27 Jul 2017 Maureen Ann Colclough · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 2 Inadequate staff training to recognise emergency situations View source Reliance on presumptions when assessing unresponsive patients in serious situations 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
Maureen Ann Colclough · 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 Ann Colclough was found unresponsive at home on 16 December 2016 and was later confirmed deceased by paramedics. The report states that she was likely in a comatose state and that earlier medical intervention could have saved her. The principal concerns were inadequate staff training to recognise an emergency and reliance on presumptions when finding an unresponsive patient in a serious situation.
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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 staff training to recognise emergency situations
Wider context from the report “1. Inadequate training of staff to recognise emergency situation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Reliance on presumptions when assessing unresponsive patients in serious situations
Wider context from the report “2. Relying on presumptions when finding an unresponsive patient in a serious situation .
” 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 reviewing emergency training and service oversight.
Verbatim wording from the response “We also agreed to conduct an inspection of the service, reviewing staff training in the event of an emergency and also the oversight that is provided by ████████. Two inspectors visited the service on 11 September 2017 and 21 September. I have detailed some of our findings under your specific questions below.” Source location 2017-0318-Response-by-CQC
Open published response
21 Jul 2017 James David Allbones · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Failure of the Paediatric team to recognise and act on sepsis red flag signs View source Failure to ensure Consultant Paediatrician involvement in Emergency Department disposition decisions for critically ill children View source Failure to support frank discussion and staff speaking up about deteriorating children View source Insufficient Paediatric staffing at Bassetlaw Hospital View source Lack of a face-to-face medical handover protocol 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
James David Allbones · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James David Allbones, aged five, died from sepsis caused by Influenza B virus infection at Bassetlaw Hospital on 2 March 2016, after being admitted within 12 hours and having been unwell with cough and breathlessness. The report identified concerns that the seriousness of his condition and red-flag signs of sepsis were not recognised, sepsis fluid management was not given, Consultant management and review were limited, and he was not considered early for transfer to a hospital providing Paediatric Intensive Care. Further concerns included paediatric staffing, handover arrangements, and communication about deteriorating children.
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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 the Paediatric team to recognise and act on sepsis red flag signs
Wider context from the report “That the ‘red flag signs’ of sepsis will not be recognised and acted upon by the Paediatric team unless there is further training and awareness raising. I suggest The Paediatric Consultant team access external training and mentoring by senior colleagues ideally within their Critical Care network.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure Consultant Paediatrician involvement in Emergency Department disposition decisions for critically ill children
Wider context from the report “That a child as ill as James will again be moved from the Emergency Department to the ward or Assessment Unit at the Hospital, rather than being transferred out for ongoing care – there is no reassurance that a sick child will be seen by a Consultant Paediatrician in the Emergency Department to assist with this decision
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to support frank discussion and staff speaking up about deteriorating children
Wider context from the report “that the Consultant team have rejected a model of care that encourages frank discussion with nursing and other staff on the ward , aimed at helping all staff speak up when worried about a deterioration child (the RCPCH SAFE model)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 Paediatric staffing at Bassetlaw Hospital
Wider context from the report “the level of Paediatric staffing at Bassetlaw Hospital . I understand there is often only one junior doctor available , and that the middle grade doctor is on duty for 24 hours .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of a face-to-face medical handover protocol
Wider context from the report “that there is still no protocol for face to face medical handover
” Open source report
21 Jul 2017 Pauline Taylor · Prevention of Future Deaths report West Yorkshire (West)
View report summary
Concerns raised 9 Potential fire hazard from low-paraffin emollient creams View source Failure to verbally inform over-the-counter purchasers of fire hazards from low-paraffin emollient creams View source Fire escalation hazard from polyurethane coating on Nimbus 6 airflow mattress coverings View source Failure to provide private community-care companies with alerts about relevant medicines and medical devices View source Failure to offer a further fire-risk-assessment referral or review after a major change in circumstances View source Lack of healthcare professional awareness of fire hazards from low-paraffin emollient creams View source Lack of care-home awareness of fire hazards from low-paraffin emollient creams View source Failure to display fire-risk warnings on all product packaging View source Failure to undertake a further risk assessment after a significant change in circumstances View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Pauline Taylor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Pauline Taylor, who was bedbound and living alone, died in her home after a fire developed around her bed on 30 May 2015. The report identified concerns about the fire risks of low-paraffin emollient creams, limited warnings and awareness of those risks, the contribution of the airflow mattress, and the absence of a further risk assessment after her circumstances changed.
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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 Potential fire hazard from low-paraffin emollient creams
Wider context from the report “(1) Zerobase and other emollient creams which contain a low level of paraffin pose a potential fire hazard risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to verbally inform over-the-counter purchasers of fire hazards from low-paraffin emollient creams
Wider context from the report “(4) Members of the public are able to purchase emollient creams across the counter but are not verbally made aware of the potential fire hazards of emollient cream containing a low level of paraffin .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 escalation hazard from polyurethane coating on Nimbus 6 airflow mattress coverings
Wider context from the report “(7) The polyurethane coating used in the outer covering of the nimbus 6 airflow mattress appears to have contributed to the speed of the fires development and also its intensity.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 private community-care companies with alerts about relevant medicines and medical devices
Wider context from the report “(5) Private companies who provide carers in the community do not receive alerts with regard to medicines and medical devices which could impact on the risk assessments and the manner in which carers working in the private sector provide care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to offer a further fire-risk-assessment referral or review after a major change in circumstances
Wider context from the report “(9) A further fire risk assessment referral/review was not offered to Mrs Taylor by Locala following a major change in her circumstance (she had become bedbound in March 2017.)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 healthcare professional awareness of fire hazards from low-paraffin emollient creams
Wider context from the report “(3) Health care professionals both in a hospital and community setting may not be aware of the potential fire hazard posed by emollient creams which contain a low level of paraffin.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of care-home awareness of fire hazards from low-paraffin emollient creams
Wider context from the report “(6) Care homes (in both the local authority and private sector) who provide residential/nursing care may not be aware of the potential fire hazard risk of emollient creams which contain low levels of paraffin.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to display fire-risk warnings on all product packaging
Wider context from the report “(2) Warnings of such risks are not displayed on all product packaging.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake a further risk assessment after a significant change in circumstances
Wider context from the report “(8) Following a significant change in Mrs Taylor's circumstances in March 2015 a further risk assessment had not been undertaken by Locala.
” Open source report
21 Jul 2017 James Albert Harris · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 8 Unavailability of a registered care home manager View source Failure to offer analgesia to residents reporting pain after a fall View source Failure to ensure carers read residents’ care plans and risk assessments View source Insufficient staffing capacity to accompany residents assessed as at risk of falls when mobilising View source Failure to record routine resident checks View source Failure to make the falls protocol clearly available to staff View source Failure to sufficiently educate and assess staff on falls policy awareness and application View source Failure to follow the falls protocol requiring immobilisation and medical attention after a painful fall View source See 5 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
James Albert Harris · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Albert Harris died in hospital on 3 April 2017 after a fall at his care home, sustaining a fractured neck of femur and subsequently deteriorating with pneumonia, Clostridium difficile infection and underlying health conditions. Concerns included inadequate falls-policy awareness and application, failure to seek medical attention after he reported pain, lack of analgesia, inadequate records of routine checks, and the care home being without a registered manager.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a registered care home manager
Wider context from the report “6. The home is currently without a registered manager and has been for sometime .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to offer analgesia to residents reporting pain after a fall
Wider context from the report “4. Mr. Harris was not offered any analgesia despite his reports of pain .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure carers read residents’ care plans and risk assessments
Wider context from the report “1. At the time of his fall none of his carers ████████ had not read his care plan or 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 Insufficient staffing capacity to accompany residents assessed as at risk of falls when mobilising
Wider context from the report “2. His care plan stipulated that he was at medium risk of falls and should be accompanied when mobilising yet he mobilised to the bathroom from the lounge without assistance because the only member of staff present in the lounge was assigned to a resident requiring one to one observation and therefore could not accompany Mr. Harris .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 routine resident checks
Wider context from the report “5. Records of routine checks on residents are not made . Therefore whilst it was asserted that Mr. Harris was checked hourly throughout following the fall there is no evidence that the checks were carried out, by whom and what was found .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to make the falls protocol clearly available to staff
Wider context from the report “3. Having fallen Mr. Harris complained of pain in his groin. The home’s ‘Protocol for all Falls’ included that if the resident complains of pain in any part of the body following a fall they ought not to be moved and medical attention should be sought. Medical attention was not sought and Mr. Harris was returned to his room. The three carers who gave evidence at the inquest ████████
████████ and ████████ all gave evidence that they had not seen the document entitled ‘Protocol for all Falls’ prior to Mr. Harris’ fall on the 26th January 2017 ,
although ████████ and ████████ were not found to be credible witnesses, ████████ was credible. Evidence of police investigations identified that the Protocol ought to have been clearly available for staff around the home as a result of issues raised by the CQC prior to this incident.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to sufficiently educate and assess staff on falls policy awareness and application
Wider context from the report “All of the above contribute to a concern that staff at Cherry Lodge are not being sufficiently educated at falls policy and assessed on their awareness and application of policies , and also that there is inadequate record keeping.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the falls protocol requiring immobilisation and medical attention after a painful fall
Wider context from the report “3. Having fallen Mr. Harris complained of pain in his groin. The home’s ‘Protocol for all Falls’ included that if the resident complains of pain in any part of the body following a fall they ought not to be moved and medical attention should be sought. Medical attention was not sought and Mr. Harris was returned to his room. The three carers who gave evidence at the inquest ████████
████████ and ████████ all gave evidence that they had not seen the document entitled ‘Protocol for all Falls’ prior to Mr. Harris’ fall on the 26th January 2017,
although ████████ and ████████ were not found to be credible witnesses, ████████ was credible. Evidence of police investigations identified that the Protocol ought to have been clearly available for staff around the home as a result of issues raised by the CQC prior to this incident.
” 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 Monitor the provider’s application to register the new manager.
Verbatim wording from the response “The Registered Provider made attempts to recruit a Registered Manager and an offer was made to one applicant to start in June 2017 but they then later declined. At the inspection it was confirmed that a new manager had been in post at Cherry Lodge since 14 July 2017, and CQC were advised that they were in the process of applying for registration. CQC will monitor this application and the provider has been made aware that failure to have a registered manager places them in breach of their registration and could result in criminal enforcement action.” Source location 2017-0334-Response-by-Care-Quality-Commission
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 Care staff cannot administer non-prescribed pain relief because the home is not a nursing home and staff lack necessary clinical skills.
Verbatim wording from the response “The Registered Provider had a system to ensure that service users received their prescribed medication, including medicines prescribed on an as required basis. However, individual care staff had not followed the provider’s protocol when Mr Harris complained of pain. The policy of the Cherry Lodge was not to offer or keep homely remedies on the premises. This means, if a service user required pain relief not already prescribed by a GP, a care worker cannot administer the medicine. In such an event, the Registered Provider’s protocol is to call for assistance either through 111 or 999. Cherry Lodge is not a nursing home and as such care staff do not have the necessary clinical skills to make judgments about people’s health, or the risk associated with administering medication that had not been prescribed.” Source location 2017-0334-Response-by-Care-Quality-Commission
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 Registered Provider remains responsible for employing sufficient suitably qualified staff to support service users safely.
Verbatim wording from the response “The Registered Provider is responsible for ensuring sufficient numbers of suitably qualified, competent, skilled and experienced care staff are employed in order to minimise and reduce the risk of harm to service users, (Regulation 18 the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). If there is a lack of care staff there is a risk that service users will not receive the level of support required to keep them safe from risk of harm.” Source location 2017-0334-Response-by-Care-Quality-Commission
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 Registered Provider remains responsible for ensuring monitoring checks are conducted and accurately recorded.
Verbatim wording from the response “The Registered Provider has a duty to ensure processes are followed to protect service users from the risk of harm, which includes monitoring the checks made on service users were conducted and reviewing the records of these checks. The care staff at Cherry Lodge were aware that they should have recorded when checks were made on Mr Harris. However, the Registered Provider has the overall responsibility to ensure there are appropriate processes in place which should ensure regular monitoring checks are made on people and accurately recorded.” Source location 2017-0334-Response-by-Care-Quality-Commission
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 Registered Provider is responsible for ensuring staff competence, training, and compliance with care plans, risk assessments, policies and procedures.
Verbatim wording from the response “The Registered Provider is responsible for ensuring care staff are competent, skilled and experienced and that they are appropriately trained as is necessary to enable them to carry out their duties, (Regulation 12 the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014).The Registered Provider has the responsibility to ensure care staff follow service users care plans, and to make staff aware of the importance of knowing how to effectively and safely support service users and the appropriate actions to take by following a service users care plan. If care staff fail to read care plans there is a risk that they will not provide the care that is appropriate to a specific service user and thus putting that service user’s safety at risk.” Source location 2017-0334-Response-by-Care-Quality-Commission
Open published response
7 Jun 2017 Dennis Allen Teesdale · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 15 Lack of timely on-site emergency laboratory testing and results View source Failure to recognise severe clinical deterioration on consultant ward rounds View source Poor multidisciplinary communication for consistent systematic patient management View source Unavailability of specialist facilities or clinicians for peri-operative PEG insertion View source Lack of assured competence for peri-operative PEG insertion View source Failure to seek expert advice during daytime working hours View source Lack of out-of-hours radiology and on-site CT diagnostic capacity View source Failure to follow written guidance for PEG insertion View source Failure to follow written guidance for post-operative abdominal pain after PEG insertion View source Lack of on-site specialist clinical support for complications View source Lack of formal PEG insertion training and independent competency assessment View source Inconsistent daytime consultant presence in the High Dependency Unit View source Delays in transferring patients requiring post-operative specialist care View source Lack of assured general surgical competence in out-of-hours cover View source Failure to risk-assess the appropriateness of PEG insertion View source See 12 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
Dennis Allen Teesdale · 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 Allen Teesdale underwent surgery including insertion of a PEG tube on 17 October 2016 and subsequently developed severe abdominal pain, multi-organ failure and septic shock. He was found to have peritonitis caused by leakage of bowel contents from the PEG tube passing through the bowel, and died on 20 October 2016. Concerns included the insertion and post-operative management of the PEG, delayed recognition and treatment of deterioration, delayed transfer, and limitations in specialist, diagnostic and laboratory services at Queen Victoria Hospital.
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 timely on-site emergency laboratory testing and results
Wider context from the report “12. There are no haematology or biochemistry services at QVH . A courier service is required for emergency laboratory tests . This has the potential to either not request ‘bloods’ and/or a delay in obtaining results .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 severe clinical deterioration on consultant ward rounds
Wider context from the report “10. There was no recognition of how unwell Mr Teesdale was on the consultant surgical ward round at or around 0900 on the 19th October 2016, despite considerable evidence present at the time that Mr Teesdale had developed multi-organ failure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Poor multidisciplinary communication for consistent systematic patient management
Wider context from the report “11. Poor communication between nursing staff, anaesthetic staff and surgical staff making it difficult to provide an overall consistent and systematic approach to the management of Mr Teesdale in a small High Dependency Unit with an inconsistent consultant presence during the day.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Unavailability of specialist facilities or clinicians for peri-operative PEG insertion
Wider context from the report “2. There are no facilities or clinicians (radiologist or gastroenterologists who normally undertake such procedures) available to place a PEG prior to surgery , thereby requiring oral maxillo-facial surgeons of variable and unclear experience to undertake the procedure peri-operatively.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 assured competence for peri-operative PEG insertion
Wider context from the report “2. There are no facilities or clinicians (radiologist or gastroenterologists who normally undertake such procedures) available to place a PEG prior to surgery, thereby requiring oral maxillo-facial surgeons of variable and unclear experience to undertake the procedure peri-operatively .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 expert advice during daytime working hours
Wider context from the report “8. As an isolated hospital, Queen Victoria Hospital has no ‘on site’ clinical specialist experience to assist when patients develop complications. As a consequence, there was no specialist available to assess Mr Teesdale’s abdominal pain as detailed in guidance of post-operative pain following PEG insertion. No effort was made to seek such expert advice during ‘daytime working hours’ .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of out-of-hours radiology and on-site CT diagnostic capacity
Wider context from the report “Similarly, there is no ‘out of hours’ radiology service and there is no CT scanner on site to assist in a diagnosis (which was required as part of the management guidelines prepared by QVH).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to follow written guidance for PEG insertion
Wider context from the report “3. Written guidance by the surgeons for insertion of PEG’s was not followed with little reflection as to whether this was an acceptable procedure given Mr Teesdale’s previous extensive surgery at or around the point where the PEG was inserted with concomitant poor gastroscopic trans-illumination.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to follow written guidance for post-operative abdominal pain after PEG insertion
Wider context from the report “6. The post-operative management of Mr Teesdale did not follow the written guidance for the management of abdominal pain after PEG insertion . This resulted in a delay in seeking appropriate advice, timely intervention and optimal treatment of this complication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 on-site specialist clinical support for complications
Wider context from the report “8. As an isolated hospital, Queen Victoria Hospital has no ‘on site’ clinical specialist experience to assist when patients develop complications . As a consequence, there was no specialist available to assess Mr Teesdale’s abdominal pain as detailed in guidance of post-operative pain following PEG insertion. No effort was made to seek such expert advice during ‘daytime working hours’.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of formal PEG insertion training and independent competency assessment
Wider context from the report “5. No formal ‘training’ programme for the insertion of PEG or independent competency based 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 Inconsistent daytime consultant presence in the High Dependency Unit
Wider context from the report “11. Poor communication between nursing staff, anaesthetic staff and surgical staff making it difficult to provide an overall consistent and systematic approach to the management of Mr Teesdale in a small High Dependency Unit with an inconsistent consultant presence during the day .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 transferring patients requiring post-operative specialist care
Wider context from the report “7. Mr Teesdale’s transfer was delayed because of a reluctance to transfer in the immediate post operative period complicated by the associated logistical difficulties of doing so given his major surgery.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 assured general surgical competence in out-of-hours cover
Wider context from the report “9. Mr Teesdale was cared for ‘out of hours’ by a trainee oral-maxillo-facial surgeon with unknown general surgical experience who did not recognise or manage the severity of a surgical complication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to risk-assess the appropriateness of PEG insertion
Wider context from the report “4. No risk assessment was undertaken as to whether a PEG insertion would have been appropriate , given that a non-invasive alternative of a feeding tube for enteral feeding was available.
” 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 Obtain assurances about further changes to PEG practice following the trust’s external review.
Verbatim wording from the response “Regarding the issue of the PEG being placed peri-operatively, the trust is obtaining an external review of its current PEG practices as part of the action plan following learning from Mr Teesdale’s death. A review is currently being carried out by surgeons from other trusts, including a consultant gastro-intestinal surgeon. We will obtain assurances around any further changes to practice following the review as part of our routine engagement with the trust.” Source location 2017-0202-Response-by-Care-Quality-Commission
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor the trust’s prospective PEG audit through routine engagement, including adherence to policy and timely escalation of deterioration.
Verbatim wording from the response “Although the trust carried out two PEG insertions since the request, only one of these took place after they introduced the new PEG Pathway on 5 June 2017. The trust confirmed the PEG Pathway was followed for this patient. We will continue to monitor the trust’s prospective PEG audit, which will capture this information, as part of our ongoing engagement with the trust.” Source location 2017-0202-Response-by-Care-Quality-Commission
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request and review the trust’s completed prospective PEG audit to obtain assurances about safe care and treatment.
Verbatim wording from the response “The trust have carried out 16 percutaneous endoscopic gastrostomy (PEG) tube insertions since Mr Teesdale’s death, with two of these taking place since the inquest. The trust’s lead cancer nurse is auditing all PEG insertions since January 2017 to provide assurances patients have received safe care and treatment. The trust have shared their audit tool with us, and we saw that this will allow the trust to provide assurances around areas including multidisciplinary involvement, risk assessment, and contraindications. CQC will request that the trust send us a copy of the completed audit by 30 September 2017. We will subsequently review the audit to obtain assurances of safe care and treatment.” Source location 2017-0202-Response-by-Care-Quality-Commission
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor the trust’s progress on its business case for an on-site CT scanner through ongoing engagement.
Verbatim wording from the response “As part of the trust’s action plan produced following the inquest into Mr Teesdale’s death, the trust has put forward a business case for a CT scanner on site. CQC will monitor the trust’s progress against this action as part of our ongoing engagement.” Source location 2017-0202-Response-by-Care-Quality-Commission
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local competency assessments, experience checks and supervised practice are considered sufficient because no nationally recognised PEG training courses exist.
Verbatim wording from the response “CQC’s National Professional Advisor for Surgery has informed us that currently, no nationally recognised training courses for PEG insertion exist. His view is that it would be very difficult to provide a comprehensive training course given that there are not large numbers of PEG tubes inserted nationally. The important aspect is that trainees are able to gain experience as available and that they do not undertake independent practice until signed off as competent. We would therefore expect registers of providers to use their own competency assessment to provide themselves with assurances that all staff carrying out the procedure are competent and skilled to do so.” Source location 2017-0202-Response-by-Care-Quality-Commission
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No national guidance requires PEG insertion to be performed by radiologists or gastroenterologists; competence rather than specialty is considered important.
Verbatim wording from the response “The trust told us that where these processes did not provide sufficient assurances of a consultant’s competency to carry out particular work, then the consultant would complete a period of supervised practice as part of their induction. CQC’s National Professional Advisor for Surgery has confirmed that no national guidance currently exists that dictates PEG insertion must specifically be carried out by radiologists or gastroenterologists. CQC’s National Professional Advisor for Surgery feels it is appropriate that there is no national guidance to dictate the” Source location 2017-0202-Response-by-Care-Quality-Commission
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The service-level agreement provides immediate access to general surgical advice, so specialist expertise is available despite no general surgeon on site.
Verbatim wording from the response “CQC’s National Professional Advisor for Surgery is of the view that, as there is no general surgeon on site, the trust should have immediate access to the appropriate advice from a general surgeon and when required. The trust has this through their service level agreement (SLA) with Brighton and Sussex University Hospitals NHS Trust (BSUHT). This SLA was in place at the time of Mr Teesdale’s death, however, QVH staff did not escalate quickly enough. We would respectfully refer to point (7) of this response for actions the trust has taken to prevent similar delays in escalation and transfer for other patients.” Source location 2017-0202-Response-by-Care-Quality-Commission
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pre-operative assessment considers suitability for surgery based on available facilities, while the laboratory agreement requires urgent specimens to be processed within one hour.
Verbatim wording from the response “All patients having major surgery at QVH have an individual pre-operative assessment with a surgeon. This determines their suitability for surgery at the hospital, in view of the available on-site facilities. This is recorded in the patient record.” Source location 2017-0202-Response-by-Care-Quality-Commission
Open published response
10 May 2017 Cedrick Sykers · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Failure to document required smoking-risk mitigations and responses to their refusal View source Variation in nurses’ skills in smoking risk assessment View source Failure to recognise immobility and require supervision in smoking risk assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Cedrick Sykers · 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
Cedrick Sykers, a hemiplegic nursing-home resident who could not stand, reposition himself or propel his wheelchair, died in hospital after his clothes caught fire while he was smoking unsupervised in a garden. The report identified concerns about insufficient recognition and mitigation of the risks faced by immobile residents who smoke and cannot summon help, including the lack of clearly documented requirements for supervision, smoking aprons and alarm pendants.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to document required smoking-risk mitigations and responses to their refusal
Wider context from the report “The management of the Care Home and its owners, BUPA, have undertaken a thorough investigation and implemented a detailed Action Plan which has reduced many of the risks to life of accidental fires from resident’s smoking identified in the inquest. But one area remains a concern.
BUPA corporate guidance indicated, at the time of Mr Skyer’s death and now, that residents who wish to smoke must have risk assessments with their abilities, dependencies and special requirements taken into account. The concern relates to the process of mitigating the risks from personal risk assessment of immobile patients. A new safe smoking risk assessment form has been introduced, which requires assessment of safely lighting and smoking a cigarette now to be recorded. The only new question to be asked which would score a concern for a resident such as Mr Sykers, in a wheelchair, is one as to whether the resident has any difficulty in balance. If that is recorded as yes, the process requires the documentation of the steps to be taken to limit associated risks. Nowhere is the risk associated with immobility specifically recognised, yet patients who are immobile and smoke in bed are required to be supervised. A BUPA Fire Risk Advisor told the court that he would recommend the same requirement should be made for those who are immobile but smoking elsewhere.
The present policy appears to leave the nurse with the discretion as to what may be inserted into the plan. A BUPA manager informed the court that residents would be offered an apron and alarm pendant. This was not apparent in the documentation. It was not documented that a person who declined these would be expected to accept supervision, nor the importance of these for someone who is completely immobile. If this too was declined, it would seem that if the resident insisted in continuing to smoke without supervision or apron, consideration should be given as to whether this should be recorded as being a choice against professional advice.
Reviewing all the evidence, including the variation in skills of nurses in smoking risk assessment and particularly noting the fire investigator’s evidence that the resident’s clothes can be completely consumed by fire in two minutes, the mitigation of risks of death to those who smoke outside in BUPA homes and are immobile and cannot summon help seem to have not been sufficiently recognised.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 nurses’ skills in smoking risk assessment
Wider context from the report “The management of the Care Home and its owners, BUPA, have undertaken a thorough investigation and implemented a detailed Action Plan which has reduced many of the risks to life of accidental fires from resident’s smoking identified in the inquest. But one area remains a concern.
BUPA corporate guidance indicated, at the time of Mr Skyer’s death and now, that residents who wish to smoke must have risk assessments with their abilities, dependencies and special requirements taken into account. The concern relates to the process of mitigating the risks from personal risk assessment of immobile patients. A new safe smoking risk assessment form has been introduced, which requires assessment of safely lighting and smoking a cigarette now to be recorded. The only new question to be asked which would score a concern for a resident such as Mr Sykers, in a wheelchair, is one as to whether the resident has any difficulty in balance. If that is recorded as yes, the process requires the documentation of the steps to be taken to limit associated risks. Nowhere is the risk associated with immobility specifically recognised, yet patients who are immobile and smoke in bed are required to be supervised. A BUPA Fire Risk Advisor told the court that he would recommend the same requirement should be made for those who are immobile but smoking elsewhere.
The present policy appears to leave the nurse with the discretion as to what may be inserted into the plan. A BUPA manager informed the court that residents would be offered an apron and alarm pendant. This was not apparent in the documentation. It was not documented that a person who declined these would be expected to accept supervision, nor the importance of these for someone who is completely immobile. If this too was declined, it would seem that if the resident insisted in continuing to smoke without supervision or apron, consideration should be given as to whether this should be recorded as being a choice against professional advice.
Reviewing all the evidence, including the variation in skills of nurses in smoking risk assessment and particularly noting the fire investigator’s evidence that the resident’s clothes can be completely consumed by fire in two minutes, the mitigation of risks of death to those who smoke outside in BUPA homes and are immobile and cannot summon help seem to have not been sufficiently recognised.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 immobility and require supervision in smoking risk assessments
Wider context from the report “The management of the Care Home and its owners, BUPA, have undertaken a thorough investigation and implemented a detailed Action Plan which has reduced many of the risks to life of accidental fires from resident’s smoking identified in the inquest. But one area remains a concern.
BUPA corporate guidance indicated, at the time of Mr Skyer’s death and now, that residents who wish to smoke must have risk assessments with their abilities, dependencies and special requirements taken into account. The concern relates to the process of mitigating the risks from personal risk assessment of immobile patients. A new safe smoking risk assessment form has been introduced, which requires assessment of safely lighting and smoking a cigarette now to be recorded. The only new question to be asked which would score a concern for a resident such as Mr Sykers, in a wheelchair, is one as to whether the resident has any difficulty in balance. If that is recorded as yes, the process requires the documentation of the steps to be taken to limit associated risks. Nowhere is the risk associated with immobility specifically recognised, yet patients who are immobile and smoke in bed are required to be supervised. A BUPA Fire Risk Advisor told the court that he would recommend the same requirement should be made for those who are immobile but smoking elsewhere.
The present policy appears to leave the nurse with the discretion as to what may be inserted into the plan. A BUPA manager informed the court that residents would be offered an apron and alarm pendant. This was not apparent in the documentation. It was not documented that a person who declined these would be expected to accept supervision, nor the importance of these for someone who is completely immobile. If this too was declined, it would seem that if the resident insisted in continuing to smoke without supervision or apron, consideration should be given as to whether this should be recorded as being a choice against professional advice.
Reviewing all the evidence, including the variation in skills of nurses in smoking risk assessment and particularly noting the fire investigator’s evidence that the resident’s clothes can be completely consumed by fire in two minutes, the mitigation of risks of death to those who smoke outside in BUPA homes and are immobile and cannot summon help seem to have not been sufficiently recognised.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake an unannounced comprehensive inspection of Manley Court, review documentation, and consider whether measures reduce risk.
Verbatim wording from the response “We are planning to undertake a further unannounced comprehensive inspection of Manley Court in July 2017 and will review the documentation and consider whether these steps further reduce the risk to people at the service. Again we would ask that this information not be passed onto any other Interested Person(s).” Source location Response from CQC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Carry out a comprehensive inspection following the incident to assess risk assessments and staffing shortages.
Verbatim wording from the response “Prior to the receipt of your report, the CQC became aware of Mr Skyers death via Mr Skyers’ son, who told us of his father’s death on 14th March 2016. We were informed that on 13 March 2016 Mr Skyers was smoking unattended in the garden of Manley Court when a staff member saw that he had caught alight and alerted other staff who put the flames out and contacted emergency services. Mr Skyers was attended to by paramedics but sadly died later that day at Kings College Hospital.” Source location Response from CQC
Open published response
8 May 2017 David Sheppard · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 6 Failure to pass on an accurate history of events View source Failure of staff to communicate with each other during emergency response View source Lack of staff first aid training and choking-sign recognition View source Failure of staff to communicate effectively with challenging behavioural unit patients View source Poor quality of staff statements after incidents View source Failure to keep acute and contemporaneous event notes with timings View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
David Sheppard · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Sheppard choked on a doughnut at Boldmere Court on 31 July 2016 and suffered a cardiac arrest and severe hypoxic brain injury. He was taken to Good Hope Hospital, where treatment was withdrawn, and he died on 3 August 2016. The principal concerns were inadequate emergency response, poor communication, failures in record keeping, insufficient first-aid training, and inadequate post-event investigation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to pass on an accurate history of events
Wider context from the report “b. Staff failed to pass on an accurate history of what had happened to the deceased resulting in there being a poor understanding of his initial complaint – namely that the deceased was pointing to his throat and was unable to communicate. These factors would indicate choking.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to communicate with each other during emergency response
Wider context from the report “a. The initial nurse who attended the deceased after the emergency call had poor English and needed to give evidence at the inquest through an interpreter. The carer who started CPR had very poor English and also gave evidence through an interpreter. The evidence heard at the inquest was that the response to this emergency was chaotic. Inability of staff to communicate with each other contributed to the chaos and poor decision making.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of staff first aid training and choking-sign recognition
Wider context from the report “3. Training. Several of the staff who gave evidence had not received first aid training . They did not understand the signs of choking displayed by the deceased .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to communicate effectively with challenging behavioural unit patients
Wider context from the report “c. The patients on the challenging behavioural unit are extremely vulnerable and many suffer from dementia and other conditions. Staff being unable to communicate effectively with these patients may cause harm and confusion.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Poor quality of staff statements after incidents
Wider context from the report “4. Post event investigation. The quality of statements produced by staff immediately after the event was extremely poor . Subsequently staff had a very poor recollection of what happened which seriously hampered the inquest. Direction needs to be given to ensure that accurate and contemporaneous statements are taken after such an incident to ensure events are accurately recorded to enable the correct lessons to be learnt.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to keep acute and contemporaneous event notes with timings
Wider context from the report “2. Record keeping. Staff failed to keep an acute and contemporaneous note of the events that occurred with timings . This made reconstruction of the event extremely difficult.
” Open source report
8 May 2017 Name not published · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 9 Insufficient senior nursing staff in leadership roles View source Failure to complete required neurological or general observations View source Insufficient staffing levels or staff competence for safe care View source Failure to ensure completion or handover and documentation of outstanding A & E investigations View source Failure to accurately record and calculate neurological or general observations View source Failure to escalate neurological or general observations appropriately View source Lack of a clear handover and review process for transfer to AMU View source Failure to assess mental capacity during admission and transfer View source Failure to progress outstanding basic investigations and assessments View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Name not published · 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
A 79-year-old woman was admitted to hospital on 15 March 2015 with hypothermia, reduced responsiveness and reduced mobility. She developed pneumonia, sepsis and acute respiratory distress syndrome, and died on 23 March 2015. The principal concerns were failures in investigations and handover, mental-capacity assessment, monitoring and escalation of deterioration, and staffing competence and seniority.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Insufficient senior nursing staff in leadership roles
Wider context from the report “6. Staffing levels, competence and seniority. The levels and competence of staff ( whether agency or Trust employees ) needed to deliver safe and appropriate care and with sufficient senior Nursing staff in leadership roles requires assessment and implementation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to complete required neurological or general observations
Wider context from the report “5. Ensuring that all neurological and/or general observations are appropriately undertaken , accurately recorded and calculated but also escalated as necessary. It is a fundamental part of basic medical and nursing care that a patient who requires neurological or general observations has them completed in a timely manner , accurately recorded and calculated and then appropriately escalated. This was simply not done and simple systems or protocols could be introduced to ensure that this is completed. It would seem that the primary responsibility for this should be shared between the Nurse in charge of the individual patient and the nurse in charge of the AMU.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing levels or staff competence for safe care
Wider context from the report “6. Staffing levels, competence and seniority. The levels and competence of staff ( whether agency or Trust employees ) needed to deliver safe and appropriate care and with sufficient senior Nursing staff in leadership roles requires assessment and implementation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure completion or handover and documentation of outstanding A & E investigations
Wider context from the report “2. Ensuring all investigations/assessments are completed before a patient leaves A & E and ensuring an appropriate handover. It is appreciated that it will not be possible for all investigations and tests to be performed before a patient leaves the A & E department but if that is the case then the receiving ward should be informed and there should be a clear documented audit trail so it is clear what is outstanding .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record and calculate neurological or general observations
Wider context from the report “5. Ensuring that all neurological and/or general observations are appropriately undertaken, accurately recorded and calculated but also escalated as necessary. It is a fundamental part of basic medical and nursing care that a patient who requires neurological or general observations has them completed in a timely manner, accurately recorded and calculated and then appropriately escalated. This was simply not done and simple systems or protocols could be introduced to ensure that this is completed. It would seem that the primary responsibility for this should be shared between the Nurse in charge of the individual patient and the nurse in charge of the AMU.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 neurological or general observations appropriately
Wider context from the report “5. Ensuring that all neurological and/or general observations are appropriately undertaken, accurately recorded and calculated but also escalated as necessary. It is a fundamental part of basic medical and nursing care that a patient who requires neurological or general observations has them completed in a timely manner, accurately recorded and calculated and then appropriately escalated . This was simply not done and simple systems or protocols could be introduced to ensure that this is completed. It would seem that the primary responsibility for this should be shared between the Nurse in charge of the individual patient and the nurse in charge of the AMU.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 handover and review process for transfer to AMU
Wider context from the report “3. Transfer and hand over of a patient to AMU from A & E. There was no clear hand over process and review when the deceased arrived on the AMU . It would seem sensible that a Senior Nurse/Sister be informed and can then ensure appropriate care is given.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 mental capacity during admission and transfer
Wider context from the report “1. Mental Capacity. There was no apparent consideration to the issue of whether or not the deceased had mental capacity from admission to A & E and transfer to AMU .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to progress outstanding basic investigations and assessments
Wider context from the report “4. Ensuring investigations are progressed as appropriate. There was no progression of necessary basic assessments/tests which remained outstanding . For example, a chest X-ray.
” Open source report
3 Mar 2017 Joan RIMMER · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 2 Failure to distinguish inability to consent from refusal of x-ray View source Failure to take physiological readings when assessing physiological response to fracture 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
Joan RIMMER · 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
Joan Rimmer, who had dementia and lived in a residential home, suffered an unwitnessed fall on 28 November 2016 and was later diagnosed with a right hip fracture. She underwent surgery but subsequently stopped eating and drinking and died on 16 January 2017. The court was concerned that the community matron assessed her without taking physiological readings and wrongly judged that she had refused an X-ray, contributing in part to a two-week delay in diagnosing the fracture.
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 distinguish inability to consent from refusal of x-ray
Wider context from the report “Though there was no evidence that Mrs Rimmer’s death could have been avoided by earlier diagnosis of her fractured hip – the court is concerned that the Community Matron employed by Liverpool Community Health assessed her physiological response to a fracture without taking any physiological readings and further adjudged her to refuse to be x-rayed when a carer witness who was present has explained that the extent of her dementia on the 29th November was so severe she would not understand sufficient to give consent . This in part led to a two week delay before her hip fracture was diagnosed. In another case such standards of nursing could result in an avoidable death not being prevented.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to take physiological readings when assessing physiological response to fracture
Wider context from the report “Though there was no evidence that Mrs Rimmer’s death could have been avoided by earlier diagnosis of her fractured hip – the court is concerned that the Community Matron employed by Liverpool Community Health assessed her physiological response to a fracture without taking any physiological readings and further adjudged her to refuse to be x-rayed when a carer witness who was present has explained that the extent of her dementia on the 29th November was so severe she would not understand sufficient to give consent. This in part led to a two week delay before her hip fracture was diagnosed. In another case such standards of nursing could result in an avoidable death not being prevented.
” Open source report
13 Feb 2017 Roger Harold Tombs · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Failure to place fall sensor mats on a hard floor 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
Roger Harold Tombs · 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
Roger Harold Tombs died at Queen Elizabeth Hospital on 4 May 2016 after being admitted following a fall at Sunrise Care Home. He had a history of learning disabilities and an increasing risk of falls; the medical cause of death included bronchopneumonia and severe traumatic brain injury. Concerns included the failure of fall sensor mats to sound an alert and the practice of placing them on top of crash mats, which may reduce their effectiveness.
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 place fall sensor mats on a hard floor
Wider context from the report “2. The instructions for use of the sensor mats state they should be placed on a hard floor.
3. The investigating police officer from the public protection unit gave evidence that she was concerned that the crash mats below the sensor mats would reduce the effectiveness of the sensor mats and this could possibly be the reason the mat didn’t sound (there were other possible explanations).
4. The evidence was that Sunrise of Knowle is still placing sensor mats on top of crash mats.
5. No expert opinion has been sought on this practice but the evidence of the investigating police officer was that the managing director of the local distributors of the mats told her this was an unsafe practice in his view .
6. It is my opinion that there is a risk that the effectiveness of the sensor mats is being reduced by placing them on crash mats and if this is the case they may not sound when vulnerable residents are mobilising especially when there is a risk of falls, injury and potentially death.
” Open source report
3 Feb 2017 ROBERT ENTENMAN · Prevention of Future Deaths report London Inner (South)
View report summary
Concerns raised 4 Delays in communicating suction catheter difficulties to doctors View source Delays in identifying and replacing blocked endotracheal tubes View source Failure to monitor humidifier operation and temperature View source Lack of a humidifier alarm indicating when the machine is turned off 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
ROBERT ENTENMAN · 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
Robert Entenman was an intubated intensive care patient whose humidifier was turned off from around 12.00pm on 22 May 2015 until 6.00am on 23 May 2015. A mucus plug blocked his endotracheal tube, leading to cardiac arrest shortly after 6.00am; he died on 30 May 2015. Concerns included failures to observe that the humidifier was off, the absence of an alarm on the humidifier, delays in identifying and replacing the blocked tube, and possible delays in communicating suction difficulties to doctors.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Delays in communicating suction catheter difficulties to doctors
Wider context from the report “(3) There were delays in identifying that the endotracheal tube had become blocked between 5.32 and 6.00am on 23 May 2015, and thus replacing it earlier. There may have been further such delays after 6.00 am. There may have been a delay by the nursing staff in providing information about difficulties with the suction catheter to the doctors who arrived after the cardiac arrest call was put out.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Delays in identifying and replacing blocked endotracheal tubes
Wider context from the report “(3) There were delays in identifying that the endotracheal tube had become blocked between 5.32 and 6.00am on 23 May 2015, and thus replacing it earlier . There may have been further such delays after 6.00 am . There may have been a delay by the nursing staff in providing information about difficulties with the suction catheter to the doctors who arrived after the cardiac arrest call was put out.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor humidifier operation and temperature
Wider context from the report “(1) Three nurses cared for Mr Entenman between 12.00pm on 22 May 2015 and 6.00am on 23 May 2015. During that time they did not observe that the humidifier had been turned off , either handovers that took place between them or each hour when they should have recorded the temperature reading from the humidifier .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 humidifier alarm indicating when the machine is turned off
Wider context from the report “(2) The humidifier machine does not have an alarm on it, to indicate when the machine has been turned off .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The completed RCA action plan was considered sufficient to mitigate recurrence risk, with the planned actions carried out.
Verbatim wording from the response “The CQC requested a final copy of the RCA document as part of the inspection process in 2016, and received this on 28 October 2016. The document had been completed on 30 October 2015. It set out the background to the incident, the possible causes and a proposed action plan to prevent the re-occurrence of similar incidents. The CQC was satisfied that the actions set out in the RCA would be sufficient to mitigate the risk of re-occurrence and, further, that those actions had been carried out.” Source location 2017-0011-Response-by-Care-Quality-Commission
Open published response
15 Dec 2016 Mrs Winifred Elliott · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 2 Failure to keep resident transfer information readily accessible to staff View source Inappropriate resident transfers causing injury View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs Winifred Elliott · 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 Winifred Elliott, a non-weight-bearing resident of Meadbank Care Home, was transferred using a handling belt rather than the required hoist and two-person assistance, resulting in multiple fractures to her left leg. She later died in hospital, with the report stating that the injuries led to and caused her death. The principal concerns were that transfer information had been removed from display, making it harder for staff to access, and that residents might consequently be transferred inappropriately and sustain fatal injuries.
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 keep resident transfer information readily accessible to staff
Wider context from the report “1. That information in relation to transferring residents has been removed from display next to the resident e.g. from above their beds or inside their rooms.
2. That the removal of such information has made it harder for busy staff to access such information .
3. That as such, some residents may be being inappropriately transferred and thus sustaining injuries that may cause to contribute to their deaths as in this 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 Inappropriate resident transfers causing injury
Wider context from the report “1. That information in relation to transferring residents has been removed from display next to the resident e.g. from above their beds or inside their rooms.
2. That the removal of such information has made it harder for busy staff to access such information.
3. That as such, some residents may be being inappropriately transferred and thus sustaining injuries that may cause to contribute to their deaths as in this 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 Assess providers’ safe-care systems, staff understanding, and access to care plans and risk assessments during comprehensive inspections.
Verbatim wording from the response “During the inspection process the inspection team will assess the performance of the provider against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. As part of this process inspectors will assess whether or not providers are providing safe care and treatment under Regulation 12. This will include the assessment and management of risks associated with moving and handling. As stated above CQC does not have the powers to insist on how providers meet the regulations and therefore could not compel providers to develop and implement systems for displaying moving and handling information. However, CQC will assess the effectiveness of the systems providers have to assess, monitor and mitigate the risks relating to the health, safety and welfare of people using services and will take action against providers who fail to keep people safe from avoidable harm.” Source location 2016-0448-Response-by-Care-Quality-Commission
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Take enforcement action against providers failing to provide safe care, including safe moving and handling procedures.
Verbatim wording from the response “During the inspection process the inspection team will assess the performance of the provider against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. As part of this process inspectors will assess whether or not providers are providing safe care and treatment under Regulation 12. This will include the assessment and management of risks associated with moving and handling. As stated above CQC does not have the powers to insist on how providers meet the regulations and therefore could not compel providers to develop and implement systems for displaying moving and handling information. However, CQC will assess the effectiveness of the systems providers have to assess, monitor and mitigate the risks relating to the health, safety and welfare of people using services and will take action against providers who fail to keep people safe from avoidable harm.” Source location 2016-0448-Response-by-Care-Quality-Commission
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Providers are responsible for developing systems that give staff access to information while meeting residents’ individual privacy and care needs.
Verbatim wording from the response “CQC has the statutory objective of performing its functions for the general purpose of encouraging the improvement of health and social care services. This is achieved by monitoring and inspecting services to ensure that they are meeting the regulations. Providers develop ways of meeting the regulations that are individual to the service and meet people’s individual needs. CQC as the regulator does not have the power to insist that provider’s meet the regulations in a particular way. However, CQC does provide guidance for providers about how to meet the regulations on our website which can be found here: http://www.cqc.org.uk/content/guidance-providers. Also we can ensure as part of our inspections that staff have access to all of the information that they require to meet people’s individual needs appropriately and safely and take action where this is not the case.” Source location 2016-0448-Response-by-Care-Quality-Commission
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There is no evidence that CQC instructed Meadbank Care Home to remove moving and handling guidance from residents’ bedrooms.
Verbatim wording from the response “We have reviewed all of the reports written following our inspections of Meadbank Care Home on 14 July 2011, 8 November 2012, 21 May 2013, 24 September 2013, 6 November 2014, 4 April 2016 and 2 September 2016 and spoken with the lead inspectors involved in these inspections. We cannot find any evidence that CQC at any time asked staff at Meadbank Care Home to” Source location 2016-0448-Response-by-Care-Quality-Commission
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CQC lacks power to require providers to meet safety regulations through a particular method, including displaying moving and handling information.
Verbatim wording from the response “CQC has the statutory objective of performing its functions for the general purpose of encouraging the improvement of health and social care services. This is achieved by monitoring and inspecting services to ensure that they are meeting the regulations. Providers develop ways of meeting the regulations that are individual to the service and meet people’s individual needs. CQC as the regulator does not have the power to insist that provider’s meet the regulations in a particular way. However, CQC does provide guidance for providers about how to meet the regulations on our website which can be found here: http://www.cqc.org.uk/content/guidance-providers. Also we can ensure as part of our inspections that staff have access to all of the information that they require to meet people’s individual needs appropriately and safely and take action where this is not the case.” Source location 2016-0448-Response-by-Care-Quality-Commission
Open published response
24 Nov 2016 Mrs Beryl Farmer · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 4 Lack of completed falls risk assessments View source Failure to perform CT head scans after significant facial and head bruising View source Failure to justify moving patients at risk of falls from monitored to unmonitored bays View source Insufficient post-fall neurological observations before discharge View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mrs Beryl Farmer · 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 Farmer was admitted to hospital with severe hypocalcaemia and postural hypotension, fell from her bed and sustained facial and head injuries, and was discharged without a documented falls risk assessment. She was readmitted after developing headaches, was diagnosed with a subdural haemorrhage, later developed seizures, and died; concerns included inadequate falls-risk assessment, moving her to an unmonitored bay, limited neurological observations, and no CT head scan after the fall.
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 completed falls risk assessments
Wider context from the report “1. Evidence emerged during the inquest that Mrs Farmer had a risk of a falling (moderate to high risk). There was no evidence that a falls risk assessment had been completed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to perform CT head scans after significant facial and head bruising
Wider context from the report “4. In addition no CT Head scan was performed despite evidence of significant bruising to her face and head .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to justify moving patients at risk of falls from monitored to unmonitored bays
Wider context from the report “2. Given the risks of falls, there was no clear justification for moving her from a monitored bay to an unmonitored bay .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 post-fall neurological observations before discharge
Wider context from the report “3. After the fall, only one set of neurological observations were performed before her discharge .
” Open source report
14 Nov 2016 Mr Martyn Watkins · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Failure to identify deficiencies in care on Aspen Ward View source Failure to address deficiencies and outstanding issues in care on Aspen Ward View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Martyn Watkins · 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 Martyn Watkins, who was at high risk of suicide, was admitted to a mental health ward under section 2 of the Mental Health Act on 23 March 2016. He was found hanging from his belt, which had been secured to a fold-up bed in his room, and died in hospital on 1 April 2016. The report identified concerns including the unsafe room environment, inadequate checks for ligature risks, failures in admission procedures, and insufficient communication of specific 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 Failure to identify deficiencies in care on Aspen Ward
Wider context from the report “(2) The CQC should satisfy themselves that any and all deficiencies in the care provided to Mr. Watkins and generally on Aspen Ward have been identified and addressed.
(3) The CQC should satisfy themselves that an appropriate timetable and action plan are in place to ensure any outstanding issues on Aspen Ward relating to the safe care and treatment of service users are addressed at the earliest opportunity.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to address deficiencies and outstanding issues in care on Aspen Ward
Wider context from the report “(2) The CQC should satisfy themselves that any and all deficiencies in the care provided to Mr. Watkins and generally on Aspen Ward have been identified and addressed .
(3) The CQC should satisfy themselves that an appropriate timetable and action plan are in place to ensure any outstanding issues on Aspen Ward relating to the safe care and treatment of service users are addressed at the earliest opportunity .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request information and documentation from the Trust to identify and determine patient risk.
Verbatim wording from the response “In relation to this particular Trust we are exercising our statutory powers to request information and documentation to identify and determine the level of risk to patients. As part of this process we have also already exercised our statutory powers of Inspection (on 10 January 2017) and we are currently liaising with the Trust to ensure that patients are properly protected. The Inspection and the associated regulatory actions are looking at not just the matters identified in the Regulation 28 Report but also wider issues which may impact on safe care and treatment for patients.” Source location 2016-0409-Response-by-Care-Quality-Commission
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Inspect the Trust’s services to assess risks affecting patient safety.
Verbatim wording from the response “In relation to this particular Trust we are exercising our statutory powers to request information and documentation to identify and determine the level of risk to patients. As part of this process we have also already exercised our statutory powers of Inspection (on 10 January 2017) and we are currently liaising with the Trust to ensure that patients are properly protected. The Inspection and the associated regulatory actions are looking at not just the matters identified in the Regulation 28 Report but also wider issues which may impact on safe care and treatment for patients.” Source location 2016-0409-Response-by-Care-Quality-Commission
Open published response
25 Oct 2016 Ivy Atkin · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 2 Lack of reliable independent and objective assessment of Nominated Individual suitability View source Failure to obtain and consider DBS certificates for proposed Nominated Individuals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ivy Atkin · 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
Ivy Atkin was a resident at Autumn Grange Residential Care Home and died as a result of gross neglect. The Provider and its Nominated Individual were convicted of offences arising directly from her death, and an inquest recorded a conclusion of unlawful killing. Concerns included the Nominated Individual’s failure to provide a DBS certificate and a regulatory loophole affecting the independent assessment of suitability for that role.
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 reliable independent and objective assessment of Nominated Individual suitability
Wider context from the report “1. ████████ had criminal convictions including for an offence involving violence against another person. He had not provided a Disclosure and Barring Service (“DBS”) certificate to the CQC nor been asked to do so, before becoming Nominated Individual.
2. The CQC were therefore unable to assess whether or not ████████ was of good character and was suitable for the position of Nominated Individual, that person being responsible for the supervising the management of a Residential Care Home, a role which ████████ undertook.
3. This is because the CQC expected and still expects a Provider to consider DBS certificates and make decisions as to the suitability of a proposed Nominated Individual, where the Provider is (as was here) a limited company.
4. In the case of a small family owned limited company, where the controlling director and Nominated Individual are one and the same person, as in this case, there is therefore no reliable nor independent nor objective means of assessing the good character, safety and suitability of a Nominated Individual.
5. This is because the wording of the present Regulation 6 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 allows for such a “loophole”, and/or in the alternative the manner in which the CQC interprets its powers and duties in the light of this Regulation allows for such a loophole.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 and consider DBS certificates for proposed Nominated Individuals
Wider context from the report “1. ████████ had criminal convictions including for an offence involving violence against another person. He had not provided a Disclosure and Barring Service (“DBS”) certificate to the CQC nor been asked to do so, before becoming Nominated Individual.
2. The CQC were therefore unable to assess whether or not ████████ was of good character and was suitable for the position of Nominated Individual, that person being responsible for the supervising the management of a Residential Care Home, a role which ████████ undertook.
3. This is because the CQC expected and still expects a Provider to consider DBS certificates and make decisions as to the suitability of a proposed Nominated Individual , where the Provider is (as was here) a limited company.
4. In the case of a small family owned limited company, where the controlling director and Nominated Individual are one and the same person, as in this case, there is therefore no reliable nor independent nor objective means of assessing the good character, safety and suitability of a Nominated Individual.
5. This is because the wording of the present Regulation 6 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 allows for such a “loophole”, and/or in the alternative the manner in which the CQC interprets its powers and duties in the light of this Regulation allows for such a loophole.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue reviewing whether to formalise independent checks for cases where a director and nominated individual are the same person.
Verbatim wording from the response “Furthermore, we would require greater assurance where the director and nominated individual is the same person, a situation which is more common amongst small providers. As part of continuing review of the position one option in the future may be to formalise independent checks but work is ongoing to consider how this would operate in practice and where the responsibility would lie in performing such checks.” Source location 2016-0379-Response-by-Care-Quality-Commission
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a registration-application triage system to route higher-risk applications through appropriate processes and streamline lower-risk applications.
Verbatim wording from the response “An issue does however remain that FPPR may potentially be less effective in small providers due to the risk of overlap between directors and nominated individuals or other senior managers and the potential lack of assurance this would provide that proper checks were being carried out. Work is currently underway to evaluate how CQC use the fit and proper person test and it has been identified as part of this work that there continues to be risks within smaller providers. In practice our registration teams may address this risk. Work is underway to develop a triage system for registration applications to ensure that higher risk applications go through an appropriate process, and to streamline our processes for those that are lower risk.” Source location 2016-0379-Response-by-Care-Quality-Commission
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Evaluate how CQC applies the fit-and-proper-person test, including risks arising within smaller providers.
Verbatim wording from the response “An issue does however remain that FPPR may potentially be less effective in small providers due to the risk of overlap between directors and nominated individuals or other senior managers and the potential lack of assurance this would provide that proper checks were being carried out. Work is currently underway to evaluate how CQC use the fit and proper person test and it has been identified as part of this work that there continues to be risks within smaller providers. In practice our registration teams may address this risk. Work is underway to develop a triage system for registration applications to ensure that higher risk applications go through an appropriate process, and to streamline our processes for those that are lower risk.” Source location 2016-0379-Response-by-Care-Quality-Commission
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CQC will not directly check nominated individuals’ DBS records because it lacks power to approve or refuse their appointment as nominated individuals.
Verbatim wording from the response “Having given very careful consideration to the concerns you have raised we have concluded that CQC should not directly check the DBS for Nominated Individuals. This decision was authorised by ████████, Chief Inspector, Adult Social Care.” Source location 2016-0379-Response-by-Care-Quality-Commission
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Providers are responsible for assessing nominated individuals’ suitability and conducting appropriate enquiries, including DBS checks where necessary.
Verbatim wording from the response “3. This is because the CQC expected and still expects a Provider to consider DBS certificates and make decisions as to the suitability of a proposed Nominated Individual, where the Provider is (as was here) a limited company.” Source location 2016-0379-Response-by-Care-Quality-Commission
Open published response
13 Oct 2016 Robert Arthur Davidson · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Failure to train care staff in basic emergency call processes View source Lack of objectively assessed basic training and competence standards for HCAs View source Failure to train care staff in CPR and choking procedures View source Failure to highlight essential patient information during transfers between care homes 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
Robert Arthur 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
Robert Arthur Davidson, who had dementia, Alzheimer’s disease and PICA, died after choking on a plastic glove at a care home on 27 January 2016. The report identified concerns about inadequate transfer of information about his PICA, insufficient staff training and failures in emergency procedures, including calling emergency services and initiating CPR.
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 train care staff in basic emergency call processes
Wider context from the report “1. During the inquest I heard evidence that Health care staff had not been trained on basic process as follows:
• Making 999 calls – to obtain an outside line caller’s needed to first dial “9”. The HCA instructed to make the 999 call did not know this so the call was unsuccessful. The registered nurse looking after the patient whilst he was choking had to make the 999 call resulting in her leaving the patient.
• When to Start CPR. The RGN and HCA (Health Care Assistants) staff had received no training on the CPR and choking policy
The concern is that staff are not trained in basic processes and therefore not able to deal with emergency situations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of objectively assessed basic training and competence standards for HCAs
Wider context from the report “2. The two HCA’s had no experience or basic training before starting work as HCA’s. They had limited understanding of conditions and processes. Consideration needs to be given as to whether there should be mandatory training or minimum standards, which are objectively assessed, to ensure HCA’s have the necessary knowledge and understanding to undertake their role.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to train care staff in CPR and choking procedures
Wider context from the report “1. During the inquest I heard evidence that Health care staff had not been trained on basic process as follows:
• Making 999 calls – to obtain an outside line caller’s needed to first dial “9”. The HCA instructed to make the 999 call did not know this so the call was unsuccessful. The registered nurse looking after the patient whilst he was choking had to make the 999 call resulting in her leaving the patient.
• When to Start CPR. The RGN and HCA (Health Care Assistants) staff had received no training on the CPR and choking policy
The concern is that staff are not trained in basic processes and therefore not able to deal with emergency situations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to highlight essential patient information during transfers between care homes
Wider context from the report “3. The deceased PICA behaviour was not highlighted or identified on his transfer between care homes. Some process or direction from the governing body needs to be provided to care homes to ensure essential information is provided and highlighted when patients are transferred.
” 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 Inspect care homes’ emergency response, staff training, induction, and transfer-risk arrangements, including follow-up checks against the reported concerns.
Verbatim wording from the response “During the course of the CQC focused inspection of Aran Court Care Centre on 09 March 2016, we found systems in place to ensure that nurses had training in emergency first aid. Emergency First Aid at work training provides delegates with an extensive first aid skill set so that they can identify incidents and manage them appropriately, whether the patient is conscious or unconscious. The course is designed to include first aid priorities, managing incidents, basic life support (CPR), unconsciousness, control of bleeding, burns and scolds, recording and reporting First Aid Priorities.” Source location 2016-0363-Response-by-Care-Quality-Commission
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incorporate Care Certificate standards into guidance for providers and assess induction compliance during inspections.
Verbatim wording from the response “CQC refers to the Care Certificate in the ‘Guidance for providers on meeting the regulations. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014’. The guidance states, “That providers must have an induction programme that prepares staff for their role. It is expected that providers that employ healthcare assistants and social care staff support workers, should follow the Care Certificate standards to make sure new staff are supported, skilled and assessed as competent to carry out their roles”. CQC therefore on inspection looks to see if the provider’s induction incorporates the Care Certificate standards.” Source location 2016-0363-Response-by-Care-Quality-Commission
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing emergency first-aid training, shift reminders and staff competence checks were considered sufficient to address emergency response concerns.
Verbatim wording from the response “During the course of the CQC focused inspection of Aran Court Care Centre on 09 March 2016, we found systems in place to ensure that nurses had training in emergency first aid. Emergency First Aid at work training provides delegates with an extensive first aid skill set so that they can identify incidents and manage them appropriately, whether the patient is conscious or unconscious. The course is designed to include first aid priorities, managing incidents, basic life support (CPR), unconsciousness, control of bleeding, burns and scolds, recording and reporting First Aid Priorities.” Source location 2016-0363-Response-by-Care-Quality-Commission
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Care Certificate induction standards and workplace competence assessment were considered sufficient to ensure HCAs had necessary knowledge and skills.
Verbatim wording from the response “The Care Certificate was developed jointly by Skills for Care, Health Education England and Skills for Health, and introduced on 01 April 2015. These Care Certificate standards apply across both social care and health, and link to the national occupational standards. The Care Certificate is designed for new HCA staff, it also offers opportunities for existing staff to refresh or improve their knowledge. The new standards encapsulated in the Care Certificate should ensure that the health and social care workers have the required values, behaviours, competences and skills to provide high quality, compassionate care.” Source location 2016-0363-Response-by-Care-Quality-Commission
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing admission and handover documents were considered sufficient to capture known risks during transfers when completed appropriately.
Verbatim wording from the response “CQC expects that providers should actively work with others, both internal and external, to make sure the care and treatment remains safe for people using the service. When people move between services or providers, Regulation 12(2) (The Regulations) requires providers to undertake appropriate risk assessments to make sure service users’ safety is not compromised. This includes when they move between or to other bodies who may not be registered with CQC. At the inspection on 14 November 2016 at Aran Court Care Centre, we looked at Avery Homes RH Limited’s admission assessment document. This is the provider’s transfer document. Whilst we did not look specifically at Mr Davidson’s transfer document, we saw that if this admission document was completed appropriately and with sufficient detail, the information needed to ensure that where people were known to be at risk would be captured.” Source location 2016-0363-Response-by-Care-Quality-Commission
Open published response
Concerns raised 1 Failure to book follow-up appointments for discharged patients 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
Roy Gordon Millar · 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
Roy Gordon Millar attended hospital with slurred speech and facial droop, and scans identified an abnormality requiring follow-up. The repeat scan results were not sent to the correct consultant, and a requested outpatient appointment was not arranged. A brain tumour was identified after he re-presented with a more severe facial droop, but he died on the date planned for biopsy and debulking surgery; the report also describes failures to book follow-up appointments affecting approximately 146 patients.
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 book follow-up appointments for discharged patients
Wider context from the report “PHNT instigated a Root Cause Analysis following this incident, a copy of which is enclosed. ████████ the author of the Report and the Trust’s Patient Safety Lead, attended the Inquest. During the course of the hearing it emerged that the Ward Administrat or in the Neurology Department had been recently appointed. She had been trained by her predecessor. Neither the previous nor the current Ward Administrator were aware of their responsibility to book follow-up appointments for patients who had been discharged. Their understanding was that appointments would be arranged by Consultants’ secretaries and it seems apparent that a large number of appointments were made in this way.
It emerged during the course of the Inquest that the Ward Administrators in the Neurology Department had not booked follow-up appointments for approximately 26 months. As you will see from the enclosed Root Cause Analysis, PHNT has reviewed 1000 patient admissions and it has revealed that 146 patients die not have follow-up appointments booked .
In Mr Millar’s case the evidence I heard was that the follow-up scan being conducted in June 2015 was likely to have led to a biopsy which would have diagnosed the brain tumour. If Mr Millar had undergone earlier surgery, the Inquest heard that he would have had a 50% chance of surviving for a year.
” Open source report
7 Sep 2016 Glen Jordan · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 1 Failure to safely balance removal and retention of patients’ personal items in rooms 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
Glen Jordan · 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
Glen Jordan, who had a history of depression and suicidal thoughts, was admitted to Bushey Fields Hospital as an informal patient on 20 April 2016. He was found hanging with the strap from a holdall in his room at around 2am on 24 April 2016 and died shortly afterwards. The principal concern was the balance between removing potentially hazardous personal items and allowing patients to retain personal belongings under least restrictive policies; the inquest also identified a failure to respond to an obvious risk of self-harm.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to safely balance removal and retention of patients’ personal items in rooms
Wider context from the report “1. Evidence emerged during the inquest that the holdall bag with the attached strap was left in his room after being checked by staff . There is a fine balance that needs to be reached in terms of removing personal items and allowing patients to keep their personal items within their room as per guidelines for least restrictive policies .
” Open source report
7 Aug 2016 Mr. Rohan Fitzsimons · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Insufficient availability of in-patient mental health beds when detention is required following a Mental Health Act Assessment View source Failure to carry out required Mental Health Act Assessments promptly when a bed is unavailable View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr. Rohan Fitzsimons · 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. Rohan Fitzsimons, who had been detained under the Mental Health Act and was receiving inpatient psychiatric care, died after jumping from Clifton Suspension Bridge while on unescorted leave on 25 November 2015. The principal concern was that a necessary Mental Health Act Assessment was delayed for four days because no inpatient bed was available, with evidence that this commonly occurred and that assessments were not carried out until a bed became available.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of in-patient mental health beds when detention is required following a Mental Health Act Assessment
Wider context from the report “(1) The Avon & Wiltshire Mental Health Partnership NHS Trust (AWP) told the Inquest that the provision of in-patient beds is subject to the funding provided by the Bristol Clinical Commissioning Group (CCG) .
(2) The Inquest heard evidence that no Mental Health Act Assessment was carried out on the Deceased when it was determined to be necessary because no bed was available and that this was a situation which commonly occurred .
(3) In the case of the Deceased the assessment was not performed until four days after it was deemed necessary and was only carried out once a bed was available. Whilst the Inquest did not hear evidence to indicate that the delay in carrying out the Mental Health Act Assessment contributed to the Deceased taking his own life it must follow that in some circumstances such a delay could lead to an individual taking their own life before the assessment was performed and a bed was made available.
(4) The CCG should review urgently its commissioning of in-patient mental health beds so as to ensure, in so far as reasonably practicable, that a bed is available when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment .
The CCG should work with AWP in carrying out this review and determine what action can and should be taken when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment but no bed is available. If a person meets the criteria for a Mental Health Act Assessment such an assessment should be carried out promptly and not be delayed for an indeterminate period owing to a lack of beds.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 required Mental Health Act Assessments promptly when a bed is unavailable
Wider context from the report “(1) The Avon & Wiltshire Mental Health Partnership NHS Trust (AWP) told the Inquest that the provision of in-patient beds is subject to the funding provided by the Bristol Clinical Commissioning Group (CCG).
(2) The Inquest heard evidence that no Mental Health Act Assessment was carried out on the Deceased when it was determined to be necessary because no bed was available and that this was a situation which commonly occurred.
(3) In the case of the Deceased the assessment was not performed until four days after it was deemed necessary and was only carried out once a bed was available . Whilst the Inquest did not hear evidence to indicate that the delay in carrying out the Mental Health Act Assessment contributed to the Deceased taking his own life it must follow that in some circumstances such a delay could lead to an individual taking their own life before the assessment was performed and a bed was made available .
(4) The CCG should review urgently its commissioning of in-patient mental health beds so as to ensure, in so far as reasonably practicable, that a bed is available when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment.
The CCG should work with AWP in carrying out this review and determine what action can and should be taken when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment but no bed is available. If a person meets the criteria for a Mental Health Act Assessment such an assessment should be carried out promptly and not be delayed for an indeterminate period owing to a lack of beds .
” Open source report
25 Jul 2016 Patricia Ann Cleghorn · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Unavailability of acute mental health inpatient beds View source Limited resources and care for vulnerable people in the community View source Failure to control access to available medication for a person at risk of overdose View source Failure to undertake a formal suicide and overdose risk assessment View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Patricia Ann Cleghorn · 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
Patricia Ann Cleghorn, who had suicidal ideation and was awaiting an inpatient mental health bed, was found collapsed at home after receiving diazepam and was declared dead by paramedics on 14 December 2015. The concerns were the lack of an available inpatient bed, allowing her to self-medicate with potentially dangerous drugs despite repeated statements that she intended to overdose, and the absence of a formal risk assessment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Unavailability of acute mental health inpatient beds
Wider context from the report “(1) The deceased could not be admitted to hospital as there were no inpatient beds available . I heard evidence at the inquest that had she been admitted it is unlikely she would have died when she did. The availability of acute mental health beds means the most vulnerable people are being cared for in the community with limited resources and care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Limited resources and care for vulnerable people in the community
Wider context from the report “(1) The deceased could not be admitted to hospital as there were no inpatient beds available. I heard evidence at the inquest that had she been admitted it is unlikely she would have died when she did. The availability of acute mental health beds means the most vulnerable people are being cared for in the community with limited resources and care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to control access to available medication for a person at risk of overdose
Wider context from the report “(2) The deceased had repeatedly stated that she would end her life by taking an overdose. Despite this she was left at home self-medicating drugs including amitriptyline, MST and oromorph . No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available 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 Failure to undertake a formal suicide and overdose risk assessment
Wider context from the report “(2) The deceased had repeatedly stated that she would end her life by taking an overdose. Despite this she was left at home self-medicating drugs including amitriptyline, MST and oromorph. No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her.
” 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 Meet with the Trust in December 2016 to review the impact of its action plans and monitor continued action to minimise risks to vulnerable people.
Verbatim wording from the response “A quarterly meeting between CQC and the Trust took place 15th September 2016 where we discussed what actions they had taken. We will be meeting with the Trust again in December 2016 to review the impact of their action plans.” Source location 2016-0270-Response-by-Care-Quality-Commission
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provision of acute mental health beds rests with the Trust and clinical commissioning groups.
Verbatim wording from the response “There remains a shortage of acute beds in this Trust and in other Mental Health Trusts in the region. This shortage will continue to impact on vulnerable people in the community. The provision of acute mental health beds rests with the Trust and with the clinical commissioning groups (CCGs). The role of the CCGs is to get the best possible health outcomes for the local population, by assessing local needs, deciding priorities and strategies, and then buying services (including mental health services) on behalf of the population from providers such as this Trust. The CCGs also check on the quality and safety of such services.” Source location 2016-0270-Response-by-Care-Quality-Commission
Open published response
28 Jun 2016 Tommi-Ray Colin Vigrass · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 5 Inadequate preparation and care planning for the arrival of a premature baby View source Failure to consult the on-call consultant before making extubation decisions View source Failure to use the CO2 monitor early enough View source Inadequate handover for the arrival of a premature baby View source Delays and problems in contacting the tertiary unit through the switchboard 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
Tommi-Ray Colin Vigrass · 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
Tommi-Ray Colin Vigrass was born prematurely at 28+2 weeks’ gestation and developed respiratory distress requiring ventilator support. Following difficulties with changing and re-inserting his endotracheal tube, he suffered a hypoxic episode and significant brain damage, and died on 13 January 2016. Concerns included the decision-making around extubation and intubation, delayed contact with the tertiary unit, and inadequate handover and preparation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Inadequate preparation and care planning for the arrival of a premature baby
Wider context from the report “3. There was also evidence of an inadequate handover and preparation for the arrival of the premature baby with insufficient care plan details or consultation taking place .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to consult the on-call consultant before making extubation decisions
Wider context from the report “1. Evidence emerged during the inquest that the Paediatric Doctor in charge recognised that it was a mistake to extubate baby when he did. His words were: “What should have been a straight forward ET change turned into a nightmare”. He also confirmed that he should have consulted the Consultant on call prior to making the decision and earlier use of the CO2 monitor would have made a difference.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to use the CO2 monitor early enough
Wider context from the report “1. Evidence emerged during the inquest that the Paediatric Doctor in charge recognised that it was a mistake to extubate baby when he did. His words were: “What should have been a straight forward ET change turned into a nightmare”. He also confirmed that he should have consulted the Consultant on call prior to making the decision and earlier use of the CO2 monitor would have made a difference .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 handover for the arrival of a premature baby
Wider context from the report “3. There was also evidence of an inadequate handover and preparation for the arrival of the premature baby with insufficient care plan details or consultation taking place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Delays and problems in contacting the tertiary unit through the switchboard
Wider context from the report “2. In addition, it emerged that there were problems and delays in trying to contact the tertiary unit via the switchboard .
” Open source report
8 Jun 2016 Mrs Clarke “Betty” · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 2 Failure of staff to report injuries View source Delays in staff escalation of allegations of staff-inflicted harm 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 Clarke “Betty” · 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 Clarke “Betty”, also identified as Gwendoline Betty Clarke, sustained multiple fractures and other injuries during a significant incident at her care home on 28 December 2014. She was admitted to hospital, subsequently deteriorated with respiratory failure and sepsis, and died on 31 December 2014; concerns were that staff did not report the injury or promptly escalate her allegation that a member of staff had hurt her.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to report injuries
Wider context from the report “(1) No member of staff reported the injury that Betty sustained , and
(2) No member of staff escalated Betty’s allegations that a member of staff had hurt her until approximately 12 hours after she first made the allegation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 staff escalation of allegations of staff-inflicted harm
Wider context from the report “(1) No member of staff reported the injury that Betty sustained, and
(2) No member of staff escalated Betty’s allegations that a member of staff had hurt her until approximately 12 hours after she first made the allegation .
” Open source report
1 Jun 2016 Rhi anne Anoushka Florence BARTON · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 7 Failure to accurately record routine observations, fluid balance and gastrointestinal losses View source Failure to make specific obstetric care plans for pregnancy and labour after bariatric surgery View source Failure to provide timely obstetric consultant supervision after emergency admission View source Lack of specific clinical guidance on obstetric care after bariatric surgery View source Failure to act on markedly abnormal urine glucose findings View source Delays in undertaking appropriate investigations for unexplained abdominal pain View source Failure to consider surgical causes of abdominal symptoms after bariatric surgery 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
Rhi anne Anoushka Florence BARTON · 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
Rhi anne Barton developed severe abdominal pain and vomiting at 35 weeks of pregnancy after previous bariatric surgery and was later found to have a small bowel obstruction. She aspirated during induction of anaesthesia before surgery, developed severe physiological compromise and died in the early hours of 13 February 2015. The principal concerns included delays in investigation, diagnosis and surgical management, lack of consultant supervision, inadequate documentation and fluid monitoring, and insufficient consideration of surgical causes associated with previous bariatric surgery.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record routine observations, fluid balance and gastrointestinal losses
Wider context from the report “4. Evidence was presented of poor documentation of routine observations and an incomplete fluid balance chart . No accurate records were kept with regard to fluid intake and urine output . It was not possible to assess the amount, frequency and volume of the vomitus . There was no evidence of diarrhoea despite a diagnosis of gastroenteritis . A urine dipstick was undertaken which revealed 4+ of glucose but no action was undertaken with regard to the finding.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 specific obstetric care plans for pregnancy and labour after bariatric surgery
Wider context from the report “5. The obstetric consultant made no specific plans with regard to the obstetric care that Rhi anne would receive during pregnancy and labour despite knowing that she had undergone bariatric surgery . I also heard evidence that bariatric surgery was becoming increasingly common but the Royal College of Obstetrics and Gynaecology had not specifically addressed this issue in their guidance to practicing clinicians.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely obstetric consultant supervision after emergency admission
Wider context from the report “1. Rhi anne’s named obstetric consultant was not informed of her emergency admission . Although there was a consultant obstetrician on the ward on the 11th February there was no request for Rhi anne to be seen and in any event it was not common practice for patients to be seen by another consultant. As such there was no obstetric consultant supervision of Rhi anne from the time of admission until shortly before her surgery; approximately 43 hours after admission .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of specific clinical guidance on obstetric care after bariatric surgery
Wider context from the report “5. The obstetric consultant made no specific plans with regard to the obstetric care that Rhi anne would receive during pregnancy and labour despite knowing that she had undergone bariatric surgery. I also heard evidence that bariatric surgery was becoming increasingly common but the Royal College of Obstetrics and Gynaecology had not specifically addressed this issue in their guidance to practicing clinicians .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to act on markedly abnormal urine glucose findings
Wider context from the report “4. Evidence was presented of poor documentation of routine observations and an incomplete fluid balance chart. No accurate records were kept with regard to fluid intake and urine output. It was not possible to assess the amount, frequency and volume of the vomitus. There was no evidence of diarrhoea despite a diagnosis of gastroenteritis. A urine dipstick was undertaken which revealed 4+ of glucose but no action was undertaken with regard to the finding .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 undertaking appropriate investigations for unexplained abdominal pain
Wider context from the report “3. I also heard evidence that whilst the rarity of an omental band may make it difficult to diagnose there was still a responsibility to exclude other causes of abdominal pain in the absence of an obstetric cause , by undertaking appropriate investigations in a timely fashion .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to consider surgical causes of abdominal symptoms after bariatric surgery
Wider context from the report “2. No consideration was given to excluding a surgical cause of Rhi anne’s symptoms despite the history of sudden onset of upper abdominal pain in the knowledge that she had had bariatric surgery . I heard evidence that bariatric surgery can, not infrequently, result in an omental/internal hernia causing small bowel obstruction but that it was not widely understood and should be given greater recognition nationally as more women are becoming pregnant following bariatric surgery.
” Open source report
16 May 2016 Mr Critall · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 23 Minimal respiratory consultant documentation View source Outdated chest drain management protocol lacking complication actions View source Use of 6 f gauge pigtail catheters for pleural effusions without supporting evidence View source Excessive patient caseloads and unclear experience among senior resident medical staff View source Failure to document clinical examination View source Failure to complete consent detailing chest drain complications View source Failure to request repeat inflammatory markers View source Poor communication of the post-procedure care plan to ward staff View source Failure to use a WHO checklist for radiological interventions View source Proactive chest drain insertion without objective clinical evidence View source Absence of a documented management plan View source Failure to use real-time ultrasound guidance for chest drain insertion View source Failure to establish clinical necessity for chest drain insertion View source Lack of Acute or Basic Life Support training for the radiologist View source Reliance on emergency paramedic attendance to provide hospital care before transfer View source Insufficient nursing competence in resuscitation and chest drain management View source Lack of independent radiological indications for chest drain insertion View source Chest drain insertion decisions influenced by the day of the week View source Failure to radiologically confirm the position of a non-draining chest drain View source Failure to record observations before and after chest drain procedures View source Admission of acutely unwell patients without onsite HDU/ITU facilities View source Absence of operational protocols for hospital emergency situations View source Absence of HDU or ITU capability for hospital emergency situations View source See 20 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 Critall · 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 Critall, an 80-year-old man, developed a haemothorax after insertion of a chest drain while being treated for pneumonia and died on 6 July 2014 after further deterioration and emergency treatment. The report raised concerns about the necessity and technique of the drain insertion, the failure to confirm its position, inadequate monitoring and resuscitation, and the hospital’s lack of appropriate emergency facilities and protocols. It also recorded that his family were not contacted after he became unwell or died.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Minimal respiratory consultant documentation
Wider context from the report “11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission . There was no management plan in place, no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Outdated chest drain management protocol lacking complication actions
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 6 f gauge pigtail catheters for pleural effusions without supporting evidence
Wider context from the report “8. The use of a 6 f gauge pig tail catheter in the management of pleural effusions with or without an empyema was against both national guidelines and expert evidence heard at inquest and was unsupported by either international research or any recent local audits undertaken to justify their use in preference for larger small bore chest drains .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 patient caseloads and unclear experience among senior resident medical staff
Wider context from the report “1. The admission of an acutely unwell patient with pneumonia to a private hospital dealing primarily with elective surgical procedures with no HDU/ITU facilities in case of deterioration. The most senior doctor in the hospital, other than visiting clinicians was an RMO of unclear experience who usually has the care of more than 50 patients at any one time but can be as many as 72 . This is alongside nursing staff who have no significant grounding in resuscitation and an unclear understanding of chest drain insertion for pneumonic pleural effusions, usually having to deal with malignant pleural effusions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 clinical examination
Wider context from the report “11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission. There was no management plan in place, no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to complete consent detailing chest drain complications
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications , radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to request repeat inflammatory markers
Wider context from the report “11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission. There was no management plan in place, no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Poor communication of the post-procedure care plan to ward staff
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to use a WHO checklist for radiological interventions
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist , no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Proactive chest drain insertion without objective clinical evidence
Wider context from the report “9. The court heard evidence there was a ‘local’ proactive approach for the insertion of chest drains based on no objective evidence other than a belief that the very smallest catheters were safer and more comfortable and reduced referral for surgical management of an empyema. This view was against expert evidence at inquest and concern was raised that this approach inevitably led to an excess of chest drains being inserted unnecessarily particularly when BTS guidelines were not being routinely applied and/or no evidence of a developing or actual empyema.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Absence of a documented management plan
Wider context from the report “11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission. There was no management plan in place , no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to use real-time ultrasound guidance for chest drain insertion
Wider context from the report “5. Real time ultrasound visualisation was not used to guide the chest drain insertion against ‘best practice’ . I was led to believe ‘best practice’ was not commonly practiced at the Royal Surrey County Hospital and in many other hospitals nationally. I also heard evidence real time ultrasound visualisation would have assisted the insertion as the effusion was small and lay in an awkward position close to tethering of the lung to the chest wall (which was not documented in the hospital notes or radiologist’s statement but was clearly present on ultrasound pictures examined by ████████ and acknowledged to be present by the radiologist who undertook the chest drain insertion in oral testimony).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 clinical necessity for chest drain insertion
Wider context from the report “3. The insertion of a chest drain on the 4th July was not supported by British Thoracic Society (BTS) guidelines and was attempted on a background of an improving clinical picture without repeat of relevant investigations (e.g. inflammatory markers) or evidence of a developing or actual empyema or a further medical review, by either the radiologist or responsible clinician, to confirm its necessity .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 Acute or Basic Life Support training for the radiologist
Wider context from the report “10. The radiologist did not have Acute or Basic Life Support training as would be expected for all clinical hospital staff as part of mandatory training for NHS appointments.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Reliance on emergency paramedic attendance to provide hospital care before transfer
Wider context from the report “2. The absence of operational protocols and a HDU/ITU facility to manage emergency situations and a reliance on a 999 call for paramedics to provide care for a hospital who undertakes such procedures prior to transferring an unwell patient to an NHS hospital .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Insufficient nursing competence in resuscitation and chest drain management
Wider context from the report “1. The admission of an acutely unwell patient with pneumonia to a private hospital dealing primarily with elective surgical procedures with no HDU/ITU facilities in case of deterioration. The most senior doctor in the hospital, other than visiting clinicians was an RMO of unclear experience who usually has the care of more than 50 patients at any one time but can be as many as 72. This is alongside nursing staff who have no significant grounding in resuscitation and an unclear understanding of chest drain insertion for pneumonic pleural effusions , usually having to deal with malignant pleural effusions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 independent radiological indications for chest drain insertion
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant , a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Chest drain insertion decisions influenced by the day of the week
Wider context from the report “4. I heard evidence that the insertion of a chest drain may pre-empt difficulties that may arise if Mr Critall deteriorated over the approaching weekend. This was contrary to expert evidence that chest drain insertion should only be considered as a necessity and should not be influenced by the day of the week .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to radiologically confirm the position of a non-draining chest drain
Wider context from the report “6. The position of the non-draining (second attempt) chest drain was not radiologically confirmed, against expected practice, particularly as it was not draining . I heard exert evidence that this resulted in a delay in the recognition and prompt management of the haemothorax which contributed to Mr Critall’s 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 record observations before and after chest drain procedures
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Admission of acutely unwell patients without onsite HDU/ITU facilities
Wider context from the report “1. The admission of an acutely unwell patient with pneumonia to a private hospital dealing primarily with elective surgical procedures with no HDU/ITU facilities in case of deterioration . The most senior doctor in the hospital, other than visiting clinicians was an RMO of unclear experience who usually has the care of more than 50 patients at any one time but can be as many as 72. This is alongside nursing staff who have no significant grounding in resuscitation and an unclear understanding of chest drain insertion for pneumonic pleural effusions, usually having to deal with malignant pleural effusions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Absence of operational protocols for hospital emergency situations
Wider context from the report “2. The absence of operational protocols and a HDU/ITU facility to manage emergency situations and a reliance on a 999 call for paramedics to provide care for a hospital who undertakes such procedures prior to transferring an unwell patient to an NHS hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Absence of HDU or ITU capability for hospital emergency situations
Wider context from the report “2. The absence of operational protocols and a HDU/ITU facility to manage emergency situations and a reliance on a 999 call for paramedics to provide care for a hospital who undertakes such procedures prior to transferring an unwell patient to an NHS hospital.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations