam’s death do not reflect any ongoing risk to people currently living at the home.” Source location 2021-0120-Response-from-CQC-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Developing policy and procedures for integrated care and communication is outside the regulator’s direct remit.
Verbatim wording from the response “Whilst the CQC have no direct remit in developing policy and procedures to support integrated care and optimal communication, during inspection of a service the CQC will look at joint arrangements and how systems work to facilitate the transfer of care from one setting to another. This is considered against Regulation 12 (1) (2) (i) (j) of the Health and Social Care Act 2008 (Regulated Activities) regulations 2014 which states;” Source location 2021-0120-Response-from-CQC-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Cases where registered-service staff cannot safely meet someone’s needs are referred to the Local Authority under safeguarding protocols.
Verbatim wording from the response “The CQC have no direct remit relating to the number of suitable beds within the adult social care sector for complex cases such as Mr Massam’s. However, if the CQC receives information that staff at a registered service feel they can no longer safely meet a person’s needs we will refer the case to the Local Authority under our safeguarding protocols. The CQC will also seek assurances from the care home about how they intend to keep the person safe whilst a more suitable placement is found.” Source location 2021-0120-Response-from-CQC-Redacted
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 number of suitable adult social care beds for complex cases is outside the regulator’s direct remit.
Verbatim wording from the response “The CQC have no direct remit relating to the number of suitable beds within the adult social care sector for complex cases such as Mr Massam’s. However, if the CQC receives information that staff at a registered service feel they can no longer safely meet a person’s needs we will refer the case to the Local Authority under our safeguarding protocols. The CQC will also seek assurances from the care home about how they intend to keep the person safe whilst a more suitable placement is found.” Source location 2021-0120-Response-from-CQC-Redacted
Open published response
Concerns raised 21 Lack of procedures for safeguarding care data View source Lack of procedures for care handovers View source Failure to implement procedures for displaying SALT and allergy advice in service users’ kitchens View source Failure to incorporate significant relevant factors into regulatory risk assessment View source Failure to provide updated care information to visiting professionals View source Delays in CQC access to police and provider records after a significant event View source Inadequate safeguarding of service-user information on staff personal mobile phones View source Over-reliance on WhatsApp for care-plan updates causing delays in updating home support plans View source Unclear SALT guidance on consistency descriptions and modified or avoided foods View source Failure to promptly share policy and legislative changes through the organisation’s website View source Lack of contingency planning for sickness of the Director View source Lack of consistency in CQC decisions on using evidence for inspections or regulatory action View source Lack of procedures governing completion, storage, updating and review of risk assessments and care plans View source Lack of procedures for auditing care documentation and practice View source Failure to assign lead-carer responsibility for accurate and current home documentation View source Failure to maintain correct care plans and risk assessments at service users’ home addresses View source Failure to communicate care-plan updates to all caring staff View source Lack of understanding of the Mental Capacity Act in care delivery View source Failure to escalate regulatory risk in response to provider non-engagement and lack of an action plan View source Lack of a transparent and candid organisational culture View source Inaccurate and misleading regulatory inspection reporting View source See 18 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Anthony Wilkinson · 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
Anthony Wilkinson died on 4 April 2018 after choking, with the inquest concluding that he was unlawfully killed as a result of foreign body obstruction of the airway. The report identifies concerns about the failure to incorporate Speech and Language Therapy advice on diet and supervision into care plans, risk assessments and staff communications, alongside wider concerns about care-provider governance and regulatory oversight.
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 procedures for safeguarding care data
Wider context from the report “(11)I did not hear or see any evidence of any policy or procedure being in place at the Stars Social Support Limited which related to completion of risk assessments and care plans; where they will be kept; how they should be updated; who will look at them and where; what to do in the event that there isn't one; how documents should be presented; how technology will be used; how data will be safeguarded ; how audits will be undertaken; how handovers will be undertaken. This list is not exhaustive it is simply a list of some of the areas I am particularly concerned about in this case however I have not seen evidence of any policies produced by Stars Social Support Limited despite asking specifically for this at the end of the inquest proceedings. I have seen only an induction booklet.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of procedures for care handovers
Wider context from the report “(11)I did not hear or see any evidence of any policy or procedure being in place at the Stars Social Support Limited which related to completion of risk assessments and care plans; where they will be kept; how they should be updated; who will look at them and where; what to do in the event that there isn't one; how documents should be presented; how technology will be used; how data will be safeguarded; how audits will be undertaken; how handovers will be undertaken . This list is not exhaustive it is simply a list of some of the areas I am particularly concerned about in this case however I have not seen evidence of any policies produced by Stars Social Support Limited despite asking specifically for this at the end of the inquest proceedings. I have seen only an induction booklet.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to implement procedures for displaying SALT and allergy advice in service users’ kitchens
Wider context from the report “(7) There was no evidence that fundamental matters such as standard operating procedures for displaying SALT advice or allergy advice in a service users’ kitchen where all can see it have been implemented by the Stars Social Support Limited.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate significant relevant factors into regulatory risk assessment
Wider context from the report “(15)CQC did not take into consideration significant relevant factors when risk assessing this care provider at the start of the pandemic leading to an inappropriate risk profile being established and an exaggerated level of confidence being placed in the provider to provide safe services to residents without appropriate monitoring and oversight from the Regulator.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 updated care information to visiting professionals
Wider context from the report “(6) Secondly, visiting professionals are not able to access the WhatsApp group and therefore will not be in receipt of this updated information which may be important for some service users.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 CQC access to police and provider records after a significant event
Wider context from the report “(13)CQC did not take adequate steps to access records held by the Police or the provider in a timely fashion following Tony's death. This potentially created risk to other service users as the Regulator had not inspected the service promptly following a significant event.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 safeguarding of service-user information on staff personal mobile phones
Wider context from the report “(4) Stars Social Support Limited have implemented the use of WhatsApp to ensure staff are aware of updates to service users plans and they require staff to confirm they have read and understood the update prior to caring for an individual. Whilst this is a positive use of technology to support staff in caring for service users it is in itself a safeguarding issue to hold personal information about the service user on personal mobile phones ; this is especially the case where there are not adequate policies in place around the use of personal phones by staff members .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on WhatsApp for care-plan updates causing delays in updating home support plans
Wider context from the report “(5) The use of the WhatsApp group adds in two risks of its own, the first is that there is an over reliance on this being the means by which service users care plans are updated and by default this ends up being the service users care plan. This makes it more likely rather than less likely in my view that support plans in the service users’ home will not be updated in a timely fashion .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Unclear SALT guidance on consistency descriptions and modified or avoided foods
Wider context from the report “(18)The advice from SALT was not an issue in this case, it was the application of this advice which was the primary concern. I would like to commend the approach that the Trust have taken in learning from the issues which I raised at the conclusion of the proceedings and the openness with which the Trust have received the concerns I had. The guidance sheets which have been produced are still not clear enough and will lead to confusion including around the consistency description and a list of foods which can be modified or should be avoided . This needs to be reviewed to avoid confusion.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly share policy and legislative changes through the organisation’s website
Wider context from the report “(2) Stars Social Support Limited do not utilise their own website to ensure that policy and legislative changes can be adequately and promptly shared with service users, their families, and staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of contingency planning for sickness of the Director
Wider context from the report “(9) There is now a significant reliance on the Director updating all records and delivering care and undertaking audits whilst she improves the culture of the organisation. There was no adequate description of contingency plans in the event of sickness of this individual .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 consistency in CQC decisions on using evidence for inspections or regulatory action
Wider context from the report “(17)Where CQC are required to decide whether evidence ought to be used for the basis of an inspection OR for regulatory action, they ought to ensure there is a consistent approach to this including the consideration of policies and standard operating procedures . This should be approached on the basis of safeguarding the majority of remaining service users from harm being the priority even where that means prosecutions for breaches of Regulation may be compromised.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of procedures governing completion, storage, updating and review of risk assessments and care plans
Wider context from the report “(11)I did not hear or see any evidence of any policy or procedure being in place at the Stars Social Support Limited which related to completion of risk assessments and care plans; where they will be kept; how they should be updated; who will look at them and where; what to do in the event that there isn't one; how documents should be presented ; how technology will be used; how data will be safeguarded; how audits will be undertaken; how handovers will be undertaken. This list is not exhaustive it is simply a list of some of the areas I am particularly concerned about in this case however I have not seen evidence of any policies produced by Stars Social Support Limited despite asking specifically for this at the end of the inquest proceedings. I have seen only an induction booklet.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of procedures for auditing care documentation and practice
Wider context from the report “(11)I did not hear or see any evidence of any policy or procedure being in place at the Stars Social Support Limited which related to completion of risk assessments and care plans; where they will be kept; how they should be updated; who will look at them and where; what to do in the event that there isn't one; how documents should be presented; how technology will be used; how data will be safeguarded; how audits will be undertaken ; how handovers will be undertaken. This list is not exhaustive it is simply a list of some of the areas I am particularly concerned about in this case however I have not seen evidence of any policies produced by Stars Social Support Limited despite asking specifically for this at the end of the inquest proceedings. I have seen only an induction booklet.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 assign lead-carer responsibility for accurate and current home documentation
Wider context from the report “(10)The Director, in evidence, did not describe consideration of a lead carer for service users who would hold some responsibility for ensuring documentation in the service users’ home was accurate and up to date .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain correct care plans and risk assessments at service users’ home addresses
Wider context from the report “(3) Stars Social Support Limited do not have appropriate policies, procedures and checks in place to ensure that updates to care plans are communicated to all staff caring for service users or that the correct care and support plans, and risk assessments, are in the service users home address .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 communicate care-plan updates to all caring staff
Wider context from the report “(3) Stars Social Support Limited do not have appropriate policies, procedures and checks in place to ensure that updates to care plans are communicated to all staff caring for service users or that the correct care and support plans, and risk assessments, are in the service users home address.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 understanding of the Mental Capacity Act in care delivery
Wider context from the report “(8) There remained a lack of understanding about the mental capacity act and how that may affect the care delivery to service users where it meant that a carer or senior manager had to be the decision maker for specific aspects of their care such as nutrition or medication
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate regulatory risk in response to provider non-engagement and lack of an action plan
Wider context from the report “(14)CQC too readily accepted the lack of an action plan from the provider and did not use this lack of engagement from the provider to increase the risk profile for this provider. Had they done so an earlier re inspection may have been triggered or further regulatory action. This failure may have exposed other service users to unnecessary risk of harm as a result of an inaccurate risk picture being provided by the CQC.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 transparent and candid organisational culture
Wider context from the report “(1) Stars Social Support Limited have a culture which does not encourage transparency or embrace the duty of candour . This was evidenced throughout the inquest proceedings and in the lack of engagement with CQC during the inspection regime.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Inaccurate and misleading regulatory inspection reporting
Wider context from the report “(16)The report from the August 2020 inspection was inaccurate and misleading and may have caused service users to be added to this service where that ought not to be the case. The report published in October 2020 refers to their being no evidence of harm however there is a woeful lack of detail about the context of this within the report .
” 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 report-writing guidance to determine whether changes are needed to contextualise statements about harm and specific incidents.
Verbatim wording from the response “This incident is subject to a criminal investigation and as a result this inspection did not examine the circumstances of the incident.’ At that time CQC guidance in relation to report writing, did not require CQC inspection reports to reference the specific incident in future reports, only in the report where the incident prompted the inspection. This remains CQC’s guidance on reporting on specific incidents. This regulation 28 report will be referred to the CQC policy team to consider whether the guidance needs to be reviewed.” Source location 2021-0102-Response-from-CQC-Redacted
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 policy on handling evidence shared between inspection, civil enforcement and criminal investigation processes.
Verbatim wording from the response “Evidence gathered during the course of an inspection will feed into inspection reports and where relevant civil enforcement action. The information may lead CQC to carry out a criminal investigation, but the evidence gathered during a criminal investigation will not be detailed in an inspection report. A report must provide an accurate reflection of what is happening at a service, but that does not require the report to detail the criminal investigation.” Source location 2021-0102-Response-from-CQC-Redacted
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 Refer concerns about report-writing guidance to the policy team for consideration and further review.
Verbatim wording from the response “This incident is subject to a criminal investigation and as a result this inspection did not examine the circumstances of the incident.’ At that time CQC guidance in relation to report writing, did not require CQC inspection reports to reference the specific incident in future reports, only in the report where the incident prompted the inspection. This remains CQC’s guidance on reporting on specific incidents. This regulation 28 report will be referred to the CQC policy team to consider whether the guidance needs to be reviewed.” Source location 2021-0102-Response-from-CQC-Redacted
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 Implement shorter, clearer inspection-report guidance incorporating relevant service context and background information.
Verbatim wording from the response “Historically CQC did have lengthier reports, which similarly conveyed the level of detail as explained in your example. However, following a lengthy review/consultation period with commissioners/providers and the general public, about what information we should include in CQC reports, it highlighted a need to change our house style. The results of this review showed some reports were inconsistent in content from service to service, were difficult to understand, and did not effectively support people or commissioners to make an informed choice about care services. Another common theme was that many people who accessed our reports on our website did not read the inspection reports beyond the first page. The shorter report guidance was implemented in January 2019 to address comments from our main audience, commissioners and the general public.” Source location 2021-0102-Response-from-CQC-Redacted
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, inspecting and regulating the provider with service-user safety as the priority.
Verbatim wording from the response “This ensured during the pandemic, that CQC continued to carry out their regulatory function when there was extreme risk at a service. This was determined on a case by case basis. CQC’s inspection priorities remained under continuous review in line with national priorities, but our monitoring of Stars Social Support as well as their failure to provide a completed action plan in relation to the breach of regulation 19, was not assessed as an ‘extreme’ risk in all of the circumstances. CQC monitored all ASC care providers throughout the pandemic and has implemented several systems to support remote monitoring of services. A decision was taken not to inspect the service at this time and the team considered the providers failure to submit an action plan when reaching this determination.” Source location 2021-0102-Response-from-CQC-Redacted
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 Implement a monitoring system that analyses service intelligence and generates prioritisation scores to identify services most at risk.
Verbatim wording from the response “CQC’s approach to monitoring services at the beginning of the pandemic in lieu of changes to routine inspections was reviewed in December 2020 and CQC implemented a monitoring system to improve the approach that had been taken up until that date. This system analyses intelligence we hold about services and” Source location 2021-0102-Response-from-CQC-Redacted
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 action plan was requested for the Warning Notice because enforcement policy did not require one; the remaining breach posed no serious risk.
Verbatim wording from the response “We understand point 14 refers to the re-inspection of Stars Social Support following the February 2019 inspection, where the local team identified two breaches of regulations. Civil enforcement action was taken; a Warning Notice was served against the breach of regulation 17; and a Requirement Notice was served against the breach of regulation 19. As a Warning Notice was served, we did not request an action plan in line with CQC Enforcement Policy. We did, however, request an action plan be submitted to CQC by 29 May 2019 for the” Source location 2021-0102-Response-from-CQC-Redacted
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 October 2020 report will not be amended retrospectively because guidance excludes specific incidents unless they prompted the inspection.
Verbatim wording from the response “Section 6, Point 8 – Care Quality Commission should urgently review the report related to this provider from October 2020 and correct any errors or misleading statements within it.” Source location 2021-0102-Response-from-CQC-Redacted
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 Reports need not detail criminal investigations because inspection reports accurately describe current regulatory findings under the established reporting approach.
Verbatim wording from the response “Evidence gathered during the course of an inspection will feed into inspection reports and where relevant civil enforcement action. The information may lead CQC to carry out a criminal investigation, but the evidence gathered during a criminal investigation will not be detailed in an inspection report. A report must provide an accurate reflection of what is happening at a service, but that does not require the report to detail the criminal investigation.” Source location 2021-0102-Response-from-CQC-Redacted
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 Earlier reinspection was not undertaken during the pandemic because inspections required an extreme risk threshold and assessed risks did not meet it.
Verbatim wording from the response “CQC acknowledged at the Prevention of Future Deaths hearing that the re-inspection of Stars Social Support (completed on 27 August 2020 to 3 September 2020) fell outside of our usual timeframe of re-inspecting a service, rated requires improvement, 12 months from the last inspection publication date. However at that time, the decision not to inspect the service sooner we feel was justified and proportionate. COVID-19 resulted in CQC adapting its inspection priorities during the pandemic to ensure risk and people’s safety were the highest priority. A decision was taken by the CQC that during the pandemic, CQC would take on a more supportive role, as well as not adding to the overall risk and pressures COVID-19 presented to the rest of the health and social care sector. As at May 2020, there needed to be an “extreme” level of risk for CQC to cross the threshold for inspection.” Source location 2021-0102-Response-from-CQC-Redacted
Open published response
Concerns raised 5 Failure to provide assurance that patient-safety surveys inspect each relevant bedroom for hazards such as ligature points View source Incomplete Risk Assessment/Safety Summary process for assessing and protecting patients View source Failure to print medical notes and other documents from the Trust IT system in shared premises View source Failure to upload PDF medical records and important information promptly in original form to the electronic notes system View source Limited coverage of the Bed Manager function to one Trust region 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
Mina TOPLEY-BIRD · 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
Mina TOPLEY-BIRD, who had a severe and enduring mental illness and a history of suicide and self-harm attempts, was admitted to West Park Hospital after attempting to run into traffic and stab herself. On 8 May 2019, after being told that no bed was available for her in London, she said words to the effect of “I may as well kill myself”; she was later found hanging in her room and pronounced dead. Concerns included incomplete access to historic medical records, inability to print and share documents across NHS Trust systems, uncertainty about ligature-point assessments, limited bed-management coverage, and incomplete risk-assessment and safety-summary processes.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to provide assurance that patient-safety surveys inspect each relevant bedroom for hazards such as ligature points
Wider context from the report “3. The Trust (TEWV) in evidence heard that the Elm Ward at West Park Hospital had been surveyed for issues related to patient safety such as ligature points. Whilst the evidence was that the Trust was confident this had been done, no assurance could be given . One such assessment did not show clearly if the deceased's bedroom had been inspected for issues such as ligature points .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 Risk Assessment/Safety Summary process for assessing and protecting patients
Wider context from the report “5. The Trust gave evidence that the Risk Assessment/Safety Summary process for assessing and protecting patients had been improved, but accepted it was still 'a work in progress' and further work was required . It is of concern that this aspect of area of patient safeguarding appears on the evidence given at inquest not to be complete .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 print medical notes and other documents from the Trust IT system in shared premises
Wider context from the report “2. It became apparent on the evidence that whilst Trust staff were working in premises operated by another Trust (in this case, County Durham and Darlington NHS Foundation Trust - CDDFT) they could not print medical notes and other documents from the TEWV IT system onto printers in 'shared' premises such as the A&E Department of the CDDFT . This again meant important documents can be unable to be shared with staff undertaking such tasks as Mental Health Assessments .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to upload PDF medical records and important information promptly in original form to the electronic notes system
Wider context from the report “1. Evidence was heard that medical records and other important information could not be uploaded to the Trust's electronic notes system - PARIS when received in PDF form . This meant staff had to precis notes onto the system, in this case when one person was working alone, on a nightshift was required to do this whilst dealing with a variety of different tasks. Important documents that cannot not to be uploaded immediately and in their original form concerns me that attending clinicians do not have access to these documents and can be hindered in making clinical decisions without 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 Limited coverage of the Bed Manager function to one Trust region
Wider context from the report “4. Evidence was heard that within the Durham & Darlington area of the TEWV Trust funding had been secured for the post of a Bed Manager, who was to manage bed allocation, transfer and discharges to better manage access to beds for patients across this area of the Durham & Darlington area of the Trust. It was heard this role would be able to more proactively arrange transfers of patients from Trust to Trust as was a need raised in this inquest. It was disclosed that this post only operated in the Durham & Darlington area of the Trust and not across the whole Trust . On the evidence heard this post has obvious benefits for ensuring patients access to beds and I raise a concern this post is not one which cover the whole of the Trust, only one region of it .
” Open source report
Concerns raised 4 Failure to report falls-related matters to regulatory bodies View source Delayed staff supervision and discussion of falls prevention View source Failure to commence a timely investigation of falls-related matters View source Failure to apply falls risk assessment and prevention procedures 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
Pauline BRUMFITT · 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
Pauline BRUMFITT died on 15 April 2020 after a fall at a care home led to hospital admission and diagnosis of an intracranial bleed. The concerns were that falls risk assessments, prevention measures and referrals were not implemented after her previous falls, and that the incident was not promptly reported or investigated.
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 report falls-related matters to regulatory bodies
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The policies and procedures in existence at the care home pertaining to falls risk assessment and prevention were not applied to Pauline Brumfitt (as stated above) as they should have been.
(2) Pauline fell on 3 occasions and the opportunities to assess Pauline’s risks and take appropriate action to prevent further falls were not taken as they should have been.
(3) The matter was (given in evidence) not reported to the regulatory bodies and again as given in evidence an investigation had not been commenced at the time of the inquest and staff supervision/discussion re falls prevention had only been commenced in Feb/March 2021, appropriate timely action could have helped (and could still help) to prevent future deaths in similar circumstances where dependent elderly residents are at risk of falling and suffering serious injury/death as a consequence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Delayed staff supervision and discussion of falls prevention
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The policies and procedures in existence at the care home pertaining to falls risk assessment and prevention were not applied to Pauline Brumfitt (as stated above) as they should have been.
(2) Pauline fell on 3 occasions and the opportunities to assess Pauline’s risks and take appropriate action to prevent further falls were not taken as they should have been.
(3) The matter was (given in evidence) not reported to the regulatory bodies and again as given in evidence an investigation had not been commenced at the time of the inquest and staff supervision/discussion re falls prevention had only been commenced in Feb/March 2021 , appropriate timely action could have helped (and could still help) to prevent future deaths in similar circumstances where dependent elderly residents are at risk of falling and suffering serious injury/death as a consequence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to commence a timely investigation of falls-related matters
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The policies and procedures in existence at the care home pertaining to falls risk assessment and prevention were not applied to Pauline Brumfitt (as stated above) as they should have been.
(2) Pauline fell on 3 occasions and the opportunities to assess Pauline’s risks and take appropriate action to prevent further falls were not taken as they should have been.
(3) The matter was (given in evidence) not reported to the regulatory bodies and again as given in evidence an investigation had not been commenced at the time of the inquest and staff supervision/discussion re falls prevention had only been commenced in Feb/March 2021, appropriate timely action could have helped (and could still help) to prevent future deaths in similar circumstances where dependent elderly residents are at risk of falling and suffering serious injury/death as a consequence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to apply falls risk assessment and prevention procedures
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The policies and procedures in existence at the care home pertaining to falls risk assessment and prevention were not applied to Pauline Brumfitt (as stated above) as they should have been.
(2) Pauline fell on 3 occasions and the opportunities to assess Pauline’s risks and take appropriate action to prevent further falls were not taken as they should have been .
(3) The matter was (given in evidence) not reported to the regulatory bodies and again as given in evidence an investigation had not been commenced at the time of the inquest and staff supervision/discussion re falls prevention had only been commenced in Feb/March 2021, appropriate timely action could have helped (and could still help) to prevent future deaths in similar circumstances where dependent elderly residents are at risk of falling and suffering serious injury/death as a consequence.
” Open source report
26 Mar 2021 Rachel Bernadette Johnston · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 4 Failure to prevent nursing staff from working at Pirton Grange again when appropriate after investigation View source Failure to identify and investigate possible misconduct by nursing staff View source Failure to impose interim suspension of nursing staff where needed to protect residents View source Failure to report likely nursing staff misconduct to the NMC 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
Rachel Bernadette Johnston · 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
Rachel Bernadette Johnston, who had significant physical and learning disabilities, underwent dental surgery and was discharged to Pirton Grange Nursing Home, where she developed aspiration pneumonia and an unsurvivable hypoxic brain injury. She died there on 13 November 2018. The principal concerns were inadequate physiological observations and failure to seek emergency medical assistance, followed by inadequate internal investigation and disciplinary procedures concerning the nurses involved, including delayed reporting to the NMC.
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 nursing staff from working at Pirton Grange again when appropriate after investigation
Wider context from the report “(1) Following Rachel’s death, there appears to have been no adequate internal investigation or disciplinary procedure which was able to identify the gross failings of the nurses mentioned above. Accordingly, both nurses continued working at Pirton Grange for some time, without any action being taken to ensure that patients were not put at risk by their actions. Furthermore, no effort was made to report the conduct of the nurses concerned to the Nursing and Midwifery Council ( NMC ), the appropriate regulatory body, until February 2021, over 2 years after Rachel’s death;
(2) Even now, there appears to be no Policy in place at Pirton Grange which sets out a suitable and robust procedure for:
(a) identifying and investigating possible misconduct by nursing staff, e.g. where they have ignored a Policy;
(b) imposing an interim suspension on a member of the nursing staff, pending the completion of such an investigation, if in the interests of ensuring the ongoing safety of residents;
(c) if appropriate after the investigation has been completed, ensuring that member of the nursing staff does not work at Pirton Grange again ; and
(d) if the internal investigation has identified likely misconduct, reporting that member of the nursing staff to the NMC.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 and investigate possible misconduct by nursing staff
Wider context from the report “(1) Following Rachel’s death, there appears to have been no adequate internal investigation or disciplinary procedure which was able to identify the gross failings of the nurses mentioned above . Accordingly, both nurses continued working at Pirton Grange for some time, without any action being taken to ensure that patients were not put at risk by their actions. Furthermore, no effort was made to report the conduct of the nurses concerned to the Nursing and Midwifery Council ( NMC ), the appropriate regulatory body, until February 2021, over 2 years after Rachel’s death;
(2) Even now, there appears to be no Policy in place at Pirton Grange which sets out a suitable and robust procedure for:
(a) identifying and investigating possible misconduct by nursing staff, e.g. where they have ignored a Policy ;
(b) imposing an interim suspension on a member of the nursing staff, pending the completion of such an investigation, if in the interests of ensuring the ongoing safety of residents;
(c) if appropriate after the investigation has been completed, ensuring that member of the nursing staff does not work at Pirton Grange again; and
(d) if the internal investigation has identified likely misconduct, reporting that member of the nursing staff to the NMC.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 impose interim suspension of nursing staff where needed to protect residents
Wider context from the report “(1) Following Rachel’s death, there appears to have been no adequate internal investigation or disciplinary procedure which was able to identify the gross failings of the nurses mentioned above. Accordingly, both nurses continued working at Pirton Grange for some time, without any action being taken to ensure that patients were not put at risk by their actions . Furthermore, no effort was made to report the conduct of the nurses concerned to the Nursing and Midwifery Council ( NMC ), the appropriate regulatory body, until February 2021, over 2 years after Rachel’s death;
(2) Even now, there appears to be no Policy in place at Pirton Grange which sets out a suitable and robust procedure for:
(a) identifying and investigating possible misconduct by nursing staff, e.g. where they have ignored a Policy;
(b) imposing an interim suspension on a member of the nursing staff, pending the completion of such an investigation, if in the interests of ensuring the ongoing safety of residents ;
(c) if appropriate after the investigation has been completed, ensuring that member of the nursing staff does not work at Pirton Grange again; and
(d) if the internal investigation has identified likely misconduct, reporting that member of the nursing staff to the NMC.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 report likely nursing staff misconduct to the NMC
Wider context from the report “(1) Following Rachel’s death, there appears to have been no adequate internal investigation or disciplinary procedure which was able to identify the gross failings of the nurses mentioned above. Accordingly, both nurses continued working at Pirton Grange for some time, without any action being taken to ensure that patients were not put at risk by their actions. Furthermore, no effort was made to report the conduct of the nurses concerned to the Nursing and Midwifery Council ( NMC ), the appropriate regulatory body, until February 2021, over 2 years after Rachel’s death ;
(2) Even now, there appears to be no Policy in place at Pirton Grange which sets out a suitable and robust procedure for:
(a) identifying and investigating possible misconduct by nursing staff, e.g. where they have ignored a Policy;
(b) imposing an interim suspension on a member of the nursing staff, pending the completion of such an investigation, if in the interests of ensuring the ongoing safety of residents;
(c) if appropriate after the investigation has been completed, ensuring that member of the nursing staff does not work at Pirton Grange again; and
(d) if the internal investigation has identified likely misconduct, reporting that member of the nursing staff to the NMC .
” Open source report
25 Mar 2021 Azra Parveen HUSSAIN · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 7 Failure to provide families with direct remote participation in MDT meetings View source Failure to raise incident reports for significant suicide-related information View source Failure to record significant family concerns and patient accounts View source Failure to update risk screens after significant changes in presentation View source Failure to remove or mitigate ligature risks from bedroom-area doors View source Failure to communicate significant risk information in handovers and MDTs View source Continuing ligature risk from en-suite and other doors in unobserved areas of mental health units View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Azra Parveen HUSSAIN · 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
Azra Parveen HUSSAIN was found hanging from her en-suite bathroom door at Mary Seacole House on 6 May 2020 and could not be resuscitated. Concerns included that information from her family about a reported ligature attempt was not recorded, shared or used to reassess her risk, and that high-risk bathroom doors and other bedroom-area doors lacked adequate ligature mitigation. The inquest jury also identified missed opportunities concerning ECT treatment and suicide-risk 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 provide families with direct remote participation in MDT meetings
Wider context from the report “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated, an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 raise incident reports for significant suicide-related information
Wider context from the report “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated, an incident report was not raised , and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 family concerns and patient accounts
Wider context from the report “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra . Her risk screen was not updated, an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 update risk screens after significant changes in presentation
Wider context from the report “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated , an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 remove or mitigate ligature risks from bedroom-area doors
Wider context from the report “2. BSMHT had risk assessed ward 2 for ligature points, including the en-suite bathrooms, in November 2019. The en-suite bathroom doors were given the highest risk score possible on an acute ward, but no corrective action was identified to remove or mitigate the risk : the risk assessment relied on clinical assessment and observation of the service user to mitigate the risk. Evidence was given at the inquest that pressure sensor alarms have been available in the UK from numerous manufactures for 10 years. BSMHT had been investigating and testing different pressure sensor alarms for en-suite bathroom doors for approximately 2 years before Azra's death. BSMHT has now identified an appropriate pressure sensor for en-suite bathroom doors and the en-suite bathroom door of room 14 on ward 2 was replaced in November 2020 with a door incorporating a pressure sensor alarm. BSMHT has a 17 month program to fit pressure sensor alarms to all en-suite bathroom doors within its inpatient units. However, this is not being considered for other doors within the bedroom area nor is there any national requirement for in-patient mental health units to place, or consider placing, pressure sensor alarms on doors within areas where patients are afforded privacy and time alone. I am concerned that within BSMHT's inpatient units there will be a continuing risk from other doors in the bedroom area (including the main bedroom door) even when the en-suite bathroom doors are fitted with pressure sensor alarms. Although the outer face of a bedroom door will be on a communal corridor, service users on level 1 and 2 observations will have periods where they are unobserved in their rooms and could wedge a ligature at the top of a door so that it wasn't obviously visible from outside. Furthermore, in the absence of any national regulations or guidance on this topic the risk from en-suite and other doors in areas where service users spend time unobserved will persist in mental health units operated by other Trusts and private providers around the country.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate significant risk information in handovers and MDTs
Wider context from the report “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated, an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020 . Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Continuing ligature risk from en-suite and other doors in unobserved areas of mental health units
Wider context from the report “2. BSMHT had risk assessed ward 2 for ligature points, including the en-suite bathrooms, in November 2019. The en-suite bathroom doors were given the highest risk score possible on an acute ward, but no corrective action was identified to remove or mitigate the risk: the risk assessment relied on clinical assessment and observation of the service user to mitigate the risk. Evidence was given at the inquest that pressure sensor alarms have been available in the UK from numerous manufactures for 10 years. BSMHT had been investigating and testing different pressure sensor alarms for en-suite bathroom doors for approximately 2 years before Azra's death. BSMHT has now identified an appropriate pressure sensor for en-suite bathroom doors and the en-suite bathroom door of room 14 on ward 2 was replaced in November 2020 with a door incorporating a pressure sensor alarm. BSMHT has a 17 month program to fit pressure sensor alarms to all en-suite bathroom doors within its inpatient units. However, this is not being considered for other doors within the bedroom area nor is there any national requirement for in-patient mental health units to place, or consider placing, pressure sensor alarms on doors within areas where patients are afforded privacy and time alone. I am concerned that within BSMHT's inpatient units there will be a continuing risk from other doors in the bedroom area (including the main bedroom door) even when the en-suite bathroom doors are fitted with pressure sensor alarms. Although the outer face of a bedroom door will be on a communal corridor, service users on level 1 and 2 observations will have periods where they are unobserved in their rooms and could wedge a ligature at the top of a door so that it wasn't obviously visible from outside. Furthermore, in the absence of any national regulations or guidance on this topic the risk from en-suite and other doors in areas where service users spend time unobserved will persist in mental health units operated by other Trusts and private providers around the country .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor the trust’s ligature-risk and care-planning improvements through monthly leadership meetings and weekly progress reports.
Verbatim wording from the response “Conditions were placed on the trust’s registration certificate by CQC following the inspection on 23 November 2020 which identified concerns in relation to ligature risks, risk assessment and care planning. The Trust has complied with our conditions and have been submitting monthly updates on their progress to replace doors and improve care planning. Inspectors have been meeting monthly with the trust leadership team to discuss the progress and improvements made to date. As a result of the meetings CQC has asked for weekly reports on the ward improvements programmes to understand ongoing mitigation whilst the replacement of en-suite doors is incomplete.” Source location 2021-0082-Response-from-CQC-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CQC inspections assess overall ligature-risk mitigation and do not specifically check whether doors have pressure sensors.
Verbatim wording from the response “There is currently no national requirement, regulations or guidance for in-patient mental health units to place pressure sensors on doors. Any such guidance would be produced by NHS Estates in their building’s guidance. When CQC inspects a service of this nature, as part of the inspection we check the providers compliance with ligature risks as part of the safe domain and we check the environment is suitable for use as part of our assessment. An inspection team would not check specifically for pressure sensors on doors. If we find ligature risks to be present, we establish if the trust has identified and mitigated that risk. Failure to do so represents a breach of regulations that may result in enforcement action.” Source location 2021-0082-Response-from-CQC-Redacted
Open published response
Concerns raised 17 Failure to expedite emergency MRI scanning and document escalation attempts View source Failure by treating clinicians to recognise and record activation of the septic shock pathway View source Independent operation of adverse-incident review and Legal Services departments View source Failure to obtain family views and concerns during the adverse-death review View source Inappropriate and undocumented prioritisation of urgent MRI scans View source Incomplete investigation of suspected high cervical-spine infection View source Delays in completing adverse-death review reports View source Radiology scan prioritisation dependent on personal clinician attendance or discussion rather than clinical need View source Failure to identify the responsible specialty and document its management in medical records View source Failure to perform the required contrast MRI scan initially View source Ineffectual detection of adverse outcomes after tertiary-centre transfer and subsequent death View source Failure to expedite scanning or contact tertiary neurosurgical services after specialist input View source Insufficient senior clinical oversight of review conclusions View source Factual inaccuracies in adverse-incident review summaries View source Inappropriate allocation of cases to structured judgement review View source Insufficient MRI scanner capacity for urgent scans View source Failure to evaluate whether MRI capacity changes improve urgent scan times View source See 14 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Frank Charles Medley · 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 Frank Charles Medley presented with acute weakness in all four limbs, but an MRI scan that was considered urgent was delayed for four working days. He underwent surgery for multiple paraspinal abscesses and died on 14 July 2019. The principal concerns included delays and inadequate prioritisation of imaging, deficiencies in the Trust’s adverse incident review, and shortcomings in systems for detecting adverse outcomes and coordinating relevant departments.
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 expedite emergency MRI scanning and document escalation attempts
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan . There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan ;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 treating clinicians to recognise and record activation of the septic shock pathway
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest ;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Independent operation of adverse-incident review and Legal Services departments
Wider context from the report “(3) The Department undertaking reviews of adverse incidents appears to operate independently from the Legal Services Department
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain family views and concerns during the adverse-death review
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest .
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Inappropriate and undocumented prioritisation of urgent MRI scans
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category . There is no documentation as to any rationale for the priority allocation ;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 investigation of suspected high cervical-spine infection
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG ;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 completing adverse-death review reports
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance ;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Radiology scan prioritisation dependent on personal clinician attendance or discussion rather than clinical need
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need ;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 the responsible specialty and document its management in medical records
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to perform the required contrast MRI scan initially
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day .
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Ineffectual detection of adverse outcomes after tertiary-centre transfer and subsequent death
Wider context from the report “(1) The Trust has an ineffectual system to detect adverse outcomes where the patient is transferred to a tertiary centre for treatment and subsequently dies ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 expedite scanning or contact tertiary neurosurgical services after specialist input
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services ;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 senior clinical oversight of review conclusions
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Factual inaccuracies in adverse-incident review summaries
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading ;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Inappropriate allocation of cases to structured judgement review
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review ;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 MRI scanner capacity for urgent scans
Wider context from the report “(4) The delay in obtaining the scan was partly attributed to a lack of MRI scanner capacity . At the inquest the Trust could only provide conjecture as to whether or not alterations to scan capacity had made any difference to the time taken to obtain urgent scans.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 evaluate whether MRI capacity changes improve urgent scan times
Wider context from the report “(4) The delay in obtaining the scan was partly attributed to a lack of MRI scanner capacity. At the inquest the Trust could only provide conjecture as to whether or not alterations to scan capacity had made any difference to the time taken to obtain urgent scans .
” Open source report
19 Feb 2021 Ms Lisa Grant · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 1 Significantly increased risk of deep vein thrombosis associated with obesity, inactivity and a rare recognised Risperidone side effect 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
Ms Lisa Grant · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ms Lisa Grant was admitted to Hallam Street Hospital in July 2019 and collapsed on the ward on 1 August 2019, later dying at Sandwell Hospital. The inquest identified bilateral pulmonary embolism due to deep vein thrombosis, and concerns included her increased DVT risk associated with obesity and inactivity, alongside a recognised rare risk associated with risperidone, despite an assessment that no further DVT treatment or assessment was required.
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 Significantly increased risk of deep vein thrombosis associated with obesity, inactivity and a rare recognised Risperidone side effect
Wider context from the report “1. Evidence emerged during the inquest that both the consulting Psychiatrist and the Hospital’s Manager said that Ms Grant was assessed upon admission to hospital in accordance with the national guidelines for the assessment for Deep vein thrombosis (DVT). As per the guidance criteria checklist, the clinician considered that there was no significant reduction in mobility, and therefore no further treatment or assessment for this condition was required.
2. Miss Grant had a significantly increased risk of DVT due to the effects of obesity and inactivity. In addition, there was a rare but recognised side effect of Risperidone.
” Open source report
Concerns raised 3 Failure of doctors considering opiate prescriptions to contact the registered GP View source Lack of an effective national procedure for circulating Patient Alerts to pharmacies View source Failure of dispensing pharmacists to contact the registered GP when checking prescription appropriateness View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Katie Emma Corrigan · 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
Katie Emma Corrigan had a history of chronic pain, anxiety and depression, and developed an addiction to pain-relieving medication. She obtained medication from multiple sources, and the report raised concerns that doctors, pharmacists and alert systems did not prevent her from obtaining sufficient opiate medication to cause her death.
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 doctors considering opiate prescriptions to contact the registered GP
Wider context from the report “The GP who gave evidence at the inquest, Dr ████████ from Bodriggy Health Centre in Hayle, stated that she had never been contacted by any other doctor considering the prescription of opiate or other medication to Mrs Corrigan . She was able to procure the medication in sufficient quantities first to require an emergency admission to hospital and latterly to result in her death.
Similarly, the registered GP was not contacted by any dispensing pharmacist checking whether the prescription was appropriate.
After Dr ████████ became aware of the two on-line pharmacies who had dispensed the medication to Mrs Corrigan that led to her admission into hospital, she attempted to raise an alert through NHS England, in order that the unsuitability of prescribing opiate medication to Mrs Corrigan could be raised with clinicians. This was sent out regionally but Dr ████████ has since been advised there is no formal procedure for circulating Patient Alerts to pharmacies on a national level.
I am further given to understand that non NHS contacts would only receive a redacted version of the alert in any event.
What seems clear is that the alert proved ineffective in preventing Mrs Corrigan from improperly obtaining sufficient quantities of opiate medication to result in her death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective national procedure for circulating Patient Alerts to pharmacies
Wider context from the report “The GP who gave evidence at the inquest, Dr ████████ from Bodriggy Health Centre in Hayle, stated that she had never been contacted by any other doctor considering the prescription of opiate or other medication to Mrs Corrigan. She was able to procure the medication in sufficient quantities first to require an emergency admission to hospital and latterly to result in her death.
Similarly, the registered GP was not contacted by any dispensing pharmacist checking whether the prescription was appropriate.
After Dr ████████ became aware of the two on-line pharmacies who had dispensed the medication to Mrs Corrigan that led to her admission into hospital, she attempted to raise an alert through NHS England, in order that the unsuitability of prescribing opiate medication to Mrs Corrigan could be raised with clinicians. This was sent out regionally but Dr ████████ has since been advised there is no formal procedure for circulating Patient Alerts to pharmacies on a national level .
I am further given to understand that non NHS contacts would only receive a redacted version of the alert in any event .
What seems clear is that the alert proved ineffective in preventing Mrs Corrigan from improperly obtaining sufficient quantities of opiate medication to result in her death .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 dispensing pharmacists to contact the registered GP when checking prescription appropriateness
Wider context from the report “The GP who gave evidence at the inquest, Dr ████████ from Bodriggy Health Centre in Hayle, stated that she had never been contacted by any other doctor considering the prescription of opiate or other medication to Mrs Corrigan. She was able to procure the medication in sufficient quantities first to require an emergency admission to hospital and latterly to result in her death.
Similarly, the registered GP was not contacted by any dispensing pharmacist checking whether the prescription was appropriate .
After Dr ████████ became aware of the two on-line pharmacies who had dispensed the medication to Mrs Corrigan that led to her admission into hospital, she attempted to raise an alert through NHS England, in order that the unsuitability of prescribing opiate medication to Mrs Corrigan could be raised with clinicians. This was sent out regionally but Dr ████████ has since been advised there is no formal procedure for circulating Patient Alerts to pharmacies on a national level.
I am further given to understand that non NHS contacts would only receive a redacted version of the alert in any event.
What seems clear is that the alert proved ineffective in preventing Mrs Corrigan from improperly obtaining sufficient quantities of opiate medication to result in her death.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share key learning and practice points from the inquest with relevant providers and stakeholders.
Verbatim wording from the response “Where CQC identifies that regulations are not being met, we use our enforcement powers to require improvements to be made. We continue to do this and will share key learning and practice points from the inquest into the death of Katie Corrigan.” Source location 2021-0045-Response-from-CQC-Redacted
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 Inspect each registered online provider identified from the inquest and review their medication-prescribing management processes.
Verbatim wording from the response “CQC has inspected each of the registered online providers that you identified from the inquest into Ms Corrigan’s death that Ms Corrigan may have used. At each inspection, management processes for prescribing medications were reviewed and if concerns were identified we took regulatory action against the provider or the inspection report shared details of the areas needing improvement.” Source location 2021-0045-Response-from-CQC-Redacted
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 using enforcement powers to require improvements when online providers fail to meet regulatory requirements.
Verbatim wording from the response “Where CQC identifies that regulations are not being met, we use our enforcement powers to require improvements to be made. We continue to do this and will share key learning and practice points from the inquest into the death of Katie Corrigan.” Source location 2021-0045-Response-from-CQC-Redacted
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 Submit proposals to DHSC for legislative changes addressing regulatory safety gaps in independent online primary care services.
Verbatim wording from the response “Since January 2021 CQC has been in discussions with, and submitted, proposals for legislative changes to the Department of Health and Social Care (DHSC), to improve CQC’s ability to take action against independent providers of online primary care services that are putting people’s lives at risk. In particular, we are looking to address safety gaps in the following areas:” Source location 2021-0045-Response-from-CQC-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish guidance setting expectations for providers to inform patients’ GPs about prescribed medicines and assess safety when information sharing is declined.
Verbatim wording from the response “CQC has published guidance for providers¹. The guidance describes the expectations of providers to ensure a patient’s GP is informed of prescribed medications from their service. We also expect that should the patient decline to consent for the sharing of such information to take place, the prescriber should consider whether it is still safe to continue and accept the full responsibility for their actions and act in line with GMC prescribing guidance.” Source location 2021-0045-Response-from-CQC-Redacted
Open published response
Concerns raised 9 Inadequacy of the action plan for reducing delays in NG tube insertion and decompression View source Failure to check medical records completed by junior doctors View source Lack of audit of the effectiveness of safety measures View source Failure of the serious incident investigation to identify why NG tube placement failures were not escalated or referred back to requesting teams View source Failure of nursing escalation when an NG tube cannot be sited and clinical review has not occurred View source Failure to identify and document the staff member, records, and actions relevant to an arterial blood gas during the investigation View source Failure to ensure factual accuracy and evidential support for reported EWS escalation View source Lack of clear allocation of overall clinical responsibility for patients remaining in the Accident and Emergency Department View source Failure to complete or appropriately refer mandated clinical reviews triggered by EWS scores View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Gillian McKinlay · 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
Gillian McKinlay, aged 68, was admitted to Royal Blackburn Hospital on 23 April 2018 with a provisional diagnosis of small bowel obstruction. A nasogastric tube requested by clinicians was not sited before her death four hours later, and the Coroner considered this contributed to the death. Concerns included unclear responsibility for patients in the Accident and Emergency Department, failure to undertake or escalate a clinically indicated review, and inadequacies in the Trust's investigation and subsequent measures.
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 Inadequacy of the action plan for reducing delays in NG tube insertion and decompression
Wider context from the report “1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care.
2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams.
3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy.
4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken:
a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate ;
b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred;
c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken;
d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect;
e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked;
f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to check medical records completed by junior doctors
Wider context from the report “1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care.
2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams.
3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy.
4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken:
a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate;
b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred;
c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken;
d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect;
e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked ;
f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of audit of the effectiveness of safety measures
Wider context from the report “1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care.
2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams.
3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy.
4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken:
a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate;
b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred;
c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken;
d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect;
e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked;
f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 investigation to identify why NG tube placement failures were not escalated or referred back to requesting teams
Wider context from the report “1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care.
2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams.
3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy.
4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken:
a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate;
b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred;
c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken;
d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect;
e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked;
f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing escalation when an NG tube cannot be sited and clinical review has not occurred
Wider context from the report “1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care.
2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams.
3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy .
4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken:
a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate;
b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred;
c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken;
d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect;
e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked;
f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 and document the staff member, records, and actions relevant to an arterial blood gas during the investigation
Wider context from the report “1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care.
2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams.
3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy.
4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken:
a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate;
b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred;
c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken ;
d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect;
e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked;
f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 factual accuracy and evidential support for reported EWS escalation
Wider context from the report “1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care.
2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams.
3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy.
4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken:
a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate;
b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred;
c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken;
d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect ;
e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked;
f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 allocation of overall clinical responsibility for patients remaining in the Accident and Emergency Department
Wider context from the report “1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care .
2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams.
3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy.
4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken:
a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate;
b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred;
c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken;
d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect;
e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked;
f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 or appropriately refer mandated clinical reviews triggered by EWS scores
Wider context from the report “1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care.
2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams .
3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy.
4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken:
a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate;
b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred;
c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken;
d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect;
e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked;
f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect.
” Open source report
11 Feb 2021 Ruth Jones · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Lack of guidance for managing falls risk during resident isolation View source Failure to support effective communication and understanding of the health baseline of vulnerable frail elderly patients during hospital presentation and assessment View source Insufficient staffing capacity for continuous observation of residents at risk of falls during self-isolation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ruth Jones · 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
Ruth Jones, a resident of The Beeches Care Home who was at risk of falls, fell while unobserved after being isolated because Covid-19 was suspected. She was admitted to hospital with a fractured neck of femur and bronchopneumonia and later died there. Concerns included the lack of guidance and staffing arrangements for safely observing residents at risk of falls during required isolation, and the difficulties caused when frail patients attended hospital without family support.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for managing falls risk during resident isolation
Wider context from the report “1. The inquest heard that Mrs Jones was frail and at risk of falls. The home had a falls risk plan in place that was based around her being observed during the day in communal areas. The home was not staffed to provide one to one observations for residents required to self-isolate. As a result when Covid 19 was suspected by the GP, and the home were directed to isolate her she could not be observed by staff as would generally be the case in the day. The home took some steps with sensors to ensure they were aware if she stood up whilst in her room but could not provide continuous observation. It was unclear how homes were being advised to safely manage residents at risk of falls where isolation was required . The home were unaware of any guidance that they should follow to manage the risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to support effective communication and understanding of the health baseline of vulnerable frail elderly patients during hospital presentation and assessment
Wider context from the report “2. When Mrs Jones had to go to hospital she was sent alone and her family could not go with her due to Covid 19 restrictions. The inquest heard that Mrs Jones was frail and vulnerable. The inquest was told that the unsupported presentation/assessment of vulnerable, frail and elderly patients such as Mrs Jones presented significant problems to clinicians in terms of effective communication and understanding their health baseline to support appropriate and timely clinical decision making.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 staffing capacity for continuous observation of residents at risk of falls during self-isolation
Wider context from the report “1. The inquest heard that Mrs Jones was frail and at risk of falls. The home had a falls risk plan in place that was based around her being observed during the day in communal areas. The home was not staffed to provide one to one observations for residents required to self-isolate . As a result when Covid 19 was suspected by the GP, and the home were directed to isolate her she could not be observed by staff as would generally be the case in the day . The home took some steps with sensors to ensure they were aware if she stood up whilst in her room but could not provide continuous observation . It was unclear how homes were being advised to safely manage residents at risk of falls where isolation was required. The home were unaware of any guidance that they should follow to manage the risk.
” 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 Undertake an unannounced targeted inspection of The Beeches covering falls risk management, hospital transfers and infection prevention and control.
Verbatim wording from the response “Upon receipt of the concerns raises as part of the Regulation 28 report issued to CQC by the coroner an unannounced targeted inspection of The Beeches was undertaken. This was completed to ensure that the circumstances of Mrs Jones death did not raise any ongoing risk to people currently living at the home.” Source location 2021-0038-Response-from-CQC-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The provider and registered manager, not CQC, are responsible for deciding how to address identified care risks and implement improvements.
Verbatim wording from the response “In accordance with CQC’s regulatory remit, we highlight breaches of the Regulations to a provider and where appropriate ask them what they are going to do to make improvements. We do not tell them what they should do. That is for the provider and/or registered manager (both being registered persons for CQC purposes) to decide.” Source location 2021-0038-Response-from-CQC-Redacted
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 individualised care plans and additional welfare checks were considered sufficient to mitigate Mrs Jones’s fall risk while unwell.
Verbatim wording from the response “We have reviewed Mrs Jones’ care records, and in this case, we believe that the service had taken all reasonable steps to mitigate the risk of falls for Mrs Jones. There were care plans in place to manage the risk of falls for Mrs Jones and these were relevant whether she was in communal areas or in her bedroom. Reference to times when Mrs. Jones was unwell were made and indicated that staff should make additional checks of Mrs Jones’ welfare at those times. In our view, the registered manager had assessed Mrs Jones on an individual basis and despite her not being funded for one to one care had assessed risk and put measures in place to support Mrs Jones whilst she was unwell.” Source location 2021-0038-Response-from-CQC-Redacted
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 red bag scheme and hospital passport were considered sufficient to address risks during Mrs Jones’s transfer to hospital.
Verbatim wording from the response “The Beeches participated in the red bag scheme. This is a national scheme that assists care home residents admitted to hospital to be discharged quicker. The bags contain key paperwork (hospital passport), medication and personal items like glasses, slippers and dentures. The hospital passport contained relevant information about the individual’s current needs, a brief medical history, as well as important contact details and other relevant information about a person’s preferences. These are handed to ambulance” Source location 2021-0038-Response-from-CQC-Redacted
Open published response
10 Feb 2021 Eric Harold Bird · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 10 Failure to provide timely out-of-hours access to the care home for ambulances View source Failure to follow the policy requiring 999 calls after falls involving head injury View source Inaccurate recording of falls on monthly accidents and incidents forms View source Delays in contacting emergency ambulance services after a fall View source Failure to complete required referral to the physiotherapy team View source Failure to follow the policy requiring 999 calls after falls involving head injury View source Failure to identify and address patterns of falls and increasing risk View source Delays in notifying senior management after a fall View source Failure to update falls risk assessments and care plans after every fall View source Failure to update falls risk assessments and care plans after every fall View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Eric Harold Bird · 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
Eric Harold Bird, a 91-year-old man with dementia and assessed as being at high risk of falls, suffered seven falls during a four-week period in a specialist care centre. After a fall on 21/11/20, he sustained a subdural haematoma and died in hospital on 30/11/20. The principal concerns included failures to follow procedures after head injuries, delays in contacting emergency services and gaining ambulance access, and inadequate updating and review of his falls risk documentation and care 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 Failure to provide timely out-of-hours access to the care home for ambulances
Wider context from the report “5. On arrival the ambulance was unable to gain access to the care home until 22.11 as there was no answer at the door . I heard evidence at the inquest that arrangements had now been made for a staff member to wait in the reception area when an ambulance is now called out of hours to facilitate entry;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the policy requiring 999 calls after falls involving head injury
Wider context from the report “2. The inquest heard that Castlehill polices had not been followed after each fall whereby Mr Bird hit his head . Mr Bird was taking apixaban which meant he was at a higher risk of bleeding. Evidence was heard that policy required 999 to be called . This was not done on 1/11/20 nor on 14/11/20 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Inaccurate recording of falls on monthly accidents and incidents forms
Wider context from the report “9. There were discrepancies in the recording of the falls on the monthly accidents and incidents form and no evidence that any consideration had been given to a pattern of falls which needed to be addressed to reduce Mr Bird’s apparent increasing risks.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 contacting emergency ambulance services after a fall
Wider context from the report “4. On 21/11/20 I heard evidence that the fall occurred at approximately 20.20/20.30 hours. Records suggested the 111 service was contacted at 21.06 . I heard evidence that it was the 111 service that made arrangements for an ambulance to attend and the EPR showed that the ambulance was contacted at 21.34 arriving on site at 21.47 ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to complete required referral to the physiotherapy team
Wider context from the report “1. After Mr Bird’s admission and initial falls risk assessment, there was a reference that Mr Bird needed to be referred to the physio team but no evidence this was actually done ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the policy requiring 999 calls after falls involving head injury
Wider context from the report “3. On 21/11/20 the nurse on duty called 111 instead of following policy to call 999 ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 and address patterns of falls and increasing risk
Wider context from the report “9. There were discrepancies in the recording of the falls on the monthly accidents and incidents form and no evidence that any consideration had been given to a pattern of falls which needed to be addressed to reduce Mr Bird’s apparent increasing risks .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 notifying senior management after a fall
Wider context from the report “8. I heard evidence that after the fall on 21/11/20 whereby Mr Bird was taken to hospital, that senior management who were off site were not contacted for over 2 hours after Mr Bird fell ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 update falls risk assessments and care plans after every fall
Wider context from the report “7. There was no evidence of any changes being made to Mr Birds falls care plan after the fall on 14/11/20 and no rationale recorded for not doing so ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 update falls risk assessments and care plans after every fall
Wider context from the report “6. There was no evidence that Mr Bird’s falls risk assessment and falls care plan had been updated after every fall ;
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct management reviews and assess available evidence about the provider’s falls-management concerns.
Verbatim wording from the response “The matters of concern which arose from the preventing future deaths report have prompted the CQC to take action. In direct response, we held a management review meeting on 17 February 2021. Following the management review meeting, we reviewed the evidence we held about Castlehill Specialist Care Centre, the information held following the specific incident review related to Mr Bird’s death and information following the inspection completed in January 2021.” Source location 2021-0122-Response-from-Care-Quality-Commission-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CQC will not progress a criminal investigation because the evidence does not meet the required threshold of proving avoidability beyond reasonable doubt.
Verbatim wording from the response “• As a result of these findings, CQC held a management review meeting on 18 March 2021 to discuss the findings under our specific incident guidance. In order to open a formal criminal investigation, we have to be able to evidence a Registered Person (either a Registered Provider or Registered Manager) failed to provide safe care and treatment to Mr Bird in relation to this incident and can prove beyond reasonable doubt this incident was avoidable. We did not feel that this threshold was met and therefore will not progress the case.” Source location 2021-0122-Response-from-Care-Quality-Commission-Redacted
Open published response
19 Jan 2021 Vhari Ingall · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 5 Unavailability of a centralised or regionalised database for emergency access to TEP/DNAR information View source Failure to ensure treatment-withdrawal decisions are not made by frontline paramedics View source Failure to ensure accurate and checkable TEP/DNAR information for emergency decision-making View source Failure to review TEP/DNAR documents when clinically significant diagnostic information changes View source Failure to limit Do Not Resuscitate document applicability to natural deaths 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
Vhari Ingall · 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
Vhari Ingall died from an oxycodone drug overdose, with the inquest returning a conclusion of suicide. The principal concerns were the failure to review an outdated Treatment Escalation Plan/Do Not Resuscitate form after her diagnosis changed, and whether healthcare professionals and emergency services could access accurate and current information about such forms.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a centralised or regionalised database for emergency access to TEP/DNAR information
Wider context from the report “The Paramedics in both of these cases were faced with extremely difficult situations and on the front line are having to make very difficult decisions and need to rely on the best available information which needs to be accurate. In Vhari’s case, Vhari herself was able to explain that the diagnosis of the pancreatic tumour was incorrect but that may not always be the case in every similar situation and in fact when the paramedics attended Mrs. Johnson she presented initially with a Glasgow coma scale of 7 and was not really responsive at any time when the paramedics were present.
I would be grateful if you would please consider as part of your inspection methodology including looking at the system in place for the management of TEP/DNARs, as my concern is that with inaccurate information and the inability to check that information that potentially decisions could be made that perhaps would not be made leading to allowing somebody to die that was based on inaccurate information.
B) DEPARTMENT OF HEALTH
Leading on from the above section addressed to the Care Quality Commission, whilst present practice places an obligation on the patient to have available the TEP/DNAR, even to the extent that I believe there is a practice of advising that a copy be left in the fridge/freezer at the patient’s home. ████████ himself did not have a copy of the TEP/DNAR which he signed on his case records at the surgery on the basis that he said that the original is left with the patient. I did express some surprise about that as to why at least a photograph of the document could not have been taken and transferred on to the case records, the original photograph then deleted from whatever device took it. As an alternative so that any health care professional can access the best available information as regards the existence of a TEP/DNAR, especially when the patient may not be able to assist at the scene and may not have told a relative of friend of its existence, I do question why there is not some central database or even as an alternative a regionalised database that could be accessed by the emergency services including health care practitioners . These are important documents and it may be the case that the individual concerned does not have a friend or relative that they can make aware of the existence of such a document and may be truly alone and unresponsive at the time the emergency services attend.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 treatment-withdrawal decisions are not made by frontline paramedics
Wider context from the report “Even though neither of these cases have proceeded to a final Inquest hearing in accordance with Regulation 28 of the Coroners (Investigation) Regulation 2013 a report to prevent future deaths can be made if evidence comes before the Coroner that causes a concern and triggers the Coroner’s duty to submit such a report if the Coroner thinks it is appropriate. I am of the view that this duty has now been triggered because the death of Ms. Ingall raises the same issue and concern that I have following the death of Mrs. Johnson. The concern is that the Do Not Resuscitate document applies to all my sociality a natural death. We know that Mrs. Johnson did not die a natural cause of death and there were sufficient information indicators at the scene and the Paramedics were aware that she had taken, more likely than not, an overdose. The same appears to be the case with Ms. Ingall although this is subject to confirmation following the post mortem examination. A person dying as a result of self-harm and as a result of an overdose cannot if any way whatsoever be regarded as a natural death, it is my view and concern that Paramedics are being placed in a difficult position as well of those that they are responsible for caring for if they do not intervene appropriately. It may be the case at hospital and potentially with the involvement of mental health professionals that a decision is taken to withdraw treatment, but I am concerned, especially having regard to Article 2 of the European Convention of Human Rights that that decision is not taken by frontline Paramedics and I would ask you to urgently review the instructions and guidance given to your frontline Paramedics in these situations .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accurate and checkable TEP/DNAR information for emergency decision-making
Wider context from the report “The Paramedics in both of these cases were faced with extremely difficult situations and on the front line are having to make very difficult decisions and need to rely on the best available information which needs to be accurate . In Vhari’s case, Vhari herself was able to explain that the diagnosis of the pancreatic tumour was incorrect but that may not always be the case in every similar situation and in fact when the paramedics attended Mrs. Johnson she presented initially with a Glasgow coma scale of 7 and was not really responsive at any time when the paramedics were present.
I would be grateful if you would please consider as part of your inspection methodology including looking at the system in place for the management of TEP/DNARs, as my concern is that with inaccurate information and the inability to check that information that potentially decisions could be made that perhaps would not be made leading to allowing somebody to die that was based on inaccurate information .
B) DEPARTMENT OF HEALTH
Leading on from the above section addressed to the Care Quality Commission, whilst present practice places an obligation on the patient to have available the TEP/DNAR, even to the extent that I believe there is a practice of advising that a copy be left in the fridge/freezer at the patient’s home. ████████ himself did not have a copy of the TEP/DNAR which he signed on his case records at the surgery on the basis that he said that the original is left with the patient. I did express some surprise about that as to why at least a photograph of the document could not have been taken and transferred on to the case records, the original photograph then deleted from whatever device took it. As an alternative so that any health care professional can access the best available information as regards the existence of a TEP/DNAR, especially when the patient may not be able to assist at the scene and may not have told a relative of friend of its existence, I do question why there is not some central database or even as an alternative a regionalised database that could be accessed by the emergency services including health care practitioners. These are important documents and it may be the case that the individual concerned does not have a friend or relative that they can make aware of the existence of such a document and may be truly alone and unresponsive at the time the emergency services attend.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 TEP/DNAR documents when clinically significant diagnostic information changes
Wider context from the report “During the Inquest into the death of Vhari I heard evidence from the Senior Partner of her GP surgery, New Court Surgery at Royal Wootton Bassett, Wiltshire as I had a concern in relation to the Treatment Escalation Plan/Do Not Resuscitation (“TEP/DNAR”) form which ████████ had completed with Vhari back in February 2017. I have enclosed a copy of that TEP/DNAR marked “A”. As you will see the reason for issuing it was that Vhari had been diagnosed, late during the previous year, with a pancreatic tumour and she was considered for palliative care only. Towards the end of 2017, the Consultant at Great Western Hospital in charge of her care, reviewed Vhari’s case and the diagnosis changed to one of chronic pancreatitis as opposed to a terminal tumour. This was confirmed in writing to the surgery on the 17 September 2017. During the course of ████████ evidence he explained to me the quite sensible reason why there is no fixed date review of these types of documents but did indicate that such a review was entirely appropriate when it was clinically appropriate to review the TEP/DNAR document. I was firmly of the view that a change in such a fundamental diagnosis should have ordinarily given rise to a review , however, I found no evidence that was recorded in Vhari’s case to suggest that such a review was undertaken by the surgery even though there was a number of consultations with different doctors following Mr. Payne’s letter of September 2017. The notes were completely silent as regards any such review being carried out . In fact I noted an entry in the records on the 5 March 2020 by one of the doctors at the surgery, ████████ who referred to “reminder/alert: DNAR-priority: high.” I also heard evidence from Vhari’s sister, ████████ that in going through Vhari personal possession she found no subsequent TEP/DNAR form after the February 2017 form.
I did consider sending a Regulation 28 Report to the surgery but heard evidence from ████████ that they now have provided by the local CCG an add on to their SystemOne system called an Arden’s module which assists in clinical decision making which they are also using in relation to recording TEP/DNARs. Whilst there is never a 100% guarantee that such a failure to review a document like this will not occur in the future and in respect of Vhari’s case it was in no way contributory to her death, I was satisfied that this step was an improvement and an attempt to mitigate against the risk of such a recurrence.
Obviously, this package is available to surgeries within my own coronial area, but I am unclear as to the position in other areas and obviously you have a greater awareness of these sorts of matters as part of your inspection processes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 limit Do Not Resuscitate document applicability to natural deaths
Wider context from the report “Even though neither of these cases have proceeded to a final Inquest hearing in accordance with Regulation 28 of the Coroners (Investigation) Regulation 2013 a report to prevent future deaths can be made if evidence comes before the Coroner that causes a concern and triggers the Coroner’s duty to submit such a report if the Coroner thinks it is appropriate. I am of the view that this duty has now been triggered because the death of Ms. Ingall raises the same issue and concern that I have following the death of Mrs. Johnson. The concern is that the Do Not Resuscitate document applies to all my sociality a natural death. We know that Mrs. Johnson did not die a natural cause of death and there were sufficient information indicators at the scene and the Paramedics were aware that she had taken, more likely than not, an overdose. The same appears to be the case with Ms. Ingall although this is subject to confirmation following the post mortem examination. A person dying as a result of self-harm and as a result of an overdose cannot if any way whatsoever be regarded as a natural death , it is my view and concern that Paramedics are being placed in a difficult position as well of those that they are responsible for caring for if they do not intervene appropriately. It may be the case at hospital and potentially with the involvement of mental health professionals that a decision is taken to withdraw treatment, but I am concerned, especially having regard to Article 2 of the European Convention of Human Rights that that decision is not taken by frontline Paramedics and I would ask you to urgently review the instructions and guidance given to your frontline Paramedics in these situations.
” 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 Promote a specific inspection focus on apparent suicide attempts where a do-not-resuscitate order is present.
Verbatim wording from the response “As part of our inspection methodology, we routinely look at the training in, and presence and understanding of processes and policies surrounding the mental capacity act and best interest decisions. This is ordinarily a more generic look at such subjects, and so the addition of this focus on patients who have apparently attempted to take their own lives will be promoted within the CQC by the ambulance group.” Source location 2020-0084-Response-from-the-Care-Quality-Commission_Redacted-1
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share key learning and practice points from the inquest with inspectors.
Verbatim wording from the response “Where CQC identifies that regulations are not being met, we use our enforcement powers to require improvements to be made. We continue to do this and will share key learning and practice points from the inquest into the death of Vhari Ingall and Mary Grace Johnson with inspectors.” Source location 2020-0084-Response-from-CQC-to-further-PFD-report-Redacted
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 responding to DNAR/TEP risks through routine regulatory monitoring and inspection during the consultation period.
Verbatim wording from the response “We continue to respond to risk via routine monitoring and inspection during this consultation period, including concerns and issues raised in this report.” Source location 2020-0084-Response-from-CQC-to-further-PFD-report-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a national report on findings and recommendations concerning DNACPR decisions during the COVID-19 pandemic.
Verbatim wording from the response “In October 2020, the Department of Health and Social Care asked CQC to review the use of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions during the COVID-19 pandemic. This has been an area of shared concern about the blanket application of DNACPR decisions. Our interim report was published in November 2020. A national report of our findings and recommendations will be published by March 2021. This report will set out all the themes and trends we have found, outlining any known changes to the use of DNACPR in response to the pandemic and describing good practice for the future.” Source location 2020-0084-Response-from-CQC-to-further-PFD-report-Redacted
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 consulting on regulatory next steps and reviewing and updating regulatory approaches, including scope for end-of-life and DNAR/TEP regulation.
Verbatim wording from the response “We are currently now in a period of consultation about our next steps of regulation. During this time, we will continually keep our scope of regulation under review and” Source location 2020-0084-Response-from-CQC-to-further-PFD-report-Redacted
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 Review found non-resuscitation decisions in apparent-suicide cases legitimate and consistent with JRCALC guidance.
Verbatim wording from the response “Ongoing Management of risk
In addition to information about the management of immediate risk, the CQC asked SWASFT to review all cases of apparent suicide attended by their crews in the preceding 18 months where resuscitation had not been attempted. This review was conducted using a comprehensive review of systems used to capture information about patients and the treatment received. This demonstrated that in such cases, the decision not to resuscitate was legitimate in that these patients were past the point that resuscitation could have saved their lives – and were in accordance with the guidance provided by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC).” Source location 2020-0084-Response-from-the-Care-Quality-Commission_Redacted-1
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 Previous inspections found no relevant concerns about either practice’s policies, training, systems, or end-of-life care arrangements.
Verbatim wording from the response “CQC undertook an inspection in June 2016 at the GP practice where Vhari Ingall was registered as a patient. This inspection was undertaken prior to the death of Ms Ingall. There were no areas of concern in relation to the relevant practice policies, staff understanding, training and systems to support patients with their care, treatment or planning for their end of life.” Source location 2020-0084-Response-from-CQC-to-further-PFD-report-Redacted
Open published response
18 Jan 2021 Mrs Lynn Hadley · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 3 Lack of user knowledge of oxygen-cylinder ignition mechanisms and their ramifications View source Risk of ignition within oxygen-cylinder valve components View source Failure to follow the safe valve-opening sequence for oxygen regulators View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs Lynn Hadley · 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
On 13 April 2020, paramedics attended Mrs Lynn Hadley at home for COVID-19-type symptoms and began administering oxygen. The oxygen cylinder sparked and caught fire, and despite efforts by family members and paramedics, Mrs Hadley could not be removed from the house and died from fatal burn injuries. The concerns included possible ignition caused by adiabatic compression or particle impact when the oxygen regulator was opened, limited awareness of these risks among equipment users, and other reported cases of ignition involving oxygen-cylinder valve components.
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 user knowledge of oxygen-cylinder ignition mechanisms and their ramifications
Wider context from the report “4. Evidence from the Fire Investigation Officer, confirmed that there was little if any knowledge of either adiabatic compression or particle impact and the ramifications of such an event when opening a cylinder incorrectly by those responsible for using the equipment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Risk of ignition within oxygen-cylinder valve components
Wider context from the report “5. Evidence from the MHRA confirmed that they are aware of four cases of ignition within valve components of oxygen cylinders leading to fire since 2011 including this incident . The valve manufacturer VTI, Germany has subsequently reported nine cases of ignition . VTI are also examining a further 20 regulators. At present no defects have been 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 follow the safe valve-opening sequence for oxygen regulators
Wider context from the report “2. Although both of these phenomena are extremely rare, the sudden uncontrolled release of oxygen by rapidly opening the on/off valve of the regulator can expedite the occurrence of ignition .
3. Evidence from the paramedic confirmed that she opened the patient valve first before opening the on/off valve, thus increasing the chance of the reported phenomena occurring .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The regulator cannot issue oxygen safety guidance because it lacks clinical expertise and access to necessary specialist expertise.
Verbatim wording from the response “As a regulator it is unfortunately outside of the CQC's remit to issue or change formal guidance or policies around oxygen usage or safety. We are not clinical experts on oxygen cylinders or have access to the expertise which would be necessary in order to issue safety guidance. This role is more suited to the MHRA and HSE from whom I am aware separate responses will be sent to you.” Source location 2021-0346-Response-from-CQC_Published
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 Issuing or changing formal guidance or policies on oxygen use and safety is outside the regulator’s remit.
Verbatim wording from the response “1. ‘All agencies involved may wish to consider reviewing and issuing guidance for the operation and use of oxygen cylinders.” Source location 2021-0346-Response-from-CQC_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for issuing oxygen safety guidance lies with the MHRA and HSE.
Verbatim wording from the response “As a regulator it is unfortunately outside of the CQC's remit to issue or change formal guidance or policies around oxygen usage or safety. We are not clinical experts on oxygen cylinders or have access to the expertise which would be necessary in order to issue safety guidance. This role is more suited to the MHRA and HSE from whom I am aware separate responses will be sent to you.” Source location 2021-0346-Response-from-CQC_Published
Open published response
16 Jan 2021 Norma Lockton · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 8 Failure to update general health and mobility care plans View source Failure to regularly document repositioning View source Failure to recognise serious and deteriorating medical conditions View source Delays in organising medical assistance for serious deterioration View source Failure of management to understand how and why repositioning deficiencies occurred View source Failure to recognise changing health and mobility needs View source Failure to maintain an updated skin integrity care plan View source Failure to conduct robust management review following a death 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
Norma Lockton · 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
Norma Lockton was a resident in a nursing home whose reduced mobility and vulnerable skin required care measures that were not followed. She developed a wound behind her left knee, which became infected and led to cellulitis and systemic sepsis; medical assistance was not sought until her condition was life threatening, and she died in hospital on 4 March 2020. The principal concerns included failures in skin care planning and implementation, repositioning, recognition of changing care needs and deteriorating health, and management review following the death.
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 update general health and mobility care plans
Wider context from the report “3. The lack of recognition of Norma’s changing health and mobility needs, leading to no change in her general health and mobility care plans
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 regularly document repositioning
Wider context from the report “2. The lack of regular documented repositioning of Norma , with no understanding by the management team as to how and why this issue had occurred.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 serious and deteriorating medical conditions
Wider context from the report “4. The lack of recognition of a serious and deteriorating medical condition (that of cellulitis) , leading to no medical assistance being organised until the situation was life threatening.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 organising medical assistance for serious deterioration
Wider context from the report “4. The lack of recognition of a serious and deteriorating medical condition (that of cellulitis), leading to no medical assistance being organised until the situation was life threatening .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of management to understand how and why repositioning deficiencies occurred
Wider context from the report “2. The lack of regular documented repositioning of Norma, with no understanding by the management team as to how and why this issue had occurred .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 changing health and mobility needs
Wider context from the report “3. The lack of recognition of Norma’s changing health and mobility needs , leading to no change in her general health and mobility care plans
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 an updated skin integrity care plan
Wider context from the report “1. The lack of an updated skin integrity care plan , with little understanding by the management as to why there had been no update to it following the clear District Nurse instructions regarding skin care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct robust management review following a death
Wider context from the report “5. The lack of robust review by the management team following a death .
” Open source report
17 Dec 2020 Philip Taylor · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Failure to recognise dehydration risk View source Limited care-home staff ability to recognise and respond to escalating dehydration risk View source National pathfinder tool failing to clearly direct immediate expedited hospital transfer for sepsis View source Delays and omissions in recording GP visit observations View source Lack of national guidance for care-home staff on recognising, responding to and escalating dehydration risk View source Failure to ascertain temperature during care-home GP assessments 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
Philip 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
Philip Taylor, who had Lewy Body Dementia and lived in a residential care home, became severely dehydrated during a chest infection and died in hospital on 6 January 2020 after developing an acute kidney injury. Concerns included failure to recognise and respond to dehydration, delayed ambulance transfer and hospital assessment, inadequate monitoring, and limited national guidance for care home staff and paramedics.
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 recognise dehydration risk
Wider context from the report “1. Mr Taylor was seen by a GP the day before he died. His risk of dehydration was not recognised. The precise observations of the GP were difficult to ascertain at the inquest for a number of reasons.
• The inquest was told that the GP had been called as the care home had concerns about Mr Taylor. However, the GP did not ascertain his temperature because the inquest was told that he did not routinely carry or use a thermometer when he saw patients in a care home. The explanation provided to the inquest was that as a GP he did was not equipped with medical gadgets in the way for example NWAS staff were.
• The notes relating to the visit had not been written up until the next day and the GP could not recall all of any observations. It was unclear why that had occurred.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Limited care-home staff ability to recognise and respond to escalating dehydration risk
Wider context from the report “3. The staff in the care home were not medically qualified. The inquest heard that their ability to recognise and respond to an escalating risk of dehydration was limited . There was no national guidance to assist care home staff in understanding how to recognise; respond and escalate the risk of dehydration.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation National pathfinder tool failing to clearly direct immediate expedited hospital transfer for sepsis
Wider context from the report “2. The paramedic attending was a newly qualified paramedic and as a result was using the national pathfinder tool. Mr Taylor was scoring for sepsis on the NWAS observations. However, the crew took well over an hour to leave the care home . The inquest heard that newly qualified paramedics relied on the national pathfinder tool which did not make it clear the need for an immediate expedited transfer to hospital in such circumstances . More experienced paramedics used the Manchester triage tool which was far more explicit. The inquest was told that NWAS had recognised the issue with the national tool and were adjusting their practices to avoid the risk. However, it was not clear if other Ambulance Trusts had made similar adjustments for newly qualified paramedics.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 and omissions in recording GP visit observations
Wider context from the report “1. Mr Taylor was seen by a GP the day before he died. His risk of dehydration was not recognised. The precise observations of the GP were difficult to ascertain at the inquest for a number of reasons.
• The inquest was told that the GP had been called as the care home had concerns about Mr Taylor. However, the GP did not ascertain his temperature because the inquest was told that he did not routinely carry or use a thermometer when he saw patients in a care home. The explanation provided to the inquest was that as a GP he did was not equipped with medical gadgets in the way for example NWAS staff were.
• The notes relating to the visit had not been written up until the next day and the GP could not recall all of any observations . It was unclear why that had occurred.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 national guidance for care-home staff on recognising, responding to and escalating dehydration risk
Wider context from the report “3. The staff in the care home were not medically qualified. The inquest heard that their ability to recognise and respond to an escalating risk of dehydration was limited. There was no national guidance to assist care home staff in understanding how to recognise; respond and escalate the risk of dehydration.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 ascertain temperature during care-home GP assessments
Wider context from the report “1. Mr Taylor was seen by a GP the day before he died. His risk of dehydration was not recognised. The precise observations of the GP were difficult to ascertain at the inquest for a number of reasons.
• The inquest was told that the GP had been called as the care home had concerns about Mr Taylor. However, the GP did not ascertain his temperature because the inquest was told that he did not routinely carry or use a thermometer when he saw patients in a care home . The explanation provided to the inquest was that as a GP he did was not equipped with medical gadgets in the way for example NWAS staff were.
• The notes relating to the visit had not been written up until the next day and the GP could not recall all of any observations. It was unclear why that had occurred.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing website information and links to authoritative guidance provide providers with the information needed to support service users’ hydration needs.
Verbatim wording from the response “Information on the CQC website to signpost providers on meeting Regulation 14 is available. This includes links to a variety of best practice guidance including Diet, nutrition and obesity (National Institute for Health and Care Excellence) which is deemed relevant to all service providers. Other specific guidance to adult social care service included links to BAPEN (British Association for Parenteral & Enteral Nutrition): BAPEN: Malnutrition universal screening tool; Malnutrition Universal Screening Tool (MUST) explanatory booklet; Nutrition for specific groups (Royal College of Nursing); Nutrition support in adults (National Institute for Health and Care Excellence); Nutrition support in adults (NICE); Nutritional care and older people (Social Care Institute for Excellence, March 2009).” Source location 2020-0289-Response-from-CQC-Redacted
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 review found insufficient evidence of regulatory breaches, with appropriate nutrition and hydration care plans, monitoring records and assessments in place.
Verbatim wording from the response “The death of Mr Taylor was reviewed as part of our regulatory duties, to assess whether there was any evidence of failings by a Registered Person that amounted to a breach of the Regulations. The conclusion of the initial review found that there was insufficient evidence of a breach of the Regulations. Mr Taylor had a nutrition and hydration care plan in place, along with a variety of other appropriate and relevant care plans. These were being reviewed on a monthly basis. An assessment of Mr Taylor’s nutrition needs had also been recently reviewed in December 2019. Daily records were being completed and included food and fluid charts. The latter records both food offered and fluid taken by Mr Taylor, which would have assisted with auditing to ensure appropriate fluid levels were maintained. The meal chart is a similar mechanism for ensuring appropriate food intake.” Source location 2020-0289-Response-from-CQC-Redacted
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 Publishing detailed standards for specific conditions falls outside the regulator’s remit because authoritative expert organisations provide that guidance.
Verbatim wording from the response “CQC does not publish detailed standards and expectations about specific conditions. To do so would duplicate the work of more appropriate expert sources (for example NICE and SCIE - see below). We expect Registered Persons to keep up to date with, take on board and implement good practice standards provided by relevant authoritative organisations.” Source location 2020-0289-Response-from-CQC-Redacted
Open published response
1 Dec 2020 Anthony Slack · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Failure to maintain staff clarity about PPE requirements View source Limited documentation of care home staff observations View source Failure to share and implement changes to PPE guidance View source Lack of risk assessment for admission of new residents View source Failure to undertake observations of sufficient quality View source Insufficient ambulance availability for timely transport to an acute setting 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
Anthony Slack · 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
Anthony Slack, who had underlying health issues including asbestos-related pulmonary fibrosis, suffered an unwitnessed fall at a care home and waited over four hours for an ambulance. He later deteriorated, was transferred to hospital, and died on 13 April 2020. Concerns included limited care-home documentation and observations, unclear Covid-19 admission risk assessment and PPE arrangements, and ambulance delays linked to pandemic-related capacity pressures.
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 maintain staff clarity about PPE requirements
Wider context from the report “4. Staff were unclear as to the PPE requirements as a result of changes to the guidance that were occurring on a regular basis and it was unclear how changes were being shared with staff and implemented.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Limited documentation of care home staff observations
Wider context from the report “1. The documentation available at the inquest from the home was limited in detail . As a result, it was difficult to understand what observations had been undertaken by care home staff were monitoring him.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to share and implement changes to PPE guidance
Wider context from the report “4. Staff were unclear as to the PPE requirements as a result of changes to the guidance that were occurring on a regular basis and it was unclear how changes were being shared with staff and implemented .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 for admission of new residents
Wider context from the report “3. The inquest heard that after the home went into lockdown Covid 19 was found in residents within the home. At the inquest the home were unclear if staff had brought it into the home or if the admission of residents from the community who were not tested for Covid 19 before admission were the cause of the entering the home. There was no risk assessment in place relating to admission of new residents.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake observations of sufficient quality
Wider context from the report “2. The evidence given at the inquest was that the observations were of limited quality notwithstanding the diagnosis of Covid 19 and his vulnerability.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 ambulance availability for timely transport to an acute setting
Wider context from the report “5. The inquest heard that the ambulance was delayed due to shortages of available ambulances . The inquest was told this was driven by a number of factors. This included staff absences due to the need to self-isolate awaiting testing and the increased cleaning needs in relation to ambulances required by Covid 19. The inquest was told that at some points in the day and in some acute trusts, ambulance crews were being supported by on-site cleaning crews. This meant quicker turnaround times and increased capacity. This was not consistent and not on a 24/7 basis. As a result, ambulances were struggling to reach vulnerable and unwell members of the public and transport them to an acute setting .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish COVID-19 guidance for adult social care providers to support implementation of current requirements.
Verbatim wording from the response “With regards to The Vicarage Residential Care Home, CQC expects registered persons to keep up to date with, take on board and implement government guidance. We have during the Covid 19 pandemic remained in regular contact with the Provider. This included engagement calls in March, April and May 2020. These were supportive calls to ensure that the Provider was aware of any updates to guidance and to signpost appropriate support if needed. CQC also published COVID-19 related guidance for ASC providers on the CQC website. From mid-March 2020 the Provider also received daily updates from TMB which included updates on guidance, resources and support.” Source location 2020-0264-Response-from-CQC-Redacted
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 regional ambulance performance and delays through engagement, performance reports, internal meetings, monthly meetings and national forums.
Verbatim wording from the response “We are continually monitoring the regional ambulance picture, through ongoing engagement, performance reports and internal meetings.” Source location 2020-0264-Response-from-CQC-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake an unannounced focused inspection of the care home covering infection control, risk management, falls, records and access to health support.
Verbatim wording from the response “Following receipt of the concerns raised by the Coroner at the conclusion of the inquest into the death of Mr. Slack which resulted in the prevention of future deaths report, CQC undertook an unannounced, focused inspection of The Vicarage Residential Care Home. This was undertaken to ensure that the circumstances of Mr. Slack’s death did not raise concerns about any ongoing risk to current service users” Source location 2020-0264-Response-from-CQC-Redacted
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 arrangements for communicating PPE guidance, training staff and maintaining PPE supplies are considered sufficient to manage PPE risks.
Verbatim wording from the response “We have confirmed, through engagement conversations with the Provider in March, April and May 2020, and at our inspections in July 2020 and January 2021 that the Provider was accessing the government guidance current at that time on use of PPE. On all of these occasions the Provider demonstrated that they were aware of current guidance and were ensuring staff were made aware of any changes via a staff WhatsApp group, emails and staff handovers. The Provider confirmed they were receiving updates from TMBC which included links to any changes in guidance to PPE use.” Source location 2020-0264-Response-from-CQC-Redacted
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 post-fall and illness-management processes address the known risks, including appropriate observations, medical support and documentation.
Verbatim wording from the response “CQC expects all services to have robust systems to ensure the quality of service and monitors that policies and procedures are being followed. We found there were a variety of checks and audits carried out in the home to ensure it was safe for the people living there. These included reviews of action taken following accidents and incidents, care record entries and observation records. These were overseen by the Provider to ensure any actions were completed.” Source location 2020-0264-Response-from-CQC-Redacted
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 admission controls, including government guidance, isolation and regular testing, are considered sufficient to manage infection risks.
Verbatim wording from the response “Throughout the Covid 19 pandemic government guidance has been issued to providers on admissions to care homes and testing of staff. This did not at the time of Mr Slacks death include the requirement to test staff or residents before admission.” Source location 2020-0264-Response-from-CQC-Redacted
Open published response
Concerns raised 3 Failure to provide all GP practice staff with training on domestic violence and safeguarding policies View source Lack of early warning systems in practices for unexplained prescription non-collection or appointment cancellation View source Lack of domestic violence and safeguarding policies in GP practices View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Avis Mary Addison · 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
Avis Mary Addison died on 22 February 2017 after being murdered by her late husband; the recorded medical cause of death included suffocation, and the inquest conclusion was unlawful killing. The substantive concerns included possible failures or delays in recognising domestic abuse and safeguarding issues, and whether GP practices had appropriate domestic violence and safeguarding policies, training, and early-warning processes.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to provide all GP practice staff with training on domestic violence and safeguarding policies
Wider context from the report “Given CQC is the agency responsible for inspection of GP practices, one way to ensure GP practices have domestic violence and safeguarding policies in place, and to ensure that all staff have received training on their contents , is to include checks in this regard as part of your inspection regime. It is, of course, entirely possible that this is already part 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 Lack of early warning systems in practices for unexplained prescription non-collection or appointment cancellation
Wider context from the report “Another matter that you may feel would be beneficial to inspect is whether practices have in place some form of ‘early warning system’ where, for example, prescriptions are not collected or appointments are cancelled without good reason (eg by a controlling partner.)
I accept this may be more difficult to do in non-prescribing practices but with clear guidance I would hope that it may still be possible to achieve.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of domestic violence and safeguarding policies in GP practices
Wider context from the report “Given CQC is the agency responsible for inspection of GP practices, one way to ensure GP practices have domestic violence and safeguarding policies in place , and to ensure that all staff have received training on their contents, is to include checks in this regard as part of your inspection regime. It is, of course, entirely possible that this is already part of the process.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Training records are not routinely checked in every inspection because inspection checks depend on the service, inspection type and concerns raised.
Verbatim wording from the response “CQC do not always routinely check all training records as part of an inspection. This will depend on the service; the type of inspection and what concerns have been raised.” Source location 2020-0216-Response-from-CQC-Redacted.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation GP practices are responsible for determining mandatory and additional staff training and how it is delivered, rather than CQC prescribing a definitive list.
Verbatim wording from the response “CQC does not provide a list of mandatory training expected members of the GP practice team. This is because training requirements will depend on the role and specific responsibilities of practices, and the needs of the people using the service. Ultimately, the practice is responsible for determining what mandatory and additional training staff need and how this is delivered. Although there is no definitive list of mandatory training. Examples of training CQC would expect to see evidence of include training to the appropriate level on safeguarding adults at risk and safeguarding children.” Source location 2020-0216-Response-from-CQC-Redacted.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing inspection processes already assess systems for managing vulnerable patients, including missed appointments and uncollected prescriptions.
Verbatim wording from the response “CQC will consider as part of the inspection of a practice, the systems in place to support the management of vulnerable patients. This includes a review of the process to manage where patient prescriptions have not been collected or appointments are not attended.” Source location 2020-0216-Response-from-CQC-Redacted.pdf
Open published response
9 Oct 2020 WYNTER SOPHIA ANDREWS · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Failure to provide sufficient midwifery care capacity for multiple families View source Failure to base critical care-allocation decisions on individualised patient risk View source Failure to listen and respond to staff safety concerns View source Failure to promote and facilitate professional challenge View source Lack of robust initial critical analysis of deaths View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
WYNTER SOPHIA ANDREWS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Wynter Sophia Andrews died after being delivered by caesarean section on 15 September 2019, following missed opportunities to monitor her wellbeing and concerns that she should have been delivered earlier. The report identified concerns about the lack of robust initial critical analysis of deaths and an unsafe culture within Midwifery Services, including failures to respond to staff safety concerns, facilitate professional challenge, and make decisions based on individualised patient risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to provide sufficient midwifery care capacity for multiple families
Wider context from the report “(a) Failure to listen to and respond to staff safety concerns
I have made findings that the Maternity Services were operated in an unsafe manner on 14 – 15 September 2019. Staff told me this was not the first time, nor the last time, that they have been asked to care for multiple families simultaneously, meaning that those families cannot receive the time, focus and dedication they require . Staff further told me that they have repeatedly raised their concerns about patient safety, but their concerns have been met with silence. I saw evidence that staff were repeatedly raising their concerns through the Datix system, but they told me they would receive no feedback in reply nor would anything change.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 base critical care-allocation decisions on individualised patient risk
Wider context from the report “(c) Failure to reach decisions based on individualised patient risk
It was custom and practice that critical decisions, such as which patient to transfer to the labour suite when demand outstripped supply, were made in isolation without reading the patient notes, speaking with the midwife caring for the patient, without seeing the patient, without seeking medical input and, crucially, without assessing individualised patient risk at the point the patient was unable to receive the care on the labour ward that they required.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to listen and respond to staff safety concerns
Wider context from the report “(a) Failure to listen to and respond to staff safety concerns
I have made findings that the Maternity Services were operated in an unsafe manner on 14 – 15 September 2019. Staff told me this was not the first time, nor the last time, that they have been asked to care for multiple families simultaneously, meaning that those families cannot receive the time, focus and dedication they require. Staff further told me that they have repeatedly raised their concerns about patient safety, but their concerns have been met with silence . I saw evidence that staff were repeatedly raising their concerns through the Datix system, but they told me they would receive no feedback in reply nor would anything change .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 promote and facilitate professional challenge
Wider context from the report “(b) Failure to promote and facilitate professional challenge
Midwives spoke of their inability to professionally challenge plans made by medical staff , even in circumstances where they felt the plan might harm mother or baby. The culture failed to promote professional challenge and multi-disciplinary care of women. Decisions were often made in isolation, without understanding the full background and patient wishes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of robust initial critical analysis of deaths
Wider context from the report “1. Lack of robust initial critical analysis of deaths
Prior to 1 October 2019, when the Notification of Deaths Regulations 2019 came into force, the Trust were mandated by local agreement to refer every child death (even expected deaths) to HM Coroner.
However, the implementation of the Regulations, removed the discretion of coroners to set local referral criteria. Wynter’s death occurred just two weeks prior to the implementation of the Regulations, and was therefore referred to HM Coroner as ‘standard procedure’.
The referral itself expressed that Wynter’s death was ‘Expected’ and as a result, there had been no review performed by the Rapid Response Clinician for Unexpected Paediatric Deaths.
The checklist on the reverse of the referral to HM Coroner indicated that the only trigger for referral was the “Deceased’s Age”. The boxes for neglect, unnatural death, allegations of negligence, and death associated with a clinical incident were all left unticked.
The detail within the body of the report made no reference to any of the failings that have become apparent throughout the inquest, and indeed, would have been apparent upon robust scrutiny of the CTG trace and medical records available at the time.
The referral explained that the reporting doctor was happy to propose a cause of death, and happy to complete the Medical Certificate of Cause of Death. The effect of this, would have meant Wynter’s death being registered as a natural death and without investigation by the Coroner.
As is usual practice, before the Coroner reaches a decision, the Coroner’s officer makes contact with the family to see if they have any concerns. Understandably, this is a shocking and upsetting time for the family, but they had the clarity of thought at that stage to express some concerns about the events leading up to labour, which were sufficient for the Coroner to direct an independent post mortem examination.
The full picture then unfolded through the coronial investigation and the separate Health Sector Investigation Branch inquiry.
I am concerned that the lack of robust initial critical analysis of deaths has the potential to lead to missed opportunities to learn lessons that are vital to improving patient safety . Mrs ████████ agreed that one of the recommendations to come out of this inquest is a review of the current 72-hour table top review of care. This risk goes beyond obstetric deaths and has the ability to prevent learning from deaths within other Divisions of the Trust.
For that reason, I am informing the Trust’s Chief Executive of my concerns through a PFD report.
” Open source report
28 Sep 2020 Mr William Ivan McKibbin · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Lack of documentation checks confirming bed brakes are on View source Failure to maintain a culture in which staff can speak up about errors and poor practice View source Lack of a minimum-information standard for cross-hospital specialist advice communication View source Lack of guidance for identifying, securing and gathering evidence in clinical incident investigations View source Failure of the Statutory Notification process to require timely submission of relevant evidence about deaths View source Unavailability of medical records across Trust hospital sites View source Lack of documentation checks confirming bed-rails are in the appropriate position View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mr William Ivan McKibbin · 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 William Ivan McKibbin died at Trafford General Hospital on 20 August 2018 following complications of a traumatic brain injury sustained in an unwitnessed fall in hospital. The report raised concerns about bed-rail and bed-brake checks, the culture of openness and candour, communication between specialists and hospital sites, incident investigations, and the process for learning from 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 documentation checks confirming bed brakes are on
Wider context from the report “2. It is a matter of concern that NHS nursing documentation, such as Intentional Rounding Checklists, in use at the Trust and in other hospitals, currently do not include ‘tick-box’ checks to confirm bed-rails are in the appropriate position, and the bed brakes are on .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 a culture in which staff can speak up about errors and poor practice
Wider context from the report “1. The evidence heard at this inquest left me with residual concerns as to the prevailing culture at the Trust, and by extension, within the NHS .
It was clear from the evidence that by the time of Mr McKibbin’s death, Managers from the Trust were aware at the very least that the brakes simply cannot have been applied to his bed at the time he sustained the fall which led to his death.
Despite this, no confirmation of this fact was made to Mr McKibbin’s family, or in the report of his death to the Coroner. Similarly, this conclusion was not drawn by a number of internal investigations undertaken by the Trust, or indeed in evidence given to the court by Professor ████████, Chief Nurse and a member of the Trust’s board.
For a duty of candour to have meaning, it is essential the prevailing culture of an organisation is one where staff have freedom to speak out. For the reasons set out by Sir ████████ QC in his PFD Report into events at Mid Staffordshire NHS Foundation Trust, unless staff of all levels feel able to speak up about their own errors, and to point out to highlight poor practice of others, a significant risk of future deaths will remain .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of a minimum-information standard for cross-hospital specialist advice communication
Wider context from the report “3. Given the operating model of the Trust, whereby different specialists provide services at different hospitals, it is a matter of concern that no proforma documentation / communication paradigm exists which sets out the minimum standard of information expected to be conveyed when a clinician seeks advice from a specialist based at another hospital .
The risk of death in this regard is currently compounded by the fact that medical records from one hospital are not necessarily accessible from another site within the Trust group.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for identifying, securing and gathering evidence in clinical incident investigations
Wider context from the report “4. In view of the importance of robust and reliable investigations into clinical incidents to reducing the risk of future deaths, it is a matter of concern that no guidance currently exists for on-call managers and investigators as to quickly identifying, securing and gathering relevant evidence .
Improvements in gathering evidence would assist the Trust in reliably identifying the underlying cause or causes of incidents, which in turn would better inform actions to be taken with a view to reducing the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of the Statutory Notification process to require timely submission of relevant evidence about deaths
Wider context from the report “5. In order to enhance learning from deaths, consideration should be given to modifying the Statutory Notification process following death of a service-user so as to require Registered Providers to lodge specified relevant evidence as to how the death occurred within a defined period .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Unavailability of medical records across Trust hospital sites
Wider context from the report “3. Given the operating model of the Trust, whereby different specialists provide services at different hospitals, it is a matter of concern that no proforma documentation / communication paradigm exists which sets out the minimum standard of information expected to be conveyed when a clinician seeks advice from a specialist based at another hospital.
The risk of death in this regard is currently compounded by the fact that medical records from one hospital are not necessarily accessible from another site within the Trust group .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 documentation checks confirming bed-rails are in the appropriate position
Wider context from the report “2. It is a matter of concern that NHS nursing documentation, such as Intentional Rounding Checklists, in use at the Trust and in other hospitals, currently do not include ‘tick-box’ checks to confirm bed-rails are in the appropriate position , and the bed brakes are on.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Promote appropriate reporting of deaths and patient safety incidents through regulatory activities.
Verbatim wording from the response “our preferred option is to continue to receive this information through the NRLS /STEIS routes and promote the right level of reporting through our regulatory activities.” Source location 2020-0185-Response-from-CQC-Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review notifications guidance to clarify reporting requirements concerning the circumstances of a person’s death.
Verbatim wording from the response “In general, we consider that the information received through NRLS/STEIS reports is adequate to enable CQC to fulfil its regulatory responsibilities. However, we will review our existing notifications guidance in light of the findings from Mr McKibbin’s death, to determine if it could be clearer about the reporting requirements relating to the circumstances of a person’s death. We have a programme to improve how we receive, analyse and assess the information we receive via NRLS and STEIS to monitor patient safety.” Source location 2020-0185-Response-from-CQC-Redacted.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Changing death-reporting arrangements would require legislative action brought forward by the Department of Health and Social Care.
Verbatim wording from the response “Any changes to the current arrangement for reporting of deaths would require legislative change brought forward by the Department of Health and Social Care. CQC’s view is that creating a separate, and potentially parallel reporting requirement for providers could create confusion and undermine appropriate reporting to both routes with an impact on national learning from patient safety incidents. Therefore,” Source location 2020-0185-Response-from-CQC-Redacted.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NRLS/STEIS reporting is considered adequate for CQC’s regulatory responsibilities, so a separate direct death-notification requirement is not preferred.
Verbatim wording from the response “The current arrangements by which CQC receives notifications of deaths via the NRLS rather than directly from NHS Trusts was put in place to reduce the complexity of reporting routes and minimise burden on NHS providers. Although direct notifications to CQC contain questions which have the potential to elicit more detail about a specific incident, the quality of the data is equally dependent on staff reporting culture and practice.” Source location 2020-0185-Response-from-CQC-Redacted.pdf
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations