24 Apr 2020 Mary Brady · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Failure to implement controls to prevent recurrence of unsafe clinical waste disposal View source Failure to dispose of clinical waste in the designated secure clinical waste bin View source Failure to escalate recurring unsafe clinical waste disposal to senior managers View source Failure to update care plans following identified mouthing risks View source Failure to document and risk assess observed mouthing of foreign non-food items View source Failure to prevent unsupervised access by residents with dementia to hazardous waste in communal areas View source See 3 more concerns
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AI-generated summary
Mary Brady · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mary Brady, who had vascular dementia and lived in a care home, was found unresponsive after being left unobserved in a communal area. A used pair of latex gloves was removed from her airway, and she died shortly after midnight on 11 March 2019. Concerns included accessible open waste baskets, improper disposal and insufficient escalation of used gloves, and failures to document and risk-assess her previous ingestion of non-food items or update her care plan.
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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 implement controls to prevent recurrence of unsafe clinical waste disposal
Wider context from the report “2. The gloves were clinical waste and had been disposed of other than in the clinical waste bin in the secure area. The inquest heard that there had been previous instances of used gloves being found in the waste baskets. However the issue had not been escalated to senior managers and no steps had been taken to avoid the issue reoccurring .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to dispose of clinical waste in the designated secure clinical waste bin
Wider context from the report “2. The gloves were clinical waste and had been disposed of other than in the clinical waste bin in the secure area . The inquest heard that there had been previous instances of used gloves being found in the waste baskets. However the issue had not been escalated to senior managers and no steps had been taken to avoid the issue reoccurring.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 recurring unsafe clinical waste disposal to senior managers
Wider context from the report “2. The gloves were clinical waste and had been disposed of other than in the clinical waste bin in the secure area. The inquest heard that there had been previous instances of used gloves being found in the waste baskets . However the issue had not been escalated to senior managers and no steps had been taken to avoid the issue reoccurring.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 care plans following identified mouthing risks
Wider context from the report “3. Mrs Brady had been seen putting foreign non-food items in her mouth by staff. These instances had not been appropriately documented and risk assessed. The level of risk she presented was not fully understood as a result and her care plan was not updated .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to document and risk assess observed mouthing of foreign non-food items
Wider context from the report “3. Mrs Brady had been seen putting foreign non-food items in her mouth by staff. These instances had not been appropriately documented and risk assessed . The level of risk she presented was not fully understood as a result and her care plan was not updated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 unsupervised access by residents with dementia to hazardous waste in communal areas
Wider context from the report “1. The inquest heard that the home at the time of Mrs Brady’s death, in common with many similar establishments had open waste paper baskets in the communal areas . Residents with dementia were left unsupervised in these areas and there was always a risk that they might access material from these waste baskets . In this case the gloves should not have been in the bin at all but there were other items in there which could have presented a choking hazard . The home had since removed all open wastebaskets from communal areas to avoid the risk. The inquest was told that similar baskets were common in care homes nationally.
” 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 Open waste baskets were not themselves causally linked to the death, which resulted from individual staff error rather than registered-person failings.
Verbatim wording from the response “The death of Mrs Brady 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 this review found that there was insufficient evidence of a breach of the Regulations. The CQC view was that the presence of open waste baskets could not in themselves be causally linked to the death of Mrs Brady and that Mrs Brady’s death was the result of individual staff error (failure to dispose of clinical waste appropriately) rather than a failure by a registered person.” Source location 2020-0105-Response-from-Care-Quality-Commission_Redacted-1.pdf
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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 risk-management arrangements and the action plan’s handover, communication, and assessment processes were considered to address known choking and non-food-item risks.
Verbatim wording from the response “The CQC is satisfied that appropriate steps have been taken to ensure that staff recognise risks from choking and document them appropriately. This is based on our previous knowledge of this location, how they have responded to this incident and the input from Tameside Local Authority in developing an action plan.” Source location 2020-0105-Response-from-Care-Quality-Commission_Redacted-1.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 glove-disposal policies, staff awareness, safety checks, and the new PPE policy and checking system were considered sufficient responses.
Verbatim wording from the response “It would be good practice for staff to discuss such incidents with the manager so these could be addressed at a senior level. There were clear policies for the disposal of gloves and all staff were aware of the correct procedure. Therefore, any failure to dispose of gloves appropriately (or escalate incidents where gloves had not been appropriately disposed of) does not seem to be attributable to failings of a registered person. The CQC understood that these previous incidents were dealt with as isolated incidents and were not considered to be a trend or ongoing risk presented by visiting external health care services.” Source location 2020-0105-Response-from-Care-Quality-Commission_Redacted-1.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 Visiting healthcare professionals are responsible for safely disposing of their own clinical waste under their external services’ procedures.
Verbatim wording from the response “home stated that there were two separate incidents whereby health professionals had disposed of their clinical gloves incorrectly. 1) by a paramedic who had left their gloves for the home care to dispose of and 2) again by a paramedic who left clinical gloves after treating a resident to dispose of. External health care services will have their own policies and procedures for disposing of clinical waste, such as disposable gloves, when visiting community settings and care homes. It would be the visiting professional’s responsibility to safely dispose of their own clinical waste.” Source location 2020-0105-Response-from-Care-Quality-Commission_Redacted-1.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 The provider’s action plan and removal of open waste baskets were considered sufficient to reduce ongoing risks in the care home.
Verbatim wording from the response “However, CQC were of the opinion that the registered persons had taken reasonable steps to ensure the safe disposal of gloves. We have reviewed the action plan developed by Balmoral Care Home and local authority and are satisfied that enough action has been taken in response to reduce further risks within this care home. This will be reviewed at our next inspection of the service.” Source location 2020-0105-Response-from-Care-Quality-Commission_Redacted-1.pdf
Open published response
2 Mar 2020 HARRY RICHFORD · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 20 Lack of cross-site clinical working opportunities View source Failure to notify the Coroner of a child death View source Uncertain auditing and logging of neonatal resuscitation pro forma completion View source Unclear guidance for obtaining anaesthetic help in paediatric emergencies View source Failure to retain placentae for examination after severe foetal distress View source Lack of clear requirements for consultant assessment of locum competence before overnight responsibility View source Failure to produce timely and sufficiently detailed statements after deaths View source Failure to assess and supervise locum clinicians View source Lack of clarity about when to call a consultant at night View source Failure to record consultant telephone advice View source Failure to record feedback and audit locum recruitment View source Insufficient consultant availability for night-time emergencies View source Lack of staff knowledge of applicable clinical guidelines and policies View source Failure to share important independent safety reports with staff View source Lack of paediatric team knowledge of neonatal collapse guidelines View source Lack of clarity about prompt action in obstetric emergencies View source Substandard obstetric record keeping View source Inaccurate and incomplete child death notification forms View source Inadequate neonatal resuscitation training View source Inaccurate MBRRACE maternal and neonatal death reporting View source See 17 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
HARRY RICHFORD · 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
Harry Richford was born at QEQM on 2 November 2017 and died at William Harvey Hospital on 9 November 2017 after being transferred there. The report describes delays in delivery, shortcomings in the caesarean delivery and neonatal resuscitation, and subsequent hypoxia and brain injury. Substantive concerns included locum recruitment, assessment and supervision; clarity about escalation to consultants; neonatal resuscitation training; record keeping and adherence to guidelines; and inaccurate death notifications and reporting.
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 cross-site clinical working opportunities
Wider context from the report “Concern 8
Prior to Harry's death both ████████████████, a senior member of staff who had the care of Harry at the William Harvey Hospital, accepted that there were no opportunities for cross site working between QEQM and the William Harvey Hospital . Currently two out of eight middle grade doctors have had the opportunity to spend time at the William Harvey, which has a much higher specification neo natal unit. ████████ described the lack of opportunities before Harry's death as ‘at best, very surprising'.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the Coroner of a child death
Wider context from the report “Concern 17
The child death notification form was incorrectly completed in that Harry's death was recorded as 'expected'. No notification was made to the Coroner . No details were filled in on the notification form giving any detail of the problems leading to Harry's death. As a result, the Child Death Overview Panel would have been unaware of the problems encountered and could not have shared learning to prevent other such deaths occurring. I make no recommendation in respect of the lack of notification to the Coroner as I am aware that the Senior Coroner has already dealt with this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Uncertain auditing and logging of neonatal resuscitation pro forma completion
Wider context from the report “Concern 15
The East Kent Trust should consider a review as to the use or otherwise of a resuscitation pro forma. A pro forma has since Harry's death been adopted by the East Kent Trust which, on the evidence of ████████, has improved the oversight of neo natal training and governance. It is not clear whether that pro forma is being audited or logged , or what actions are being done to ensure its completion and preservation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 guidance for obtaining anaesthetic help in paediatric emergencies
Wider context from the report “Concern 9
The resuscitation of Harry was eventually carried out by ████████, the anaesthetist looking after ████████. His evidence was that leaving his own patient to help the paediatric team was an unusual action to take in the UK although he had often performed such actions in Nepal. Doctors at QEQM indicated that there was an informal policy that if a middle grade paediatrician found themselves in an emergency, they could seek help from their anaesthetic colleagues . It was unclear whether the anaesthetists were aware of this informal policy . This informal policy should be clarified, and guidance given because there is a risk, that in an emergency, it will be overlooked .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to retain placentae for examination after severe foetal distress
Wider context from the report “Concern 12
The placenta of Harry was not retained . Examination of the placenta will in some circumstances assist in cases of severe foetal distress. The Royal College of Pathologists states that it is 'essential' for the placenta to be sent for examination in cases of severe foetal distress requiring admission to a neo natal unit.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 requirements for consultant assessment of locum competence before overnight responsibility
Wider context from the report “Concern 2
The current policy of the East Kent Trust states that it is the responsibility of the healthcare professional who will be supervising the locum to assure themselves of his/her competence. This did not happen in this case. There is at present no requirement for a locum to be assessed on a day shift by a consultant before being left in charge overnight . There is no clear direction that it is the responsibility of the assessing consultant to satisfy themselves of the locum's experience and capability . One specialist from outside the East Kent Trust, ████████, also stated that it would assist the assessing consultants to be able to see not only the locum's CV but also their references and any training records available.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to produce timely and sufficiently detailed statements after deaths
Wider context from the report “Concern 16
In order to try to prevent future deaths it is important that there are clear records and statements made when a death occurs so that lessons can be learnt. In this instance many of the statements were very scanty in their content and some were made a long time after the event . In some instances, staff had to make statements from memory without the advantage of seeing the medical notes . Contemporaneous (or as near as possible) notes are also very much in the interests of the staff involved so that they can give clear accounts of their actions and reasons for them if required to do so at a later 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 assess and supervise locum clinicians
Wider context from the report “Concern 1
████████ was recruited as a locum registrar by the Hospital Trust without there appearing to have been any assessment of his skills and abilities or any supervision of him at the hospital . This was not an emergency appointment after, for example, a doctor calling in sick at the last minute. ████████ gave evidence that the recruitment, assessment and supervision of locums is a national problem and that there is a need for a review on a national level. This raises concerns that there may be a risk to other lives both at this trust and at other trusts in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about when to call a consultant at night
Wider context from the report “Concern 5
There appeared to be from the evidence given at the inquest substantial confusion amongst staff as to when a consultant should be called at night . The East Kent Trust now has some 70 hours a week consultant attendance on the wards. That leaves 14 hours a day when there is no consultant present. Staff, whether doctors, nurses or midwives should know the circumstances in which consultant help should be sought and should not feel inhibited from making their views known. If staff are unaware or unsure of when the consultant should be called that potentially poses a continuing risk to life.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 consultant telephone advice
Wider context from the report “Concern 14
There are no current records kept by consultants who are telephoned at home for advice . In this case there was a dispute about the number of calls made to ████████ and as to the content of these calls. The advice given and the actions taken as a result are important for the preservation of life.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 feedback and audit locum recruitment
Wider context from the report “Concern 3
████████ had worked two night time shifts at the QEQM before the night of Harry's birth. The extent to which there was any feedback from the consultants on call those two nights to ████████ is unclear. She, erroneously, believed the East Kent Trust had employed ████████. There is no record of any written feedback . From the evidence of the medical director of the East Kent Trust it appears that the current locum recruitment policy is not being checked or audited . There is a potential for further risks to life arising from these shortfalls.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 consultant availability for night-time emergencies
Wider context from the report “Concern 6
The current contracts at the East Kent Trust permit consultants to live up to 30 minutes travel time from the hospital . This poses considerable problems and risks for night time emergencies .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 staff knowledge of applicable clinical guidelines and policies
Wider context from the report “Concern 10
There appeared to be considerable confusion among members of staff as to which, if any, guidelines and policies affected them . While two senior members of staff, ████████████████ (consultant), said that the East Kent Trust has systems in place to ensure knowledge of and compliance with Trust policies neither of them was able to say whether this was effective. Significant issues remain as to the knowledge of staff as to which guidelines govern their behaviour (this was also a finding of the Health and Safety Investigation Board in 2019). Such confusion or lack of knowledge increases 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 to share important independent safety reports with staff
Wider context from the report “Concern 19
Important independent reports do not appear to have been shared within the East Kent Trust's staff , for instance the HSIB report into Harry's death appeared during the inquest to be unknown to a number of the 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 paediatric team knowledge of neonatal collapse guidelines
Wider context from the report “Concern 11
There was a lack of knowledge within the paediatric team of guidelines issued by the Department of Women's Health . The evidence from the East Kent Trust doctors was that the guidelines issued by the department directed to 'all maternity and neonatal staff who may be involved with the immediate care and support of a collapsed neonate' would not have been known to the paediatric team at the relevant time. Even senior clinicians, such as ████████, were not aware of the relevant guidelines.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about prompt action in obstetric emergencies
Wider context from the report “Concern 4
There is a risk to the life of both mothers and babies if there is a lack of clarity as to the processes or the need to take prompt action where it is necessitated in the event of an obstetric concern or emergency developing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Substandard obstetric record keeping
Wider context from the report “Concern 13
The standard of record keeping on the obstetric unit was substantially sub-standard . The quality of the note taking and records is of considerable importance to new staff taking over responsibility for mother and baby. Without there being clear accurate records there is a risk of further mistakes being made leading, at the worst, to the risk of death. An example of this in Harry's case is that the record of the syntocinon prescribed to ████████ over a long period of time is inconsistent with the evidence of the midwives and the registrar who gave it to her.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 incomplete child death notification forms
Wider context from the report “Concern 17
The child death notification form was incorrectly completed in that Harry's death was recorded as 'expected' . No notification was made to the Coroner. No details were filled in on the notification form giving any detail of the problems leading to Harry's death . As a result, the Child Death Overview Panel would have been unaware of the problems encountered and could not have shared learning to prevent other such deaths occurring. I make no recommendation in respect of the lack of notification to the Coroner as I am aware that the Senior Coroner has already dealt with this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Inadequate neonatal resuscitation training
Wider context from the report “Concern 7
The evidence of ████████ raised substantial concerns about the quality of training and learning in respect of neonatal resuscitation at the East Kent Trust. His evidence was that it would be desirable for middle grade doctors to attend the ARNI course (the advanced resuscitation of the new born infant). He also recommended that there should be simulated drills in neo natal resuscitation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 MBRRACE maternal and neonatal death reporting
Wider context from the report “Concern 18
The MBRRACE form in respect of Harry Richford was inaccurate in a number of important areas . The form is important to provide robust national data to support the delivery of safe, high quality maternal and new born care as well as identifying errors and faults, if any, where there has been a maternal or infant death so that future deaths can be avoided.
” Open source report
27 Feb 2020 Mr Kenneth Clarke · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 5 Lack of formal policies for kitchen and cupboard locks View source Lack of formal policies for residents on a liquid food diet View source Lack of formal policies for observing residents View source Lack of formal policies for residents with dementia View source Lack of formal policies for food storage 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
Mr Kenneth Clarke · 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 Kenneth Clarke, a 74-year-old resident of a nursing home with dementia and a high risk of choking, left his room on 23 July 2017, accessed bread that had been left out, choked and died. The inquest identified that the nursing home had no formal policies covering resident observation, food storage, kitchen and cupboard locks, dementia residents, or residents on a liquid food diet.
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 formal policies for kitchen and cupboard locks
Wider context from the report “1. Evidence emerged during the inquest that Normanton Village View Nursing Home had no formal policies covering how residents were to be observed, how foods were to be stored, locks on the kitchen and cupboards , dementia residents or residents on a liquid food diet.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of formal policies for residents on a liquid food diet
Wider context from the report “1. Evidence emerged during the inquest that Normanton Village View Nursing Home had no formal policies covering how residents were to be observed, how foods were to be stored, locks on the kitchen and cupboards, dementia residents or residents on a liquid food diet .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of formal policies for observing residents
Wider context from the report “1. Evidence emerged during the inquest that Normanton Village View Nursing Home had no formal policies covering how residents were to be observed , how foods were to be stored, locks on the kitchen and cupboards, dementia residents or residents on a liquid food diet.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of formal policies for residents with dementia
Wider context from the report “1. Evidence emerged during the inquest that Normanton Village View Nursing Home had no formal policies covering how residents were to be observed, how foods were to be stored, locks on the kitchen and cupboards, dementia residents or residents on a liquid food diet.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of formal policies for food storage
Wider context from the report “1. Evidence emerged during the inquest that Normanton Village View Nursing Home had no formal policies covering how residents were to be observed, how foods were to be stored , locks on the kitchen and cupboards, dementia residents or residents on a liquid food diet.
” Open source report
25 Feb 2020 Elaine Rose Renshaw · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure of controlled drug checks to identify unaccounted drugs View source Lack of a clear process for handling and recording controlled drug use 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.
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AI-generated summary
Elaine Rose Renshaw · 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
Elaine Rose Renshaw was found unresponsive at home, resuscitated and taken to Tameside General Hospital, where she died on 8 July 2019 after attempts to reverse the effects of morphine were unsuccessful. The inquest identified inaccurate controlled-drug checks and accounting, with concern that the absence of a clear process for recording controlled-drug use could lead to similar problems in other care and nursing homes.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of controlled drug checks to identify unaccounted drugs
Wider context from the report “During the course of the inquest evidence was given that controlled drug checks processes had been such that it was not easily identified that drugs were not accounted for e.g. Stock sheets were inaccurate . The home in question had tightened up its processes since the incident. However the inquest heard that this issue may well arise in the future in other care/nursing home settings as there is no clear process for handling/recording the use of controlled drugs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear process for handling and recording controlled drug use
Wider context from the report “During the course of the inquest evidence was given that controlled drug checks processes had been such that it was not easily identified that drugs were not accounted for e.g. Stock sheets were inaccurate. The home in question had tightened up its processes since the incident. However the inquest heard that this issue may well arise in the future in other care/nursing home settings as there is no clear process for handling/recording the use of controlled drugs .
” Open source report
10 Feb 2020 Christine Rosemary Neild · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to provide reliable overnight detection of residents getting up and wandering View source Failure to escalate incidents involving residents putting non-food items in their mouths and undertake further risk assessment View source Failure to restrict access to gloves for residents who may place items in their mouths 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
Christine Rosemary Neild · 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
Christine Rosemary Neild had significant learning difficulties, dysphagia, and required feeding support. She became very unwell and died at Meade Close on 31 January 2020; the medical cause of death was a sub-acute bowel obstruction associated with an incisional hernia. Concerns included accessible gloves and other non-food items, a failure to escalate an earlier ingestion incident or undertake further risk assessment, and the lack of regular sensors to alert staff when residents got up at night.
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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 provide reliable overnight detection of residents getting up and wandering
Wider context from the report “3. The inquest heard that in care settings such as this one for those with learning disabilities there was no regular use of sensors to alert night staff of a resident getting up and wandering . Staff relied on hearing a resident getting up despite this being difficult if they were delivering personal care onto another 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 escalate incidents involving residents putting non-food items in their mouths and undertake further risk assessment
Wider context from the report “2. There had been an earlier incident when Christine Neild had put non-food items in her mouth. The carer did not escalate this and there was no further risk assessment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict access to gloves for residents who may place items in their mouths
Wider context from the report “1. During the course of the inquest evidence was heard that gloves were in open and easily accessible locations throughout the home including in rooms and the kitchen area . The inquest was told that this is standard practice in care settings for people with learning disabilities even where residents do not have insight into what items can safely be placed in their mouths .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue using enforcement powers to require improvements when providers are not meeting 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 Miss Christine Neild with inspectors and registered persons.” Source location 2020-0192-Responses-from-Trafford-Council-and-CQC_Redacted.pdf
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 Check the provider’s regulatory compliance at the next service inspection and require improvements or highlight breaches where warranted.
Verbatim wording from the response “We will check the provider’s compliance with the regulations on our next inspection of the service using our key lines of enquiry and in accordance with CQC’s” Source location 2020-0192-Responses-from-Trafford-Council-and-CQC_Redacted.pdf
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 resident did not require a night sensor because assessments identified no harm risk, while an alert mat could create a trip hazard.
Verbatim wording from the response “From our observations of care planning documents and following discussions with the registered manager of the service Miss Neild did not require a sensor mat to be in place during the night. Support plans and corresponding risk assessments identified Miss Neild was fully mobile during the day and on occasions at night and was not at risk of harm. The inquest heard how Christine would sometimes seek staff out at night as she liked to do this. Placing an alert mat on the floor when someone is fully mobile can present as a trip hazard and becomes an additional risk. Whatever method a service chooses to help keep people safe it must be the least restrictive option, so people retain an element of control and independence in their lives.” Source location 2020-0192-Responses-from-Trafford-Council-and-CQC_Redacted.pdf
Open published response
16 Dec 2019 Arnold Fletcher Ward · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to recognise and escalate significant pressure-ulcer deterioration promptly View source Unavailability or non-use of required wound dressings View source Failure of pressure-ulcer forms to capture deterioration and require detailed monitoring View source Lack of a system to follow up unanswered specialist referrals View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Arnold Fletcher Ward · 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
Arnold Fletcher Ward was a resident at Fernlea Nursing Home who developed a deteriorating grade 4 sacral pressure ulcer, later associated with osteomyelitis, and died in hospital on 21 January 2019 from a myocardial infarction. Concerns included inadequate monitoring and escalation of the pressure ulcer, failure to follow up a referral to the Tissue Viability Nursing Team, and the resulting lack of appropriate wound dressing.
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 and escalate significant pressure-ulcer deterioration promptly
Wider context from the report “The inquest heard that within the home the forms used did not capture the deterioration of the pressure ulcer or require detailed monitoring/use of photographs to track its progress. This meant that the significant and steep deterioration was not recognised and escalated at an early opportunity to the Tissue Viability Nursing team for expert wound management input. As a result the type of wound dressing he required were not utilised/available.
It had been captured in the notes that there had been a referral to the Tissue Viability Nursing team in October. There was no system in the home to chase up the team after a number of weeks had elapsed and there had been no response. The inquest heard that even in non-urgent cases the Tissue Viability Nursing team would contact a home requesting support in at least 10 days and more quickly in an urgent case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Unavailability or non-use of required wound dressings
Wider context from the report “The inquest heard that within the home the forms used did not capture the deterioration of the pressure ulcer or require detailed monitoring/use of photographs to track its progress. This meant that the significant and steep deterioration was not recognised and escalated at an early opportunity to the Tissue Viability Nursing team for expert wound management input. As a result the type of wound dressing he required were not utilised/available .
It had been captured in the notes that there had been a referral to the Tissue Viability Nursing team in October. There was no system in the home to chase up the team after a number of weeks had elapsed and there had been no response. The inquest heard that even in non-urgent cases the Tissue Viability Nursing team would contact a home requesting support in at least 10 days and more quickly in an urgent case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of pressure-ulcer forms to capture deterioration and require detailed monitoring
Wider context from the report “The inquest heard that within the home the forms used did not capture the deterioration of the pressure ulcer or require detailed monitoring/use of photographs to track its progress . This meant that the significant and steep deterioration was not recognised and escalated at an early opportunity to the Tissue Viability Nursing team for expert wound management input. As a result the type of wound dressing he required were not utilised/available.
It had been captured in the notes that there had been a referral to the Tissue Viability Nursing team in October. There was no system in the home to chase up the team after a number of weeks had elapsed and there had been no response. The inquest heard that even in non-urgent cases the Tissue Viability Nursing team would contact a home requesting support in at least 10 days and more quickly in an urgent case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of a system to follow up unanswered specialist referrals
Wider context from the report “The inquest heard that within the home the forms used did not capture the deterioration of the pressure ulcer or require detailed monitoring/use of photographs to track its progress. This meant that the significant and steep deterioration was not recognised and escalated at an early opportunity to the Tissue Viability Nursing team for expert wound management input. As a result the type of wound dressing he required were not utilised/available.
It had been captured in the notes that there had been a referral to the Tissue Viability Nursing team in October. There was no system in the home to chase up the team after a number of weeks had elapsed and there had been no response . The inquest heard that even in non-urgent cases the Tissue Viability Nursing team would contact a home requesting support in at least 10 days and more quickly in an urgent case.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the extended comprehensive inspection of Fernlea Care Home, examining pressure-ulcer management and management oversight.
Verbatim wording from the response “The matters of concerns which arose from the preventing future deaths report were reviewed by CQC and a decision was made to undertake an unannounced, focused inspection of the Fernlea Care Home. This was because the concerns indicated that the registered provider may have been/may still be in breach of the following fundamental standards:” Source location 2019-0433-Response-from-the-Care-Quality-Commission-Redacted
Open published response
2 Dec 2019 Sidney Clarence Baker · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Failure to maintain accurate and adequate care records View source Failure to maintain contemporaneous documentation of Dieticians or Falls Team referrals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sidney Clarence Baker · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sidney Clarence Baker, a frail elderly man with multiple co-morbidities, died at the Royal Albert Edward Infirmary in Wigan after a deterioration in health and treatment for acute kidney injury following a fall. The report raised concerns that required dietician and falls-team referrals were not documented, and that care-plan entries, including weight-monitoring information, were incorrect and record keeping was generally poor.
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 accurate and adequate care records
Wider context from the report “2. There were concerns that entries contained in Mr Baker's care plan were incorrect , including vital information contained on his weight monitoring sheet . Furthermore, the general quality of record keeping was poor .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 contemporaneous documentation of Dieticians or Falls Team referrals
Wider context from the report “1. There were no contemporaneous documents that a Dieticians or Falls Team referral had been made by the Care Home personnel in question
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Highlight three possible regulatory breaches concerning record keeping, staff training and support, and provider quality monitoring.
Verbatim wording from the response “In accordance with CQC’s regulatory remit, we will be highlighting three possible breaches of the Health and Social Care Act 2008 (Regulated Activities)” Source location 2019-0407-Response-by-CQC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a further comprehensive inspection within 12 months to verify that the provider has addressed the identified breaches.
Verbatim wording from the response “We will carry out a further comprehensive inspection within 12 months, to ensure action has been taken and the provider is no longer in breach. Should this not be the case, we will consider further regulatory action.” Source location 2019-0407-Response-by-CQC
Open published response
22 Nov 2019 MAUREEN MILTON · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 2 Lack of awareness of petrol-based emollient fire risks View source Fire ignition of clothing impregnated with petrol-based emollient cream 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
MAUREEN MILTON · 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
Maureen Milton, aged 74, died after her clothing caught fire while she was attempting to light a cigarette with a long match; petrol-based emollient cream on her clothing likely accelerated the fire, and she was pronounced dead at the scene. The principal concern was a lack of awareness among medical professionals, carers, victims and families about the fire risks associated with petrol-based emollients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of petrol-based emollient fire risks
Wider context from the report “Evidence given by fire investigators was that they are increasingly attending fires involving (mostly) the elderly where there is evidence of petrol based emollient cream in use. The petrol base is found in a significant number of prescribed creams and creams (such as moisturisers) which are readily available over the counter. This cream impregnates clothing and is not washed away during a normal washing programme. In the event of a fire the victim is rapidly engulfed by flames with little chance of survival. The cause of death is generally burns, not inhalation of smoke. The concern is the lack of awareness of this problem by medical professionals, carers, victims and their families. It is felt appropriate heighten awareness of this growing problem amongst health professionals and others who work in the field of prescribing such creams and those caring for patients using petrol based emollients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Fire ignition of clothing impregnated with petrol-based emollient cream
Wider context from the report “Evidence given by fire investigators was that they are increasingly attending fires involving (mostly) the elderly where there is evidence of petrol based emollient cream in use. The petrol base is found in a significant number of prescribed creams and creams (such as moisturisers) which are readily available over the counter. This cream impregnates clothing and is not washed away during a normal washing programme. In the event of a fire the victim is rapidly engulfed by flames with little chance of survival. The cause of death is generally burns, not inhalation of smoke. The concern is the lack of awareness of this problem by medical professionals, carers, victims and their families. It is felt appropriate heighten awareness of this growing problem amongst health professionals and others who work in the field of prescribing such creams and those caring for patients using petrol based emollients.
” Open source report
30 Oct 2019 Mrs Annie Lloyd · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 1 Failure to independently verify warfarin dosage before prescribing 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
Mrs Annie Lloyd · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Annie Lloyd was taking warfarin and appears to have taken a higher-than-intended dose for around two weeks. She was found unconscious on 6 April 2019 with a large subdural haematoma and raised intracranial pressure, and died the same day. Concerns identified during the inquest included inadequate checking of her warfarin dosage and reliance on family members to confirm the required dose.
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 independently verify warfarin dosage before prescribing
Wider context from the report “1. Evidence emerged during the inquest that there was an inadequate process in place for checking the patient’s warfarin level dosage . It appears that a “yellow book” confirming the dosage was being copied and the GP issued the prescription without checking this .
2. The GP practice claim to have placed reliance on the family to confirm the dosage required .
” Open source report
21 Sep 2019 Ricky Barcock · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 1 Client wellbeing checks protocol failing to establish appropriate physical checks and rousing when necessary 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
Ricky Barcock · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ricky Barcock was admitted to a recovery centre for detoxification and rehabilitation and was later found unresponsive in his room after sleeping for several hours. He was found to have died from morphine toxicity, with methadone and diazepam use also recorded. The principal concern was whether resident wellbeing checks should include regular physical checks and rousing clients when necessary.
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 Client wellbeing checks protocol failing to establish appropriate physical checks and rousing when necessary
Wider context from the report “To further review the client wellbeing checks protocol of September 2018 in order to consider the appropriateness of making physical checks and rousing client’s when necessary in order to check on their wellbeing
” Open source report
6 Sep 2019 Ms Shannon Quinn · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 7 Failure to adhere to the five-minute patient observation level View source Inconsistent and minimal training for care staff in managing complex patient needs View source Minimal training for care staff in performing patient resuscitation View source Lack of a joint multidisciplinary care plan View source Inconsistent sharing of clinical documentation and care plans between statutory agencies and private-sector care providers View source Insufficient contact with the care coordinator View source Failure to provide a ligature-free environment despite escalating ligature and self-harm risk 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
Ms Shannon Quinn · 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 Shannon Quinn, a 24-year-old woman with a complex mental health history and repeated self-harm, was found hanging in her room at Oak House on 9 January 2019 and was pronounced deceased shortly afterwards. The report identified concerns including inadequate information sharing and joint care planning, insufficient staff training, escalating ligature risk without sufficient environmental measures, and failure to adhere to five-minute observations.
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 adhere to the five-minute patient observation level
Wider context from the report “5. The patient observation level of 5 minutes was introduced to minimise risk of self-harm but not adhered to .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 minimal training for care staff in managing complex patient needs
Wider context from the report “2. There was inconsistent and minimal training provided to Oak House staff in respect of managing SQ’s complex needs by the Mental Health Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Minimal training for care staff in performing patient resuscitation
Wider context from the report “6. Evidence emerged during the inquest that there had been minimal training for Oak House staff in performing resuscitation on patients . The training received included general first aid training by e-learning .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 joint multidisciplinary care plan
Wider context from the report “3. There was a lack of a joint multi-disciplinary/Trust care plan and insufficient contact with the care coordinator due to difficulties in travelling to meet the patient outside the normal Trust area and staff sickness absence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 sharing of clinical documentation and care plans between statutory agencies and private-sector care providers
Wider context from the report “1. Evidence emerged during the inquest that there was inconsistent sharing of documentation and case notes between the statutory agencies and private sector . In particular, there was no sharing of medical notes/care plans between the Birmingham and Solihull and Mental Health Trust and Oak House .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 contact with the care coordinator
Wider context from the report “3. There was a lack of a joint multi-disciplinary/Trust care plan and insufficient contact with the care coordinator due to difficulties in travelling to meet the patient outside the normal Trust area and staff sickness absence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 a ligature-free environment despite escalating ligature and self-harm risk
Wider context from the report “4. There was an escalating risk of use of ligatures and incidents of self-harm and little if any measures were introduced to try and provide a ligature free environment .
” 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 Discuss information sharing with Trust leaders and check improvements during the next Trust inspection.
Verbatim wording from the response “At our next meeting with Birmingham and Solihull Mental Health Foundation Trust we will discuss with the senior leaders how information is shared with private providers who take patients from the trust and what action has been taken to ensure essential information is being shared.” Source location 2019-0499-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 Follow up Oak House’s planned staff-training improvements at the next scheduled inspection.
Verbatim wording from the response “In response to our inspection findings, Camino Healthcare Limited submitted an action plan that detailed their intention to review the training provided to staff. We will follow this up at our next scheduled inspection to ensure that sufficient action has been taken to improve the training provided to staff.” Source location 2019-0499-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 provider actions following the external environmental risk audit and assess ongoing environmental safety-assessment systems at the next inspection.
Verbatim wording from the response “ligature risks. You must provide CQC with a copy of the risk assessment and actions taken by you as a result of the risk assessment.” Source location 2019-0499-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 Regulations do not prescribe specific staff training content or format, limiting the ability to require a particular training approach.
Verbatim wording from the response “As you may be aware the fundamental standards regulations we inspect against do not prescribe what particular training providers must provide to their staff, nor in what format. However, registered providers must ensure that:” Source location 2019-0499-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 three people currently living at Oak House did not present a risk of self-harm or suicide, qualifying the environmental ligature-risk concern.
Verbatim wording from the response “We are aware that there are only currently three people living at Oak House, and that these people do not present risk of self-harm or suicide. However, at the next scheduled inspection, we will review the actions taken in response to the external professional’s audit, and review if the provider has systems to regularly assess the safety of the environment for the remaining service users.” Source location 2019-0499-Response-from-CQC-Redacted
Open published response
7 Aug 2019 Joseph Kevin Lafferty · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure of priority dispatch systems to take patient age into account when determining response speed and acuity View source Failure to require inspectors to include external aspects of registered premises in every CQC inspection View source Failure to require inspectors to include external aspects of registered premises in every CQC inspection View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Joseph Kevin Lafferty · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joseph Kevin Lafferty, who had dementia and required 24-hour residential care, left The Cedars Rest Home unsupervised and was found outside the care home with serious injuries after a fall. He was taken to hospital and died on 24 June 2018; the inquest concluded that he died following the fall and access to an area of the grounds not intended for resident access. Concerns included that external areas of registered premises were not required to be routinely included in CQC inspections, and that the ambulance dispatch system did not specifically take the patient’s age into account when determining response speed and acuity.
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 priority dispatch systems to take patient age into account when determining response speed and acuity
Wider context from the report “In the course of the inquest, evidence was heard to the effect that, like other ambulance services, North West Ambulance Service NHS Foundation Trust utilises a priority dispatch system to triage calls whereby the answers callers gave to standard questions determined the level of response provided, and the timescales within which a response can ordinarily be expected.
It is a matter of concern that, according to the evidence of the Care Quality Commission Inspector who gave evidence at court, there is no requirement on inspectors to include external aspects of a registered premises in the course of a CQC inspection in every case.
It is a matter of concern that the system in use at this and other ambulance Trusts does not specifically take into account the age of the patient when determining the speed and acuity of response to be provided .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to require inspectors to include external aspects of registered premises in every CQC inspection
Wider context from the report “Over the course of the inquest, evidence was heard to the effect that The Cedars Rest Home had been inspected by the Care Quality Commission in 2016 and assessed as ‘Good’. Following Mr Lafferty’s death, a further inspection took place and a rating of ‘Requires Improvement’ was arrived at.
It is a matter of concern that, according to the evidence of the Care Quality Commission Inspector who gave evidence at court, there is no requirement on inspectors to include external aspects of a registered premises in the course of a CQC inspection in every case .
Consideration should be given to such areas automatically forming part and parcel of a CQC inspection where these are routinely in use by residents in the course of the provision of regulated activities.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to require inspectors to include external aspects of registered premises in every CQC inspection
Wider context from the report “In the course of the inquest, evidence was heard to the effect that, like other ambulance services, North West Ambulance Service NHS Foundation Trust utilises a priority dispatch system to triage calls whereby the answers callers gave to standard questions determined the level of response provided, and the timescales within which a response can ordinarily be expected.
It is a matter of concern that, according to the evidence of the Care Quality Commission Inspector who gave evidence at court, there is no requirement on inspectors to include external aspects of a registered premises in the course of a CQC inspection in every case .
It is a matter of concern that the system in use at this and other ambulance Trusts does not specifically take into account the age of the patient when determining the speed and acuity of response to be provided.
” Open source report
1 Jul 2019 Mr Peter Lawrence (PL) · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 5 Lack of a joint multidisciplinary and interagency care plan for responding to relapse indicators View source Excessive reliance on mental health tribunal decisions in care planning View source Inadequate follow-up engagement and monitoring after discharge View source Failure to provide assertive care coordination for patients at risk of disengagement and relapse View source Failure to coordinate multidisciplinary review and mental health act assessment when considering hospital admission View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Peter Lawrence (PL) · 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 Peter Lawrence, a 48-year-old man with paranoid schizophrenia and a history of disengagement from mental health services, was found outside his flat on 8 February 2019 after falling from the balcony and died from traumatic injuries. Concerns included the lack of a joint multi-disciplinary/agency care plan, inconsistent care coordination, and the absence of a coordinated mental health assessment and possible admission when concerns about self-care and disengagement arose.
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 joint multidisciplinary and interagency care plan for responding to relapse indicators
Wider context from the report “2. There was a lack of a joint multi-disciplinary/agency care plan (between Local authority and Mental Health Trust) which could have resulted in delays in a timely response to known relapse indicators .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Excessive reliance on mental health tribunal decisions in care planning
Wider context from the report “5. When PL was successful at the mental health tribunal and was discharged from Section 3 following his last admission to hospital in October 2017 against the view of the multidisciplinary team. The agencies involved placed too much reliance on this decision and follow up engagement and monitoring with PL reduced becoming inadequate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 follow-up engagement and monitoring after discharge
Wider context from the report “5. When PL was successful at the mental health tribunal and was discharged from Section 3 following his last admission to hospital in October 2017 against the view of the multidisciplinary team. The agencies involved placed too much reliance on this decision and follow up engagement and monitoring with PL reduced becoming inadequate .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 assertive care coordination for patients at risk of disengagement and relapse
Wider context from the report “3. A more assertive approach with consistency of care coordinator for a patient with a history of disengagement and relapse could possibly have been implemented reducing the likelihood of disengagement with services and promoted necessary concordance with 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 coordinate multidisciplinary review and mental health act assessment when considering hospital admission
Wider context from the report “4. A decision to admit to hospital under the mental health act following concerns being raised about self-care and disengagement could potentially have followed a coordinated MDT review and mental health act assessment and prevented deterioration in his mental health.
” Open source report
28 May 2019 Gloria Elizabeth MEKINS · Prevention of Future Deaths report Teesside and Hartlepool
View report summary
Concerns raised 4 Failure to provide first aid and airway-clearing assistance during choking View source Failure to remedy identified safety issues View source Failure to investigate choking-related events and identify safety issues View source Lack of clarity about the existence of a DNA CPR 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.
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AI-generated summary
Gloria Elizabeth MEKINS · 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
Gloria Elizabeth Mekins was a resident at Rossmere Park Care Home when she choked while eating a snack on 2 October 2018 and died at the care home. Concerns included the absence of first aid by the staff member who found her, confusion about the existence of a DNA CPR leading to a delay in first aid, and the care home's failure to investigate or address these issues.
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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 provide first aid and airway-clearing assistance during choking
Wider context from the report “(1) The Health Care Assistant who initially discovered Ms Mekins choking carried out no first aid , nor did she take any action to try to clear Ms Mekins' mouth or help improve her breathing, eg back slaps or Heimlich manoeuvre .
(2) There was confusion as to the existence of a DNA CPR and this led to a delay in the provision of first aid.
(3) The Care Home had not undertaken an internal investigation into events surrounding Ms Mekins' death and have not identified the above issues, nor have they attempted to remedy them. The Senior Coroner is concerned that the above issues place residents at the Care Home at risk of serious injury or 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 to remedy identified safety issues
Wider context from the report “(1) The Health Care Assistant who initially discovered Ms Mekins choking carried out no first aid, nor did she take any action to try to clear Ms Mekins' mouth or help improve her breathing, eg back slaps or Heimlich manoeuvre.
(2) There was confusion as to the existence of a DNA CPR and this led to a delay in the provision of first aid.
(3) The Care Home had not undertaken an internal investigation into events surrounding Ms Mekins' death and have not identified the above issues, nor have they attempted to remedy them . The Senior Coroner is concerned that the above issues place residents at the Care Home at risk of serious injury or 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 to investigate choking-related events and identify safety issues
Wider context from the report “(1) The Health Care Assistant who initially discovered Ms Mekins choking carried out no first aid, nor did she take any action to try to clear Ms Mekins' mouth or help improve her breathing, eg back slaps or Heimlich manoeuvre.
(2) There was confusion as to the existence of a DNA CPR and this led to a delay in the provision of first aid.
(3) The Care Home had not undertaken an internal investigation into events surrounding Ms Mekins' death and have not identified the above issues , nor have they attempted to remedy them. The Senior Coroner is concerned that the above issues place residents at the Care Home at risk of serious injury or 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 clarity about the existence of a DNA CPR
Wider context from the report “(1) The Health Care Assistant who initially discovered Ms Mekins choking carried out no first aid, nor did she take any action to try to clear Ms Mekins' mouth or help improve her breathing, eg back slaps or Heimlich manoeuvre.
(2) There was confusion as to the existence of a DNA CPR and this led to a delay in the provision of first aid .
(3) The Care Home had not undertaken an internal investigation into events surrounding Ms Mekins' death and have not identified the above issues, nor have they attempted to remedy them. The Senior Coroner is concerned that the above issues place residents at the Care Home at risk of serious injury or death.
” Open source report
2 May 2019 Alexander James Davidson · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Delays in updating electronic patient records with NHS 111 triage documents View source Failure to adapt NHS 111 telephone triage questions and wording for young and vulnerable patients View source Variation in admission for observation of paediatric patients returning to the Emergency Department View source Unclear NHS Pathways algorithm for exploring ‘soil’ or ‘coffee ground’ vomit during telephone triage View source Lack of standard lipase/amylase testing for patients under 18 with relevant abdominal symptoms 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
Alexander James Davidson · 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
Alexander James Davidson became suddenly unwell with abdominal pain, vomiting and diarrhoea, and died at the Queens Medical Centre on 26 February 2018 after developing an infected and necrotic pancreatic pseudocyst caused by gallstone pancreatitis. The report raised concerns about NHS 111 telephone triage for young or vulnerable patients, the clarity and transfer of triage information, testing for pancreatitis in young people, and the management of unscheduled returns to emergency departments.
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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 Delays in updating electronic patient records with NHS 111 triage documents
Wider context from the report “(3) The NHS 111 telephone triage service provides an electronic copy of the patient triage notes to the patient’s GP within minutes of the call ending. There was a delay of 7 days in the GP surgery uploading the 111 triage document to Alex’s patient record. This prevented Alex’s GP from reviewing the triage note prior to his consultation with the patient. There is no guidance as to expected practise with regards to the timely updating of electronic patient records, and as a result delays are all too frequent.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to adapt NHS 111 telephone triage questions and wording for young and vulnerable patients
Wider context from the report “(1) The NHS 111 telephone triage service uses the NHS Pathways computer system to triage patients via pre-determined question/answer based algorithms. The pre-determined questions are the same whether the caller is an adult or a child. Alex struggled to comprehend some of the medical terminology used during these calls. Call handlers are not permitted to deviate from the prescribed wording of the pre-determined questions, and this created confusion and inconsistency in the patient’s answers. Consideration should be given as to how young and/or vulnerable patients can be assisted to provide accurate information about their symptoms.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Variation in admission for observation of paediatric patients returning to the Emergency Department
Wider context from the report “(5) Patients who make an unscheduled return to the Emergency Department within 72 hours of discharge are required to have a review undertaken by an ED Consultant, or a ST4 trainee or above in the absence of a Consultant on the ‘shop floor’: RCEM Guidance June 2016. Some hospitals will admit returning paediatric patients for observation but practise seems to vary doctor-to-doctor and across Trusts. Consideration ought to be given to a national approach.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 NHS Pathways algorithm for exploring ‘soil’ or ‘coffee ground’ vomit during telephone triage
Wider context from the report “(2) The NHS Pathways algorithm for triaging vomiting and diarrhoea symptoms is unclear as patients may fail to understand what is meant by ‘soil’ or ‘coffee ground’ vomit . Consideration should be given to how this important diagnostic feature can be explored during telephone triage, especially when the patient is young and/or vulnerable.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 standard lipase/amylase testing for patients under 18 with relevant abdominal symptoms
Wider context from the report “(4) Adults presenting to their GP or Emergency Department with abdominal symptoms receive a lipase and/or amylase blood test as part of the standard package of blood testing. The levels of each of these enzymes can be used to diagnose pancreatitis. Patients under the age of 18 years are not offered this testing as standard , on the basis that pancreatitis is rare in paediatric patients. I heard anecdotal evidence of some doctors at Kingsmill Hospital now add this test to the standard admission bloods for older teenage patients who present with non-specific abdominal symptoms but the NICE guidance (September 2018) is not explicit in this regard . I heard evidence as to the increasing prevalence of gallstone pancreatitis in young people, in line with an increase in childhood obesity. Consideration ought to be given to a national approach for lipase/amylase testing in young people with relevant symptoms.
” Open source report
18 Apr 2019 Mrs Margaret Melia · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 1 Inadequate discharge and pre-assessment process for subcutaneous fluid requirements 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
Mrs Margaret Melia · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Margaret Melia was admitted to Dovetail Court Care Home in October 2018, later developed declining food and fluid intake, was admitted to hospital with dehydration and a lower respiratory tract infection, and died on 7 November 2018 while receiving end-of-life palliative care. The inquest identified an inadequate discharge and pre-assessment process between Lakeview Care Home and Dovetail Care Home concerning the requirement for subcutaneous fluids.
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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 Inadequate discharge and pre-assessment process for subcutaneous fluid requirements
Wider context from the report “1. Evidence emerged during the inquest that there was an inadequate discharge and pre-assessment process between Lakeview Care Home and Dovetail Care Home over the requirement of subcutaneous fluids .
” Open source report
1 Apr 2019 Andrew Robert Frank Clegg · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 2 Lack of inspector training to identify potential legionella infection risks View source Failure of care-home and healthcare-premises architects to take water safety into account 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
Andrew Robert Frank Clegg · 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
Andrew Robert Frank Clegg, a 56-year-old vulnerable individual with corticobasilar degeneration, lived in a specialist care home where problems with the water system allowed legionella bacteria to colonise it. He was infected and died from legionella pneumonia, which the inquest jury concluded resulted from an accident. Concerns included inadequate water-safety design in care homes and insufficient inspector training to identify potential legionella risks.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of inspector training to identify potential legionella infection risks
Wider context from the report “2. Care homes and other healthcare premises are regularly inspected by the Care Quality Commission. In recent years the inspection regime has included a duty on inspectors to check on water safety. Expert evidence at the inquest suggested that inspectors lacked training to help them identify risks relating to potential legionella infection .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of care-home and healthcare-premises architects to take water safety into account
Wider context from the report “1. Expert evidence suggested that architects designing care homes and healthcare premises, rarely take into account the need for water safety . In combating the risk of a proliferation of legionella bacteria, it is desirable, among other things, to design a water system with short pipe runs and with areas of maximum water usage established at the end of pipe runs to ensure a regular flushing of the pipework. Legionella bacteria, flourishing as it does at temperatures in excess of 20 degrees centigrade, precautions need to be taken to avoid heat exchange between hot and cold-water pipes, calling for cold-water pipes to be set at a distance from hot-water pipes rather than being run in parallel.
” Open source report
28 Feb 2019 Yong Keng Hong · Prevention of Future Deaths report South London
View report summary
Concerns raised 7 Failure to seek further advice from an appropriate clinician View source Failure to implement the advised observation regime View source Failure to provide therapeutic engagement View source Failure to carry out a risk assessment before returning the call bell View source Failure to obtain interpreter support for assessment of needs View source Lack of training for care home staff in carrying out risk assessments View source Failure to provide a safety net View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Yong Keng Hong · 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
Yong Keng Hong, an asylum seeker with very little English, was transferred from hospital to a care home after displaying self-harm and suicidal behaviour. Despite advice for constant observations and an immediate mental health referral, the observation regime was not implemented, no interpreter or risk assessment was arranged, and his call bell was returned; he used it to hang himself from a curtain rail on 12 July. Concerns included failures in observation, communication, risk assessment, clinical follow-up and staff training.
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 seek further advice from an appropriate clinician
Wider context from the report “(1) His GP made an immediate referral to mental health services and advised constant observations, however:
(a) the observation regime advised by the GP was not implemented
(b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding
(c) no risk assessment was carried out prior to making the decision to return his call bell.
(2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement
(3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk 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 implement the advised observation regime
Wider context from the report “(1) His GP made an immediate referral to mental health services and advised constant observations, however:
(a) the observation regime advised by the GP was not implemented
(b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding
(c) no risk assessment was carried out prior to making the decision to return his call bell.
(2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement
(3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk 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 provide therapeutic engagement
Wider context from the report “(1) His GP made an immediate referral to mental health services and advised constant observations, however:
(a) the observation regime advised by the GP was not implemented
(b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding
(c) no risk assessment was carried out prior to making the decision to return his call bell.
(2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement
(3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk 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 carry out a risk assessment before returning the call bell
Wider context from the report “(1) His GP made an immediate referral to mental health services and advised constant observations, however:
(a) the observation regime advised by the GP was not implemented
(b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding
(c) no risk assessment was carried out prior to making the decision to return his call bell .
(2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement
(3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk 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 obtain interpreter support for assessment of needs
Wider context from the report “(1) His GP made an immediate referral to mental health services and advised constant observations, however:
(a) the observation regime advised by the GP was not implemented
(b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding
(c) no risk assessment was carried out prior to making the decision to return his call bell.
(2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement
(3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk 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 Lack of training for care home staff in carrying out risk assessments
Wider context from the report “(1) His GP made an immediate referral to mental health services and advised constant observations, however:
(a) the observation regime advised by the GP was not implemented
(b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding
(c) no risk assessment was carried out prior to making the decision to return his call bell.
(2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement
(3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk 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 provide a safety net
Wider context from the report “(1) His GP made an immediate referral to mental health services and advised constant observations, however:
(a) the observation regime advised by the GP was not implemented
(b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding
(c) no risk assessment was carried out prior to making the decision to return his call bell.
(2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement
(3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments
” Open source report
27 Feb 2019 Theresa Margaret Feehan · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 6 Failure to correlate the medication list with the active problem list View source Lack of a system to address harmful medication interactions and redundant treatment View source Inadequate recording and coding of relevant medical history on the active problem list View source Insufficient supervision of administrative staff View source Lack of a clear system for identifying harmful medication interactions View source Inadequate medication review systems View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Theresa Margaret Feehan · 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
Theresa Margaret Feehan, who had severe oxygen- and steroid-dependent allergic asthma, was found deceased at home on 12 March 2018. The court recorded aspiration pneumonia and ingestion of amitriptyline and dihydrocodeine as the medical cause of death, with natural causes combined with side effects of prescribed medication. Concerns included inadequate medication review, incomplete medical-history recording, poor correlation between medication and problem lists, insufficient systems for identifying harmful medication interactions, and inadequate supervision of administrative work.
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 correlate the medication list with the active problem list
Wider context from the report “3. That there appears to be little correlation between the medication list and the active problem list such that it would make it difficult for a reviewing doctor to understand why a patient was on a particular medication and thus challenge its continuation or dosage appropriately, thus putting patients at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of a system to address harmful medication interactions and redundant treatment
Wider context from the report “4. That there appears to be no clear system for identifying medications which may interact to the detriment of the patient or no system to address such issues should they arise such as reducing or stopping redundant treatment thus putting patients at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Inadequate recording and coding of relevant medical history on the active problem list
Wider context from the report “2. That the recording and coding of relevant medical history on the active problem list is inadequate thus putting patients at risk
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Insufficient supervision of administrative staff
Wider context from the report “5. That administration systems within the practice should be audited to determine whether they are adequate and the work of the administrative staff sufficiently supervised , such that patients are not put at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear system for identifying harmful medication interactions
Wider context from the report “4. That there appears to be no clear system for identifying medications which may interact to the detriment of the patient or no system to address such issues should they arise such as reducing or stopping redundant treatment thus putting patients at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Inadequate medication review systems
Wider context from the report “1. That the system of medication review within the practice is inadequate putting patients at risk.
” 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 Inspections ultimately found no concerns in the areas identified, so there was no basis for enforcement action.
Verbatim wording from the response “The provider made significant challenges to the findings we made. We accepted those challenges and decided there was no basis for us to take enforcement action. We also carried out a full and comprehensive rated inspection in June 2019. I attach copies of the reports of both of these inspections. They are also available on our website under the “All reports” link at https://www.cqc.org.uk/location/1-549237033.” Source location 2019-0070-Amended-Response-from-Care-Quality-Commission-Redacted
Open published response
24 Feb 2019 Dr Polly Joanne Drew · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 2 Potential significant risk from doctors working alone while medically responsible for members of the public View source Inadequate recruitment process for doctors with access to anaesthetic drugs 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
Dr Polly Joanne Drew · 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
Dr Polly Joanne Drew, aged 35, died by suicide after injecting herself with Propofol and Atracurium acquired from the medical centre where she worked as a duty doctor. The report raised concerns that Central Medical Services’ recruitment process was inadequate, including not obtaining written references or completing a DBS check, despite her access to anaesthetic drugs and working alone.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Potential significant risk from doctors working alone while medically responsible for members of the public
Wider context from the report “1. The recruitment process for the appointment of a Doctor to a position of such significant responsibility, with access to anaesthetic drugs, is completely inadequate. None of the above appears to have been known to ████████ when Dr Drew was appointed. Dr Drew worked alone, putting herself and members of the public, for whom she had medical responsibility, at potential significant 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 Inadequate recruitment process for doctors with access to anaesthetic drugs
Wider context from the report “1. The recruitment process for the appointment of a Doctor to a position of such significant responsibility, with access to anaesthetic drugs, is completely inadequate. None of the above appears to have been known to ████████ when Dr Drew was appointed. Dr Drew worked alone, putting herself and members of the public, for whom she had medical responsibility, at potential significant risk.
” Open source report
1 Feb 2019 Stephen Keith Harte · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Failure to search takeaway food arriving at the unit View source Failure to effectively search staff entering the unit View source Failure to search staff food brought onto the unit View source Failure to effectively search residents returning from unsupervised leave View source See 1 more concern
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 Keith Harte · 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 Keith Harte was found unresponsive in his room at the Tamarind Centre on 18 August 2018 and could not be resuscitated. A post-mortem found a fatal dose of heroin, and the medical cause of death was recorded as heroin toxicity. The principal concern was that drugs could too easily enter the medium secure unit through routes including unsupervised takeaway deliveries, residents returning from leave, and staff bringing in unscreened food.
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 search takeaway food arriving at the unit
Wider context from the report “1) I heard evidence about the potential routes for drugs to enter the medium secure unit. This included:
(a) Residents are allowed unsupervised telephone calls to order food from external ‘takeaways’ of their choice and the food is not searched upon arrival . Historically, residents were only allowed to order from an approved list of ‘takeaways’. However, following a Care Quality Commission inspection the CQC deemed this was too restrictive and asked that the unit relax its rules. The evidence was unclear whether the CQC had similarly asked other units to relax their rules.
(b) Those residents allowed unsupervised leave are not typically searched upon their return. They walk thought a scanner, but this is unlikely to reveal small quantities of drugs on their person.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively search staff entering the unit
Wider context from the report “3) I also heard evidence that staff are not typically searched upon entering the unit . They also walk thought the scanner, but this is unlikely to reveal small quantities of drugs on their person . Further, whilst they are required to leave personal belongings in lockers, they are allowed to take their own food on to the unit which is also not searched.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to search staff food brought onto the unit
Wider context from the report “3) I also heard evidence that staff are not typically searched upon entering the unit. They also walk thought the scanner, but this is unlikely to reveal small quantities of drugs on their person. Further, whilst they are required to leave personal belongings in lockers, they are allowed to take their own food on to the unit which is also not searched .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively search residents returning from unsupervised leave
Wider context from the report “1) I heard evidence about the potential routes for drugs to enter the medium secure unit. This included:
(a) Residents are allowed unsupervised telephone calls to order food from external ‘takeaways’ of their choice and the food is not searched upon arrival. Historically, residents were only allowed to order from an approved list of ‘takeaways’. However, following a Care Quality Commission inspection the CQC deemed this was too restrictive and asked that the unit relax its rules. The evidence was unclear whether the CQC had similarly asked other units to relax their rules.
(b) Those residents allowed unsupervised leave are not typically searched upon their return . They walk thought a scanner, but this is unlikely to reveal small quantities of drugs on their person .
” 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 Directed the trust to assess individually the risks posed by patients returning from leave.
Verbatim wording from the response “Because of our findings we told the trust that they must ensure that it undertakes active individual assessment of risks posed by patients returning from leave. We told the trust that they should review practice of not allowing patients to buy food from a takeaway shop of their choice.” Source location 2019-0077-Response-by-CQC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conducted a comprehensive inspection of the trust and published the inspection reports.
Verbatim wording from the response “The Care Quality Commission commenced a comprehensive inspection of Birmingham and Solihull Mental Health Foundation NHS trust 27th–31st March 2017 and published the reports 2nd August 2017.
At that inspection we found the trust had implemented blanket restrictions with regards to the ordering of food from takeaways and in relation to patient searches. We informed the trust that it was appropriate for them to provide patients with information on hygienic ratings and to explain the benefits. However, patients with mental capacity had the right to order takeaways from the shop of their choice, and the policy did not promote an individualised approach to patient’s choice or risk. We” Source location 2019-0077-Response-by-CQC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conducted a comprehensive follow-up inspection of the trust and assessed its search and security arrangements.
Verbatim wording from the response “We visited the trust in November and December 2018 and carried out a comprehensive inspection as part of our regular inspection programme. At that inspection we found the trust had reviewed and implemented a new search and security policy based on risk assessment. We did not find any breaches related to blanket restrictions.” Source location 2019-0077-Response-by-CQC
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Decisions about searching staff entering units are assigned to each individual organisation, not made by the CQC.
Verbatim wording from the response “The Care Quality Commission did tell the trust that it must ensure that active and individual assessment of risks posed to patients who return from leave and use this to base decision on searches. The trust carried out a comprehensive review of its search policy and implemented a security policy and a new search policy in response to our requirement notice. During our inspections we do not review the searching of staff entering units although for some services we would review the security arrangement. Any decisions to search staff would be a decision taken by each individual organisation. The Care Quality Commission would review what action an organisation was taking if they informed us they had a problem of drugs entering their units and would comment on them within our reports.” Source location 2019-0077-Response-by-CQC
Open published response
28 Jan 2019 Dennis Peter Alfred Warner · Prevention of Future Deaths report West London
View report summary
Concerns raised 5 Failure to provide discharge information in a form the patient could comprehend and retain View source Use of suboptimal chest X-ray imaging after chest injury View source Lack of available appropriate examination capacity in the emergency department View source Failure of the contact and recall process to communicate effectively with the patient or GP View source Delays in senior clinician review of reported chest X-rays 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
Dennis Peter Alfred Warner · 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
Dennis Peter Alfred Warner died in hospital on 6 December 2016 after falling at home and sustaining a chest injury. The principal concerns were that his advanced dementia affected his ability to understand discharge information, that the emergency department was overcrowded, that chest X-ray could underestimate injury, and that senior review and efforts to contact and recall him were inadequate.
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 discharge information in a form the patient could comprehend and retain
Wider context from the report “(1) Mr Warner suffered from advanced dementia and was the main carer for his elderly wife who also suffered with dementia. He was given information about managing his injury on discharge which he was demonstrably unable to comprehend or remember. Specifically, it was recorded by the examining clinicians that he was unable to answer any orientation questions or to remember the reason for his being in hospital . (2) The Emergency department was full beyond capacity and he was examined in a meeting room as no cubicles were available (3) chest xray was performed. I heard in written evidence from ████████ Consultant in Emergency Medicine that chest xray is a suboptimal modality for imaging the chest after injury often underestimating both the number of rib fractures and the extent of any intrathoracic injury(4) there was a delay in senior clinician review of the chest xrays after reporting and a passive approach to contacting Mr Warner was taken by the reviewing clinician. An incorrect number was held for Mr Warner but even if contact had been made then he would have had difficulty comprehending and retaining the information; attempts to contact to contact the GP by phone were abandoned because the phone was not answered. A letter was sent which was described as misleading. Consequently the efforts made to contact and recall the patient were inadequate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Use of suboptimal chest X-ray imaging after chest injury
Wider context from the report “(1) Mr Warner suffered from advanced dementia and was the main carer for his elderly wife who also suffered with dementia. He was given information about managing his injury on discharge which he was demonstrably unable to comprehend or remember. Specifically, it was recorded by the examining clinicians that he was unable to answer any orientation questions or to remember the reason for his being in hospital. (2) The Emergency department was full beyond capacity and he was examined in a meeting room as no cubicles were available (3) chest xray was performed . I heard in written evidence from ████████ Consultant in Emergency Medicine that chest xray is a suboptimal modality for imaging the chest after injury often underestimating both the number of rib fractures and the extent of any intrathoracic injury (4) there was a delay in senior clinician review of the chest xrays after reporting and a passive approach to contacting Mr Warner was taken by the reviewing clinician. An incorrect number was held for Mr Warner but even if contact had been made then he would have had difficulty comprehending and retaining the information; attempts to contact to contact the GP by phone were abandoned because the phone was not answered. A letter was sent which was described as misleading. Consequently the efforts made to contact and recall the patient were inadequate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 available appropriate examination capacity in the emergency department
Wider context from the report “(1) Mr Warner suffered from advanced dementia and was the main carer for his elderly wife who also suffered with dementia. He was given information about managing his injury on discharge which he was demonstrably unable to comprehend or remember. Specifically, it was recorded by the examining clinicians that he was unable to answer any orientation questions or to remember the reason for his being in hospital. (2) The Emergency department was full beyond capacity and he was examined in a meeting room as no cubicles were available (3) chest xray was performed. I heard in written evidence from ████████ Consultant in Emergency Medicine that chest xray is a suboptimal modality for imaging the chest after injury often underestimating both the number of rib fractures and the extent of any intrathoracic injury(4) there was a delay in senior clinician review of the chest xrays after reporting and a passive approach to contacting Mr Warner was taken by the reviewing clinician. An incorrect number was held for Mr Warner but even if contact had been made then he would have had difficulty comprehending and retaining the information; attempts to contact to contact the GP by phone were abandoned because the phone was not answered. A letter was sent which was described as misleading. Consequently the efforts made to contact and recall the patient were inadequate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 contact and recall process to communicate effectively with the patient or GP
Wider context from the report “(1) Mr Warner suffered from advanced dementia and was the main carer for his elderly wife who also suffered with dementia. He was given information about managing his injury on discharge which he was demonstrably unable to comprehend or remember. Specifically, it was recorded by the examining clinicians that he was unable to answer any orientation questions or to remember the reason for his being in hospital. (2) The Emergency department was full beyond capacity and he was examined in a meeting room as no cubicles were available (3) chest xray was performed. I heard in written evidence from ████████ Consultant in Emergency Medicine that chest xray is a suboptimal modality for imaging the chest after injury often underestimating both the number of rib fractures and the extent of any intrathoracic injury(4) there was a delay in senior clinician review of the chest xrays after reporting and a passive approach to contacting Mr Warner was taken by the reviewing clinician . An incorrect number was held for Mr Warner but even if contact had been made then he would have had difficulty comprehending and retaining the information; attempts to contact to contact the GP by phone were abandoned because the phone was not answered . A letter was sent which was described as misleading . Consequently the efforts made to contact and recall the patient were inadequate .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 senior clinician review of reported chest X-rays
Wider context from the report “(1) Mr Warner suffered from advanced dementia and was the main carer for his elderly wife who also suffered with dementia. He was given information about managing his injury on discharge which he was demonstrably unable to comprehend or remember. Specifically, it was recorded by the examining clinicians that he was unable to answer any orientation questions or to remember the reason for his being in hospital. (2) The Emergency department was full beyond capacity and he was examined in a meeting room as no cubicles were available (3) chest xray was performed. I heard in written evidence from ████████ Consultant in Emergency Medicine that chest xray is a suboptimal modality for imaging the chest after injury often underestimating both the number of rib fractures and the extent of any intrathoracic injury(4) there was a delay in senior clinician review of the chest xrays after reporting and a passive approach to contacting Mr Warner was taken by the reviewing clinician. An incorrect number was held for Mr Warner but even if contact had been made then he would have had difficulty comprehending and retaining the information; attempts to contact to contact the GP by phone were abandoned because the phone was not answered. A letter was sent which was described as misleading. Consequently the efforts made to contact and recall the patient were inadequate.
” Open source report
10 Jan 2019 Natasha Learline CHIN · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 12 Lack of audit of opiate and alcohol withdrawal observations View source Inadequate training on opiate and alcohol withdrawal signs and dangers View source Failure to make datix referrals for missed medications View source Unclear governance for non-administration of prescribed medication View source Unclear and incomplete protocols for opiate and alcohol withdrawal View source Lack of audit of on-time administration of critical medication View source Lack of verification that medication safety matters have been adequately addressed View source Inadequate training of clinical staff in completing withdrawal scales View source Lack of audit of nurse prescribing and pre-prescription record checks View source Lack of audit of medical-record accuracy on System 1 View source Lack of follow-up and recording of prescribed medication non-attendance View source Lack of medication information sharing with discipline staff View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Natasha Learline CHIN · 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
Natasha Learline Chin died in her cell at HMP Bronzefield on 19 July 2016 after profuse vomiting associated with undertreated opiate and alcohol withdrawal. The report identified concerns about delayed medication, inadequate monitoring and escalation, failures in record-keeping and governance, and insufficient auditing and training.
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 audit of opiate and alcohol withdrawal observations
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 training on opiate and alcohol withdrawal signs and dangers
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to make datix referrals for missed medications
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 governance for non-administration of prescribed medication
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Unclear and incomplete protocols for opiate and alcohol withdrawal
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 on-time administration of critical medication
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 verification that medication safety matters have been adequately addressed
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 training of clinical staff in completing withdrawal scales
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 nurse prescribing and pre-prescription record checks
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 medical-record accuracy on System 1
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 follow-up and recording of prescribed medication non-attendance
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of medication information sharing with discipline staff
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report
27 Dec 2018 Kenneth Roy Bardsley · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 8 Lack of statutory minimum requirements for lift servicing View source Lack of a care home system for reviewing and passing lift examination details to the servicing company View source Lack of formal minimum qualification standards for lift engineers View source Lack of clarity about informing engineers of and following up regulatory lift examination requirements View source Electronic lift servicing appointment systems lacking checklists View source Failure of home inspections to identify unacted-on regulatory lift examination faults View source Failure to read, act on, and escalate regulatory lift examination findings View source Failure to require lift servicing and repair engineers to obtain regulatory examination reports 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.
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AI-generated summary
Kenneth Roy Bardsley · 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
Kenneth Roy Bardsley died at Salford Royal Hospital on 30 January 2017 from multiple injuries sustained as a passenger in a lift that malfunctioned at Serendipity Care Home. The inquest concluded that his accidental death was contributed to by failure of the lift’s interior door mechanism. Concerns included gaps in lift-engineer qualification requirements, failures to read and act on regulatory examination findings, unclear communication and follow-up processes, and insufficient systems for lift servicing and examination records.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of statutory minimum requirements for lift servicing
Wider context from the report “7. That the lift company Lancs and Cumbria Lifts had abandoned their old paper checklists and introduced an electronic appointment system. However that system did not include an electronic checklist. One had now been introduced. It was unclear if other companies have checklists and if so how consistent are they. The inquest heard that there was no statutory minimum expectation about the requirements of a lift service .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of a care home system for reviewing and passing lift examination details to the servicing company
Wider context from the report “5. That Serendipity Care Home did not have a system in place to ensure details from the lift examinations were read; considered and passed on to the lift servicing company ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of formal minimum qualification standards for lift engineers
Wider context from the report “1. The inquest heard that there are no formal requirements for a minimum standard of qualification for people to be lift engineers . In effect, anyone can advertise themselves as a lift engineer/maintenance company ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about informing engineers of and following up regulatory lift examination requirements
Wider context from the report “3. During the inquest evidence was given that within the specific lift company in this case and more widely, there was a lack of clarity as to how engineers should be made aware and follow up requirements made by engineers carrying out the regulatory lift examinations ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Electronic lift servicing appointment systems lacking checklists
Wider context from the report “7. That the lift company Lancs and Cumbria Lifts had abandoned their old paper checklists and introduced an electronic appointment system. However that system did not include an electronic checklist . One had now been introduced. It was unclear if other companies have checklists and if so how consistent are they. The inquest heard that there was no statutory minimum expectation about the requirements of a lift service.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of home inspections to identify unacted-on regulatory lift examination faults
Wider context from the report “4. In inspections of the home, the CQC did not pick up that there were faults identified in the regulatory examination that had not been acted upon ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to read, act on, and escalate regulatory lift examination findings
Wider context from the report “2. The evidence given to the inquest was that there was a gap in the system which meant that regulatory lift examinations could take place but not be read or acted upon , with no escalation process ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to require lift servicing and repair engineers to obtain regulatory examination reports
Wider context from the report “6. That the lift company Lancs and Cumbria engineers carrying out serving/repairs were not expected to ask to see the regulatory examination reports ;
” Open source report
20 Dec 2018 Maria Katarina HRYNIW · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to establish clear responsibility for PEG feeding assessment and key decisions View source Failure to assess the suitability and volume of continued PEG feeding in the community View source Failure to hold a community MDT when prescribing end of life medications View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Maria Katarina HRYNIW · 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
Maria Katarina HRYNIW, who was PEG fed following a stroke and had very limited mobility, developed bronchopneumonia and died at The Lakes Care centre on 14 April 2018. Concerns included the lack of assessment of the suitability and volume of continued PEG feeding near the end of life, continued administration despite reported difficulty coping with the prescribed volume, and unclear responsibilities between the SALT team and care home regarding assessment and decision-making.
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 establish clear responsibility for PEG feeding assessment and key decisions
Wider context from the report “The inquest heard evidence that Maria Katarina HRYNIW was peg fed. She was approaching the end of life but there was no assessment regarding the suitability of the use of continued peg feeding in the community or the volume given to her. The inquest heard evidence from her family that she could not cope with the volume prescribed but continued to be given it. A community MDT was not held when she was prescribed end of life medications. Maria Katarina HRYNIW lacked capacity to refuse PEG feeding and it continued as the home felt that ethically and legally they had to continue as end of life care was in place. The inquest heard that some of the difficulties arose form an lack of understanding between the SALT team and care home about who would carry out assessment and who would make the key decisions regarding the use of peg feeding.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to assess the suitability and volume of continued PEG feeding in the community
Wider context from the report “The inquest heard evidence that Maria Katarina HRYNIW was peg fed. She was approaching the end of life but there was no assessment regarding the suitability of the use of continued peg feeding in the community or the volume given to her . The inquest heard evidence from her family that she could not cope with the volume prescribed but continued to be given it . A community MDT was not held when she was prescribed end of life medications. Maria Katarina HRYNIW lacked capacity to refuse PEG feeding and it continued as the home felt that ethically and legally they had to continue as end of life care was in place. The inquest heard that some of the difficulties arose form an lack of understanding between the SALT team and care home about who would carry out assessment and who would make the key decisions regarding the use of peg feeding.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to hold a community MDT when prescribing end of life medications
Wider context from the report “The inquest heard evidence that Maria Katarina HRYNIW was peg fed. She was approaching the end of life but there was no assessment regarding the suitability of the use of continued peg feeding in the community or the volume given to her. The inquest heard evidence from her family that she could not cope with the volume prescribed but continued to be given it. A community MDT was not held when she was prescribed end of life medications. Maria Katarina HRYNIW lacked capacity to refuse PEG feeding and it continued as the home felt that ethically and legally they had to continue as end of life care was in place. The inquest heard that some of the difficulties arose form an lack of understanding between the SALT team and care home about who would carry out assessment and who would make the key decisions regarding the use of peg feeding.
” 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 Complete an inspection addressing the reported concerns, including end-of-life care and Mental Capacity Act arrangements.
Verbatim wording from the response “We look at how people’s end of life needs are met under Assessment Framework key question “Is the service Responsive?” The framework has ‘Key Lines of Enquiry’ (KLOEs) for inspectors to follow when answering the key questions. One of the KLOEs for ‘Responsive’ asks: How are people supported at the end of their life to have a comfortable, dignified and pain-free death? Inspectors explore how people, and their family, friends and other carers are involved in planning, managing and making decisions about their end of life care, and how people’s pain and other symptoms are assessed and managed effectively, including having access to specialised support.” Source location 2018-0398-Response-by-CQC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CQC does not publish detailed standards for specific conditions because this would duplicate expert sources and be impractical to keep updated.
Verbatim wording from the response “In accordance with CQC’s regulatory remit, as with other regulators, 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 (‘registered person’) to decide. CQC does not publish detailed standards and expectations about specific conditions and meeting related needs. To do so would duplicate the work of more appropriate expert sources (for example NICE and SCIE) and impossible to keep safely up to date. It would also make our assessment framework far too long and detailed. 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 2018-0398-Response-by-CQC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CQC does not prescribe how providers should improve; the provider or registered manager decides the appropriate actions.
Verbatim wording from the response “In accordance with CQC’s regulatory remit, as with other regulators, 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 (‘registered person’) to decide. CQC does not publish detailed standards and expectations about specific conditions and meeting related needs. To do so would duplicate the work of more appropriate expert sources (for example NICE and SCIE) and impossible to keep safely up to date. It would also make our assessment framework far too long and detailed. 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 2018-0398-Response-by-CQC
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations