24 Mar 2026 Ronald William MEIKLE · Prevention of Future Deaths report Milton Keynes
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Concerns raised 16 Weak supervision and staff-prisoner engagement View source Failure to maintain a clear and current drug under the influence policy View source Delays or insufficiency in psychiatric assessment and proactive mental health review View source Failure to recognise suspected synthetic cannabinoid intoxication promptly during collapse response View source Insufficient staffing capacity View source Restricted prison regimes View source Insufficiently robust identification and management of prisoners remaining behind their door because of vulnerability View source Inadequate welfare observations View source Inconsistent identification, assessment, monitoring and response to prisoners under the influence of illicit substances View source Failure to escalate prisoners with cumulative vulnerability indicators into safer custody procedures View source Availability of illicit substances in custody View source Failure to reliably consolidate and share relevant prisoner risk information View source Failure to maintain unobstructed observation panels for effective visual welfare checks View source Delays in supplying material information relevant to death investigations and future-death prevention View source Failure to implement sufficient and sustained remedial action on identified prison safety concerns View source Failure to recognise IPP status as a material vulnerability requiring structured support and review View source See 13 more concerns
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AI-generated summary
Ronald William MEIKLE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ronald William Meikle was found unresponsive in his single-occupancy cell at HMP Woodhill on 30 April 2024 and was pronounced dead at 09:43. The report identified concerns about illicit substances, inconsistent responses to suspected intoxication, fragmented information-sharing, inadequate welfare observations, management of self-isolation and vulnerability, absence of ACCT proceedings, mental-health input, emergency response, staffing, and recurring systemic problems at the prison.
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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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Weak supervision and staff-prisoner engagement
Wider context from the report “Concern 10: Staffing, supervision and regime limitations
The evidence before the court, including wider inspection material, raised concern that staffing pressures, weak supervision, poor staff-prisoner engagement , restricted regimes, and inadequate welfare observations may materially increase the risk of undetected drug use, delayed discovery of collapsed prisoners and failure to identify vulnerable men in need of intervention.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a clear and current drug under the influence policy
Wider context from the report “Concern 2: Failure consistently to identify, record and respond to prisoners under the influence
The evidence showed concerns about the consistency with which prisoners suspected or found to be under the influence of illicit substances were identified, clinically assessed, monitored, referred to substance misuse services, and managed under prison and healthcare processes. There was evidence that episodes of apparent intoxication were not always met with a consistent healthcare response or documented follow-up. The head of service had an understanding of the drug under the influence policy that was starkly different to the written document . There had been multiple updates of the drug policy which were difficult to identify as to when the policy was updated / revised . I am concerned that prisoners at acute risk of overdose or deterioration may therefore not receive timely intervention.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays or insufficiency in psychiatric assessment and proactive mental health review
Wider context from the report “Concern 8: Delay or insufficiency in mental health and psychiatric input
The evidence raised concern that prisoners with known vulnerabilities, substance misuse history and symptoms of deteriorating mental health may not always receive timely psychiatric assessment or sufficiently proactive mental health review . Delays in specialist assessment can increase the risk of unmanaged distress, relapse to substance use and 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise suspected synthetic cannabinoid intoxication promptly during collapse response
Wider context from the report “Concern 9: Emergency response to suspected synthetic cannabinoid collapse
The evidence raised concern about whether staff responding to collapse were adequately trained and equipped to consider synthetic cannabinoid intoxication promptly as a possible cause . Synthetic cannabinoid use can cause rapid deterioration and death. If staff do not recognise that possibility, there is a risk of delay in appropriate emergency action, clinical escalation and treatment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing capacity
Wider context from the report “Concern 10: Staffing, supervision and regime limitations
The evidence before the court, including wider inspection material, raised concern that staffing pressures , weak supervision, poor staff-prisoner engagement, restricted regimes, and inadequate welfare observations may materially increase the risk of undetected drug use, delayed discovery of collapsed prisoners and failure to identify vulnerable men in need of intervention.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Restricted prison regimes
Wider context from the report “Concern 10: Staffing, supervision and regime limitations
The evidence before the court, including wider inspection material, raised concern that staffing pressures, weak supervision, poor staff-prisoner engagement, restricted regimes , and inadequate welfare observations may materially increase the risk of undetected drug use, delayed discovery of collapsed prisoners and failure to identify vulnerable men in need of intervention.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust identification and management of prisoners remaining behind their door because of vulnerability
Wider context from the report “Concern 5: Management of self-isolation, debt, fear and vulnerability
The evidence suggested that Mr Meikle had vulnerabilities connected to self-isolation, debt, fear of other prisoners, possible coercion or bullying, mental ill-health, and substance misuse. I am concerned that the systems for identifying and managing prisoners who remain behind their door because of debt, fear, vulnerability or drug-related pressures were not sufficiently robust, coordinated or escalated .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate welfare observations
Wider context from the report “Concern 10: Staffing, supervision and regime limitations
The evidence before the court, including wider inspection material, raised concern that staffing pressures, weak supervision, poor staff-prisoner engagement, restricted regimes, and inadequate welfare observations may materially increase the risk of undetected drug use, delayed discovery of collapsed prisoners and failure to identify vulnerable men in need of intervention.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent identification, assessment, monitoring and response to prisoners under the influence of illicit substances
Wider context from the report “Concern 2: Failure consistently to identify, record and respond to prisoners under the influence
The evidence showed concerns about the consistency with which prisoners suspected or found to be under the influence of illicit substances were identified, clinically assessed, monitored, referred to substance misuse services, and managed under prison and healthcare processes . There was evidence that episodes of apparent intoxication were not always met with a consistent healthcare response or documented follow-up . The head of service had an understanding of the drug under the influence policy that was starkly different to the written document. There had been multiple updates of the drug policy which were difficult to identify as to when the policy was updated / revised. I am concerned that prisoners at acute risk of overdose or deterioration may therefore not receive timely intervention.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate prisoners with cumulative vulnerability indicators into safer custody procedures
Wider context from the report “Concern 6: Absence of ACCT despite identifiable indicators of vulnerability
The concern is not that ACCT documentation disclosed a missed risk factor, but that the available materials show Mr Meikle was not subject to ACCT proceedings, despite evidence shortly before death of self-isolation, debt-related vulnerability, known substance misuse and reduced engagement. This occurred in an establishment where HM Inspectorate of Prisons had already identified weaknesses in ACCT management and welfare checking during an unannounced inspection in 2023 and had issued an Urgent Notification which included reference to "frailties in ACCT case management". I later became aware of a second Urgent Notification issued in March 2026, shortly after completion of Mr Meikle's inquest that once again identified "frailties in ACCT case management". I am concerned that prisoners presenting with cumulative indicators of vulnerability may not be escalated into safer custody procedures when required , thereby increasing the risk that deteriorating welfare is not recognised or managed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Availability of illicit substances in custody
Wider context from the report “Concern 1: Availability of illicit substances in custody
The evidence indicated that illicit drugs ████████ were readily available within HMP Woodhill . Material before the court showed this was not an isolated issue but part of a wider and continuing prison safety problem at HMP Woodhill and likely other prisons . The availability of synthetic cannabinoids in custody creates a foreseeable risk of sudden collapse, respiratory compromise, cardiac arrest, psychosis, violence, self-harm and 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably consolidate and share relevant prisoner risk information
Wider context from the report “Concern 3: Fragmented information-sharing and record keeping
The evidence demonstrated that relevant risk information was spread across multiple recording systems and was not always shared effectively between operational staff and clinical teams . This included information relevant to substance misuse, mental health, debt, bullying or coercion, self-isolation, intelligence about threats, recent presentation under the influence. Where critical safety information is held in separate systems and not reliably brought together , there is a foreseeable risk that warning signs will be missed and protective action delayed with obvious risk of harm or death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain unobstructed observation panels for effective visual welfare checks
Wider context from the report “Concern 4: Blocked observation panels and inadequate visual welfare checks
The evidence raised serious concern that blocked observation panels were not consistently challenged or cleared , and that visual welfare checks were therefore not always effective . The jury heard evidence that officers deliberately avoided opening blocked hatches to escape abuse from the prisoners then or later. In a prison environment where prisoners may be intoxicated, unconscious, self-harming, assaulted, or otherwise incapacitated behind a locked door, failure to maintain an unobstructed observation panel creates an obvious risk of late discovery and preventable 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in supplying material information relevant to death investigations and future-death prevention
Wider context from the report “Concern 12: Failure of state agencies to supply all information in a timely fashion.
In this Inquest I was presented with material information at the eleventh hour . Aside from being discourteous to the family and the Court such tardy provision has potential to frustrate a full investigation into the death and allow elements of care which may impact on future deaths to pass unnoticed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement sufficient and sustained remedial action on identified prison safety concerns
Wider context from the report “Concern 11: Repeated systemic concerns at HMP Woodhill
Material before the court from oversight and inspection bodies demonstrated that concerns about drugs, safety, violence, self-isolation, observation panel compliance, ACCT weaknesses and welfare monitoring at HMP Woodhill had been identified over time. I am concerned that repeated identification of these issues has not resulted in sufficient or sustained remedial action , creating an ongoing risk of further deaths .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise IPP status as a material vulnerability requiring structured support and review
Wider context from the report “Concern 7: Particular vulnerability of prisoners serving IPP (Imprisonment for Public Protection) sentences
The evidence showed that prisoners serving IPP sentences may experience hopelessness, chronic frustration, deterioration in mental health and increased vulnerability to substance misuse and self-neglect . I am concerned that Mr Meikle's IPP status was not sufficiently recognised as a material risk factor requiring structured support, regular review and coordinated care .
” 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 Introduce risk-based triage to prioritise prisoners at highest risk.
Verbatim wording from the response “Concern 2: Identification, recording and response to prisoners under the influence:
We have clarified clinical roles and expectations, strengthened governance, and introduced additional audit measures within the addictions team to monitor referral timeliness and escalation. We have jointly developed a ‘SPICE’ policy and local operating procedure (LOP) that provides clear clinical guidance for assessing and managing intoxication. We have introduced a new risk-based triage model that” Source location Response from Central & North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and implement the SPICE policy and local operating procedure for assessing and managing intoxication.
Verbatim wording from the response “Concern 2: Identification, recording and response to prisoners under the influence:
We have clarified clinical roles and expectations, strengthened governance, and introduced additional audit measures within the addictions team to monitor referral timeliness and escalation. We have jointly developed a ‘SPICE’ policy and local operating procedure (LOP) that provides clear clinical guidance for assessing and managing intoxication. We have introduced a new risk-based triage model that” Source location Response from Central & North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Subject people experiencing prolonged isolation to structured review, including mental-health assessment and ongoing welfare monitoring where required.
Verbatim wording from the response “Concern 5: Management of self-isolation, debt, fear and vulnerability
We are working with staff to ensure that individuals identified as experiencing prolonged isolation are subject to structured review processes, including mental health assessment and ongoing welfare monitoring, where required. Concerns relating to isolation, debt and vulnerability are raised by staff within regular multidisciplinary forums and more complex cases are reviewed regularly.” Source location Response from Central & North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clarify clinical roles and expectations and strengthen addictions-team governance through additional referral-timeliness and escalation audits.
Verbatim wording from the response “Concern 2: Identification, recording and response to prisoners under the influence:
We have clarified clinical roles and expectations, strengthened governance, and introduced additional audit measures within the addictions team to monitor referral timeliness and escalation. We have jointly developed a ‘SPICE’ policy and local operating procedure (LOP) that provides clear clinical guidance for assessing and managing intoxication. We have introduced a new risk-based triage model that” Source location Response from Central & North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve waiting-list management by setting escalation thresholds, increasing remote clinics and reviewing priority weekly by clinical risk and waiting time.
Verbatim wording from the response “Concern 8: Delay or insufficiency of mental health and psychiatric input
We have worked on our waiting list management, setting clearer escalation thresholds, and increasing the use of remote clinics. The mental health and clinical leads review waiting lists every week and prioritise patients based on clinical risk and time waiting to ensure timely assessment and follow-up. We have also expanded clinical capacity by introducing advanced clinical practitioner roles to support routine reviews, while escalating more complex cases directly to consultant psychiatrists. Recruiting to substantive consultant posts remains a key priority for the service.” Source location Response from Central & North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise isolation, debt and vulnerability concerns in multidisciplinary forums and regularly review complex cases.
Verbatim wording from the response “Concern 5: Management of self-isolation, debt, fear and vulnerability
We are working with staff to ensure that individuals identified as experiencing prolonged isolation are subject to structured review processes, including mental health assessment and ongoing welfare monitoring, where required. Concerns relating to isolation, debt and vulnerability are raised by staff within regular multidisciplinary forums and more complex cases are reviewed regularly.” Source location Response from Central & North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train clinical staff to recognise deterioration using NEWS2 and reinforce escalation pathways across services.
Verbatim wording from the response “Concern 9: Emergency response to suspected synthetic cannabinoid collapse
We have improved staff capability to recognise deterioration linked to synthetic cannabinoid use by providing structured assessment tools, clear escalation expectations, and more visible clinical leadership. All CNWL clinical staff receive training in recognising deterioration using the NEWS2 protocol, and we have reinforced clear escalation pathways across our services, ensuring every clinician understands how and when to escalate concerns. We actively participate in joint simulation exercises and contribute to prison-led first aid and emergency response” Source location Response from Central & North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide structured assessment tools, escalation expectations and clinical leadership to improve recognition and response to synthetic-cannabinoid deterioration.
Verbatim wording from the response “Concern 9: Emergency response to suspected synthetic cannabinoid collapse
We have improved staff capability to recognise deterioration linked to synthetic cannabinoid use by providing structured assessment tools, clear escalation expectations, and more visible clinical leadership. All CNWL clinical staff receive training in recognising deterioration using the NEWS2 protocol, and we have reinforced clear escalation pathways across our services, ensuring every clinician understands how and when to escalate concerns. We actively participate in joint simulation exercises and contribute to prison-led first aid and emergency response” Source location Response from Central & North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise handover documentation, including a prompt to identify information requiring sharing with prison colleagues.
Verbatim wording from the response “Concern 3: Information sharing and record keeping.
Handover documentation has been revised. This has improved identification and escalation of concerns to prison colleagues. We are ensuring that healthcare attend multidisciplinary forums, weekly Safety Intervention Meetings, and daily wing briefings. We have added a prompt to our handover to ensure that staff consider what information needs to be shared with prison colleagues.” Source location Response from Central & North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate in joint simulation exercises and prison-led first-aid and emergency-response training.
Verbatim wording from the response “Concern 9: Emergency response to suspected synthetic cannabinoid collapse
We have improved staff capability to recognise deterioration linked to synthetic cannabinoid use by providing structured assessment tools, clear escalation expectations, and more visible clinical leadership. All CNWL clinical staff receive training in recognising deterioration using the NEWS2 protocol, and we have reinforced clear escalation pathways across our services, ensuring every clinician understands how and when to escalate concerns. We actively participate in joint simulation exercises and contribute to prison-led first aid and emergency response” Source location Response from Central & North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve governance oversight of Health and Justice services at HMP Woodhill.
Verbatim wording from the response “Concern 11: Repeated systemic concerns at HMP Woodhill
Governance oversight of Health and Justice services at HMP Woodhill has been improved. We are undertaking a focused review of incident themes. We have looked at ensuring escalation is effective and how we implement learning to ensure that it is consistent.” Source location Response from Central & North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Escalate concerns about vulnerable patients and recommend enhanced observation where necessary.
Verbatim wording from the response “Concern 4: Blocked observation panels and inadequate visual welfare checks
We are supporting prison colleagues by escalating concerns about vulnerable patients including making recommendations for enhanced observation where necessary.” Source location Response from Central & North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add an ACCT prompt to the handover sheet.
Verbatim wording from the response “Concern 6: Absence of ACCT despite identifiable indicators of vulnerability
Healthcare are aligned with the prison’s Suicide and Self-Harm Prevention policy. We have added an ACCT prompt to our handover sheet. All staff complete SASH and ACCT training and we monitor this.” Source location Response from Central & North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand clinical capacity through advanced clinical practitioner roles for routine reviews and direct escalation of complex cases to consultant psychiatrists.
Verbatim wording from the response “Concern 8: Delay or insufficiency of mental health and psychiatric input
We have worked on our waiting list management, setting clearer escalation thresholds, and increasing the use of remote clinics. The mental health and clinical leads review waiting lists every week and prioritise patients based on clinical risk and time waiting to ensure timely assessment and follow-up. We have also expanded clinical capacity by introducing advanced clinical practitioner roles to support routine reviews, while escalating more complex cases directly to consultant psychiatrists. Recruiting to substantive consultant posts remains a key priority for the service.” Source location Response from Central & North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explicitly consider IPP status in clinical risk assessments and referral processes.
Verbatim wording from the response “Concern 7: Vulnerability of IPP prisoners
We are explicitly considering IPP status within clinical risk assessment and referral processes. Because this is an explicit vulnerability, we can structure our clinical support packages and ensure regular reviews by the MDT.” Source location Response from Central & North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake a focused review of incident themes and examine escalation and consistent implementation of learning.
Verbatim wording from the response “Concern 11: Repeated systemic concerns at HMP Woodhill
Governance oversight of Health and Justice services at HMP Woodhill has been improved. We are undertaking a focused review of incident themes. We have looked at ensuring escalation is effective and how we implement learning to ensure that it is consistent.” Source location Response from Central & North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refer intoxicated prisoners to the addictions team for review within 48 hours.
Verbatim wording from the response “identifies and prioritises individuals at highest risk. Intoxicated prisoners are being immediately referred to the addictions team for review within 48 hours.” Source location Response from Central & North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure healthcare participation in multidisciplinary forums, weekly Safety Intervention Meetings and daily wing briefings.
Verbatim wording from the response “Concern 3: Information sharing and record keeping.
Handover documentation has been revised. This has improved identification and escalation of concerns to prison colleagues. We are ensuring that healthcare attend multidisciplinary forums, weekly Safety Intervention Meetings, and daily wing briefings. We have added a prompt to our handover to ensure that staff consider what information needs to be shared with prison colleagues.” Source location Response from Central & North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide SASH and ACCT training to all staff and monitor completion.
Verbatim wording from the response “Concern 6: Absence of ACCT despite identifiable indicators of vulnerability
Healthcare are aligned with the prison’s Suicide and Self-Harm Prevention policy. We have added an ACCT prompt to our handover sheet. All staff complete SASH and ACCT training and we monitor this.” Source location Response from Central & North West London NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Healthcare services alone cannot mitigate all risks within custody.
Verbatim wording from the response “Thank you for bringing your concerns to our attention. While healthcare services alone cannot mitigate all risks within custody, the Trust is committed to learning from Mr Meikle’s death and to strengthening how vulnerability is identified and responded to across Health and Justice services. Should you have any questions or comments, please do not hesitate to contact me.” Source location Response from Central & North West London NHS Foundation Trust
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1 Aug 2025 Brian Thomas RINGROSE · Prevention of Future Deaths report Milton Keynes
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Concerns raised 22 Failure to communicate before dragging a restrained person by the arms View source Failure to avoid extreme arm positioning during handcuffed restraint View source Failure to check airways and breathing rate during restraint View source Delays in mental health team assessment in the Emergency Department View source Failure to move restrained people onto their side as soon as practicable View source Discharge documentation liable to be misinterpreted as an official discharge notice View source Reliance on delayed written clinical documentation in emergency settings View source Failure to hand over critical restraint information View source Failure to seek clinical advice during restraint View source Failure to escalate concerns and arrange follow-up after incomplete mental health assessment View source Failure to listen to, interpret and respond to breathing during restraint View source Failure to provide timely final medical review before formal discharge View source Ambiguous and inadequately communicated discharge criteria View source Failure to communicate concerns that a patient is not medically fit for discharge View source Failure of officers to challenge inappropriate restraint View source Premature discharge of patients who are not medically fit View source Failure of senior clinical and nursing staff to intervene in observed restraint View source Reference in hospital policy to a non-existent police-custody discharge form View source Failure to reassess restraint actions using the National Decision Model View source Failure to limit prolonged prone restraint View source Failure to raise concerns about changing pallor during restraint View source Inappropriate recommendation for reassessment in police custody despite medical instability View source See 19 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
Brian Thomas RINGROSE · 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
Brian Thomas Ringrose died on 2 February 2021 after being taken to hospital following an overdose and then subjected to prolonged prone restraint by police. The report identifies concerns about police restraint practices and welfare monitoring, communication and handover, prioritisation of transport over welfare, and the hospital and mental health teams’ assessment, communication and discharge processes.
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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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate before dragging a restrained person by the arms
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to avoid extreme arm positioning during handcuffed restraint
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back , causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to check airways and breathing rate during restraint
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate , despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in mental health team assessment in the Emergency Department
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED) , despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to move restrained people onto their side as soon as practicable
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints , contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Discharge documentation liable to be misinterpreted as an official discharge notice
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on . This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Reliance on delayed written clinical documentation in emergency settings
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings , as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to hand over critical restraint information
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek clinical advice during restraint
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate concerns and arrange follow-up after incomplete mental health assessment
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police . They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to listen to, interpret and respond to breathing during restraint
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely final medical review before formal discharge
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged , and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ambiguous and inadequately communicated discharge criteria
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate concerns that a patient is not medically fit for discharge
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of officers to challenge inappropriate restraint
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint , despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Premature discharge of patients who are not medically fit
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of senior clinical and nursing staff to intervene in observed restraint
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Reference in hospital policy to a non-existent police-custody discharge form
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reassess restraint actions using the National Decision Model
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint , particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to limit prolonged prone restraint
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to raise concerns about changing pallor during restraint
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor , which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inappropriate recommendation for reassessment in police custody despite medical instability
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” 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 Require immediate escalation of concerns to the treating medic or nurse in charge through the Operational Policy.
Verbatim wording from the response “c. Failure to Escalate Concerns
We have strengthened our escalation pathways. A standing agenda item has been added to monthly cross-team meetings to review HLT practices. Our Operational Policy now explicitly requires immediate escalation of concerns to the treating medic or nurse in charge.” Source location Response from Central and North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver refresher and Human Factors training to support consistent application of safe-discharge principles.
Verbatim wording from the response “e. Inappropriate Discharge Recommendation
We have reinforced the principle that discharge from ED should never proceed where there are unresolved concerns about a patient’s safety, whether related to physical or mental health. This has been reiterated in team meetings and supervision sessions. Refresher training and Human Factors Training are taking place to support consistent application of this principle.” Source location Response from Central and North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Accept emergency-department referrals before medical clearance to enable earlier engagement, risk planning and support, with timely referral-response monitoring.
Verbatim wording from the response “a. Delay in Assessment
We have revised our approach to ensure that referrals are accepted even when patients are not yet medically cleared. This enables earlier engagement, risk planning, and support. A key performance indicator for the HLT is timely response to referrals. In the past six months, over 95% of ED referrals have been responded to within one hour. This reflects not only operational improvements but a cultural shift towards proactive, parallel working with ED colleagues.” Source location Response from Central and North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require escalation to emergency-department clinicians, continued emergency-department medical care and liaison-team availability for reassessment when patients cannot engage or remain medically unfit.
Verbatim wording from the response “b. Inadequate Assessment
Our revised protocol mandates that when a patient cannot engage due to intoxication (alcohol or drugs) or other factors rendering them unfit, the HLT must escalate concerns to the ED team, advise that the patient remains under ED care for ongoing medical management, and the HLT remain available for reassessment. This ensures continuity of care and avoids missed opportunities for intervention. This applies equally in cases where the patient is under police arrest within the ED.” Source location Response from Central and North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce that emergency-department discharge must not proceed when safety concerns remain, through team meetings and supervision.
Verbatim wording from the response “e. Inappropriate Discharge Recommendation
We have reinforced the principle that discharge from ED should never proceed where there are unresolved concerns about a patient’s safety, whether related to physical or mental health. This has been reiterated in team meetings and supervision sessions. Refresher training and Human Factors Training are taking place to support consistent application of this principle.” Source location Response from Central and North West London NHS Foundation Trust
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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 Implement joint clinical entries, mandatory immediate verbal handovers and contemporaneous electronic documentation after assessments, with random quality audits.
Verbatim wording from the response “d. Unsafe Communication Practices
To enhance the robustness and integrity of our documentation process, we have implemented a joint entry protocol. Under this approach, both assessors will contribute directly: the second assessor will either formally approve the initial entry or provide a complementary entry to ensure a more comprehensive and balanced record. Verbal handovers to the treating medic, or to the Nurse in Charge if the medic is unavailable, are now mandatory immediately post-assessment, followed by contemporaneous entries in ECare summarising the handover with a more detailed entry to follow based on the SystmOne entry. These changes aim to improve the” Source location Response from Central and North West London NHS Foundation Trust
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18 Jun 2025 Edward Joseph CASSIN · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 2 Lack of understanding of aspiration investigation and management policies and procedures View source Siloed working and inadequate sharing of clinical responsibility between the two Trusts View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Edward Joseph CASSIN · 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
Edward Joseph Cassin was a 66-year-old man with learning difficulties and dysphagia who was developing aspiration pneumonia while in hospital on 24 June 2023. He was given jelly despite it being contraindicated, was not properly supervised while eating, and experienced hypoglycaemic episodes that were not managed according to hospital guidelines; aspiration and the pneumonia were not recognised. The report raised concerns about staff understanding of aspiration-management policies and siloed working between the two NHS trusts providing services.
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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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of aspiration investigation and management policies and procedures
Wider context from the report “The Speech and Language Therapists (SALT) and Dietetic Service had well developed, comprehensive guidelines for investigating and managing patients prone to aspiration. Those guidelines were disseminated through the wards at Milton Keynes University Hospital and nursing and other staff were appraised of them or at least, should have been. I was disturbed to discover though that there was a lack of understanding of some of those policies and procedures some 22 months or so after the death. The SALT and Dietetic services are provided by the Central and North West London NHS Trust into the Milton Keynes University Hospital NHS Foundation Trust. It appeared to me that both Trusts were working to a degree in a siloed manner and that closer co-operation and sharing of clinical responsibility would benefit patients in a similar position in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Siloed working and inadequate sharing of clinical responsibility between the two Trusts
Wider context from the report “The Speech and Language Therapists (SALT) and Dietetic Service had well developed, comprehensive guidelines for investigating and managing patients prone to aspiration. Those guidelines were disseminated through the wards at Milton Keynes University Hospital and nursing and other staff were appraised of them or at least, should have been. I was disturbed to discover though that there was a lack of understanding of some of those policies and procedures some 22 months or so after the death. The SALT and Dietetic services are provided by the Central and North West London NHS Trust into the Milton Keynes University Hospital NHS Foundation Trust. It appeared to me that both Trusts were working to a degree in a siloed manner and that closer co-operation and sharing of clinical responsibility would benefit patients in a similar position in the future.
” 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 Coordinate a safe transition of SALT care with MKUH.
Verbatim wording from the response “We would like to respectfully clarify that the Dietetic Service is provided by MKUH and therefore our response refers only to the SALT Service. With regard to the criticism of siloed working arrangements, we have been in discussions with MKUH and have concluded that we can improve the service for patients if this is fully run by MKUH. Arrangements have been made with MKUH to transfer the service to them on the 22 October. We believe this change will support more integrated and responsive care, with a single provider responsible for coordinating all relevant services within the hospital. CNWL is working closely with MKUH to ensure a smooth and safe transition of care.” Source location Response from Central North West London NHS Foundation Trust
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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 Transfer the Milton Keynes SALT service to MKUH as the single provider on 22 October 2025.
Verbatim wording from the response “We would like to respectfully clarify that the Dietetic Service is provided by MKUH and therefore our response refers only to the SALT Service. With regard to the criticism of siloed working arrangements, we have been in discussions with MKUH and have concluded that we can improve the service for patients if this is fully run by MKUH. Arrangements have been made with MKUH to transfer the service to them on the 22 October. We believe this change will support more integrated and responsive care, with a single provider responsible for coordinating all relevant services within the hospital. CNWL is working closely with MKUH to ensure a smooth and safe transition of care.” Source location Response from Central North West London NHS Foundation Trust
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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 Provide enhanced safe-swallowing training covering referrals, recommendations and practical preparation of compliant drinks and snacks.
Verbatim wording from the response “The SALT Team continue to provide regular training and support to hospital staff on safe swallowing to enhance their knowledge and understanding. This training has been reviewed to ensure that it provides relevant information to staff about how to identify which patients require a referral to the SALT Team, how to make these referrals and how to ensure that” Source location Response from Central North West London NHS Foundation Trust
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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 MKUH provides the Dietetic Service, so responsibility for dietetic-service concerns lies with MKUH rather than CNWL.
Verbatim wording from the response “We would like to respectfully clarify that the Dietetic Service is provided by MKUH and therefore our response refers only to the SALT Service. With regard to the criticism of siloed working arrangements, we have been in discussions with MKUH and have concluded that we can improve the service for patients if this is fully run by MKUH. Arrangements have been made with MKUH to transfer the service to them on the 22 October. We believe this change will support more integrated and responsive care, with a single provider responsible for coordinating all relevant services within the hospital. CNWL is working closely with MKUH to ensure a smooth and safe transition of care.” Source location Response from Central North West London NHS Foundation Trust
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 Responsibility for delivering the SALT Service at MKUH will transfer fully to MKUH as the single coordinating provider.
Verbatim wording from the response “We would like to respectfully clarify that the Dietetic Service is provided by MKUH and therefore our response refers only to the SALT Service. With regard to the criticism of siloed working arrangements, we have been in discussions with MKUH and have concluded that we can improve the service for patients if this is fully run by MKUH. Arrangements have been made with MKUH to transfer the service to them on the 22 October. We believe this change will support more integrated and responsive care, with a single provider responsible for coordinating all relevant services within the hospital. CNWL is working closely with MKUH to ensure a smooth and safe transition of care.” Source location Response from Central North West London NHS Foundation Trust
Open published response
10 Oct 2024 Florence Elizabeth Catherine STEWART · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 2 Failure of high-level intermittent observations to maintain patient safety View source Unavailability of oxygen from a resuscitation oxygen bottle View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Florence Elizabeth Catherine STEWART · 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
Florence Elizabeth Catherine Stewart, who had been admitted to the Campbell Centre as a voluntary patient following detention under section 136 of the Mental Health Act, suffered a hypoxic brain injury after hanging herself and died at Milton Keynes University Hospital on 23 January 2024. The concerns identified were the failure of high-level intermittent observations to prevent her suicide and an oxygen bottle running out during resuscitation.
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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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of high-level intermittent observations to maintain patient safety
Wider context from the report “Firstly that the system of high level intermittent observations failed to prevent Florence's suicide and needs a fundamental review. Secondly, that the Oxygen bottle used during resuscitation ran out of oxygen.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of oxygen from a resuscitation oxygen bottle
Wider context from the report “Firstly that the system of high level intermittent observations failed to prevent Florence's suicide and needs a fundamental review. Secondly, that the Oxygen bottle used during resuscitation ran out of oxygen .
” 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 Discuss the inquest themes and the importance of observation-policy adherence with staff through supervision, group sessions and ward meetings.
Verbatim wording from the response “The Divisional Directors have provided assurance that the Campbell Centre management team has implemented new systems and processes to support staff in applying the Trust Policy on Observation and Therapeutic engagement and have introduced measures to monitor understanding, training, and compliance. They have advised that there have been meetings with all staff to emphasise the importance of adherence to the Policy.” Source location Response from Central and NW London NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed oversight of staff training uptake for observations and therapeutic engagements.
Verbatim wording from the response “The specific themes from Ms Stewart’s inquest have been discussed in group supervision, individual supervision and ward meetings. The Campbell Centre management team has strengthened how temporary and new staff members are inducted to ensure that they can better identify their patients' needs. They have also embedded a system to oversee staff uptake of training in the use of observations and therapeutic engagements.” Source location Response from Central and NW London NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed and optimise the Brigid app for real-time observation recording, rationale and frequency documentation, and random-check prompts.
Verbatim wording from the response “The Trust has fully embedded the use of the Brigid app, a hand-held device that allows staff to remain with the patient and enter real-time updates of observation records, automatically updating the Trust's clinical record system. This has been optimised since the inquest and enables staff to document the rationale and frequency of observations, including prompts for random checks.” Source location Response from Central and NW London NHS Trust
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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 Require trained nurses to conduct daily oxygen-supply checks and induct temporary and new staff on oxygen availability before care begins.
Verbatim wording from the response “The Divisional Directors have confirmed that there is always an ample supply of oxygen across the Campbell Centre, which is easily accessible to trained staff. They have checked that all of our nurses are trained to conduct daily checks of the supplies and that temporary, or new staff members, receive an induction on oxygen availability before they start providing care.” Source location Response from Central and NW London NHS Trust
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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 Participate in a Trust-wide quality-improvement project to improve patient observation quality through May 2026.
Verbatim wording from the response “The Campbell Centre is part of a Trust-wide Quality improvement project looking to improve patient observation quality. The project commenced in November 2024 and is due to continue until May 2026.” Source location Response from Central and NW London NHS Trust
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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 Realign the Nurse in Charge role to prioritise high-level observations, ensure seamless handovers and enable faster escalation when patients cannot be located.
Verbatim wording from the response “The Nurse in Charge role has been realigned to ensure that the observation system is delivered to prioritise patients requiring high-level intermittent observations and oversee a seamless handover of care when alternating staff members. This includes faster escalation” Source location Response from Central and NW London NHS Trust
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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 Strengthen observation governance through shift-level checks, daily multidisciplinary reviews of highest-risk patients and allocated senior nursing support.
Verbatim wording from the response “The Campbell Centre management team has refined its governance processes to ensure that changes have been embedded. This includes several checks carried out during each shift by a duty senior nurse to ensure that observations are completed on time, a daily review by the MDT on those patients at most risk of harm, and senior nursing input allocated to support this.” Source location Response from Central and NW London NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the observation audit schedule to monitor weekly improvement under senior practice development nurse leadership.
Verbatim wording from the response “A system of audit schedules has been revised to check for weekly improvement, this is led by a senior practice development nurse.” Source location Response from Central and NW London NHS Trust
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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 Implement systems and processes supporting adherence to the observation and therapeutic engagement policy, with monitoring of staff understanding, training and compliance.
Verbatim wording from the response “The Divisional Directors have provided assurance that the Campbell Centre management team has implemented new systems and processes to support staff in applying the Trust Policy on Observation and Therapeutic engagement and have introduced measures to monitor understanding, training, and compliance. They have advised that there have been meetings with all staff to emphasise the importance of adherence to the Policy.” Source location Response from Central and NW London NHS Trust
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 Campbell Centre always has an ample, accessible oxygen supply, disputing that the resuscitation oxygen bottle ran out.
Verbatim wording from the response “The Divisional Directors have confirmed that there is always an ample supply of oxygen across the Campbell Centre, which is easily accessible to trained staff. They have checked that all of our nurses are trained to conduct daily checks of the supplies and that temporary, or new staff members, receive an induction on oxygen availability before they start providing care.” Source location Response from Central and NW London NHS Trust
Open published response
7 Mar 2024 David Louis SIIRAK · Prevention of Future Deaths report West London
View report summary
Concerns raised 1 Failure to provide adequate unexpected simulation training for ward staff View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
David Louis SIIRAK · 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 Louis Siirak was a detained inpatient who suffered unsurvivable injuries after being seriously assaulted by another patient on 1 March 2020 and died on 4 March 2020. The principal concern was that ward staff response was described as chaotic and panicking, with evidence of inadequate training in unexpected simulation exercises to manage such emergencies.
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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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate unexpected simulation training for ward staff
Wider context from the report “Mr Siirak was discovered in his room, having been assaulted, at 1647 hours on 1 March 2020. The crash team, led by ████████, arrived at 1703 hours. The evidence was that between those times (until ████████ took charge at 1703) the response of ward staff to the incident was "chaotic" and "panicking" (as was acknowledged by the staff).
The evidence was that various members of your staff had never previously been involved in a real or simulated emergency. By "simulated emergency", I mean an unexpected dummy run on the ward, as opposed to training in the calm confines of a planned day.
One member of staff told the court that she had never been involved in an unexpected simulated emergency in the 14 years of working on the ward prior to 1 March 2020, nor in the 4 years since.
The jury found that "there was a clear failure to provide the adequate training in simulation exercises to effectively manage situations like the one that occurred on 1st March 2020. "
It was equally clear on the evidence that members of staff have still not undergone unexpected simulation training .
” 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 Train staff who facilitate simulations and provide local facilitator update training.
Verbatim wording from the response “Everyone involved in delivering and facilitating simulation has attended training provided by Milton Keynes University in 2022 and 2023, and local update training is planned for 2024. Since the launch of the programme over 100 insitu resuscitation simulations have been carried out across the trust, with 79 having occurred in the last year, one of these has occurred on Frays ward, including five members of staff.” Source location Response from Central and North West London NHS Foundation Trust
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 Build a simulation room for staff identified as needing refresher training to attend planned sessions.
Verbatim wording from the response “The Trust is also currently building a simulation room, where staff identified as having a need to refresh can attend for planned sessions.” Source location Response from Central and North West London NHS Foundation Trust
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 Deliver a Trust-wide in-situ simulation programme using standardised planning, facilitation, debriefing and recording processes for resuscitation and other emergencies.
Verbatim wording from the response “Insitu simulation: This has been developed alongside a Trust-wide insitu Simulation education programme and complements the training programme outlined above. This programme was launched and led by the head of Adult Education at CNWL in 2022. The Trust-wide programme covers many areas, with resuscitation simulation being one of those areas. This uses a unified approach to planning, running, debriefing and recording each simulation. The Resuscitation team has a suite of simulation’s developed from previous incident that have occurred across the trust.” Source location Response from Central and North West London NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue rolling in-situ simulation delivery across inpatient wards, adding sessions for areas identified as needing greater support.
Verbatim wording from the response “Over the next 12 months, a rolling programme of insitu simulations is scheduled for every inpatient ward area, with additional sessions planned for areas identifying a greater need. Areas which may be considered as requiring additional input will include teams that have been involved in a recent resuscitation event and incident reviews.” Source location Response from Central and North West London NHS Foundation Trust
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 Provide nationally accredited RCUK Level 3 Immediate Life Support training annually to substantive inpatient nurses and doctors, with compliance monitored through governance structures.
Verbatim wording from the response “Resuscitation training: In November 2022, the Trust updated its resuscitation training to the Nationally accredited RCUK Level 3 Resuscitation training also known as Immediate Life Support (ILS). It is a course where to be successful the participants need to successfully demonstrate the skills required to resuscitate a patient. Providing assurance to both the individual and the Trust. All participants are involved in multiple resuscitation simulations, all of which have been developed from incidents that have occurred within the Trust. All registered substantive Nurses and Doctors who work on inpatient areas are required to attend this course annually. The Trust monitors ILS training compliance in a range of groups, Committees and also at Board level. Through this monitoring we obtain assurance that all relevant staff have undertaken ILS training and simulation exercises.” Source location Response from Central and North West London NHS Foundation Trust
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 resuscitation and in-situ simulation arrangements provide sufficient assurance that the identified training concerns are being addressed.
Verbatim wording from the response “Resuscitation training: In November 2022, the Trust updated its resuscitation training to the Nationally accredited RCUK Level 3 Resuscitation training also known as Immediate Life Support (ILS). It is a course where to be successful the participants need to successfully demonstrate the skills required to resuscitate a patient. Providing assurance to both the individual and the Trust. All participants are involved in multiple resuscitation simulations, all of which have been developed from incidents that have occurred within the Trust. All registered substantive Nurses and Doctors who work on inpatient areas are required to attend this course annually. The Trust monitors ILS training compliance in a range of groups, Committees and also at Board level. Through this monitoring we obtain assurance that all relevant staff have undertaken ILS training and simulation exercises.” Source location Response from Central and North West London NHS Foundation Trust
Open published response
7 Mar 2024 Adrian Michael James · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 5 Lack of proactive care consideration during obvious mental health crisis View source Failure to adequately assess the risk of impulsive suicide View source Failure to provide follow-up contact or assessment after an interrupted treatment call View source Inadequate communication between the PCN MDT and psychological treatment providers View source Failure to provide consultant assessment before psychological therapy and when the patient deteriorates View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Adrian Michael James · 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
Adrian Michael James died after falling from the fourth-floor balcony of his block of flats while experiencing severe and enduring mental illness, including paranoia and a high background risk of suicide. The principal concerns were that he was not assessed by a consultant, proactive care was not considered during his mental health crisis, insufficient attention was given to impulsive suicide risk, no follow-up assessment occurred after a police-interrupted treatment session, and communications between services were inadequate.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of proactive care consideration during obvious mental health crisis
Wider context from the report “2. That no pro-active care was considered for Adrian whilst he was in obvious mental health crisis in the last 17 days of his life.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately assess the risk of impulsive suicide
Wider context from the report “3. That insufficient consideration appeared to have been given to the risk of impulsive suicide with instead assessment focussing on his denial of increased active suicidal intent .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide follow-up contact or assessment after an interrupted treatment call
Wider context from the report “4. That no follow up call or assessment was made to Adrian when his treatment session was interrupted by police attendance, and the treatment call was cut off .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication between the PCN MDT and psychological treatment providers
Wider context from the report “5. That there were inadequate communications between the PCN MDT and those providing the psychological treatment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide consultant assessment before psychological therapy and when the patient deteriorates
Wider context from the report “1. That Adrian, despite being a complex patient with multiple psychiatric diagnoses and at high risk of impulsive behaviour and suicide was not seen nor assessed by a consultant either prior to starting psychological therapy or when he deteriorated .
” 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 Issue guidance reminding staff to consider consultant psychiatrist assessment for people with complex emotional needs and suicide risk.
Verbatim wording from the response “We are issuing additional guidance around managing risk of suicide in those with a diagnosis of Personality Disorder (or more commonly now known as Complex Emotional Needs) reminding staff to consider the need for assessment by a Consultant Psychiatrist.” Source location Response from Central and North West London
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review guidance on follow-up after treatment sessions are interrupted and calls are disconnected.
Verbatim wording from the response “We are reviewing our guidance on this and will ensure staff are clear on action to be taken.” Source location Response from Central and North West London
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 Update policies to incorporate learning about proactive care during mental health crisis.
Verbatim wording from the response “We have shared learning on this with the team and are updating our policies accordingly.” Source location Response from Central and North West London
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 Clarify for staff the actions required after treatment sessions are interrupted and calls are disconnected.
Verbatim wording from the response “We are reviewing our guidance on this and will ensure staff are clear on action to be taken.” Source location Response from Central and North West London
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 Remind staff to maintain consistent and adequate communication among professionals involved in treatment.
Verbatim wording from the response “We are reminding staff of the need for consistent and adequate communication amongst professionals involved in treatment. The team members in both of the teams above attend weekly meetings where the importance of this is constantly emphasised.” Source location Response from Central and North West London
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning about proactive care during mental health crisis with the team.
Verbatim wording from the response “We have shared learning on this with the team and are updating our policies accordingly.” Source location Response from Central and North West London
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 An initial psychiatrist appointment is not required because multidisciplinary support and consultant oversight are available.
Verbatim wording from the response “The team operates as a multidisciplinary unit. Senior clinical support and decision-making are facilitated through weekly Multidisciplinary Team (MDT) meetings, direct oversight from a Consultant Psychiatrist, and participation in the daily meetings, which are regularly attended by the team's Consultant Psychiatrist. In the event of concerns raised during the meetings, there is an opportunity to schedule an appointment with the Team Consultant Psychiatrist for further discussion. However, access to support for service users with complex emotional needs does not require an initial appointment with a psychiatrist.” Source location Response from Central and North West London
Open published response
16 Feb 2024 Mr Roberto Bottello · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 7 Continued shortages in psychiatric care provision View source Failure to provide evidence in accordance with the duty of candour View source Insufficient training of SPA call handlers in patient identification and information seeking View source Failure of psychiatric liaison clinicians to consider diagnoses made by other doctors View source Insufficient use of protective film over glass in areas where patients are at increased risk of smashing windows View source Insufficient psychiatric service response capacity out of hours for section 136 usage View source Failure to identify CNWL staff operating outside policy View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Roberto Bottello · 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
Roberto Bottello, who had been experiencing depression, anxiety, panic attacks and later an acute psychotic episode, was detained under section 136 of the Mental Health Act after police found him acutely disturbed. While in a hospital cubicle, he broke the window and fell 25 feet, suffering multiple injuries including a divided axillary vein and artery; his death was announced at 07:27 on 16 September 2020. Substantive concerns included the unsuitability and inadequate safety of the cubicle, communication and information-management failures, insufficient mental-health nursing provision, confusion over his identity, limited access to section 136 suites, and wider concerns about training and psychiatric-care resources.
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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Continued shortages in psychiatric care provision
Wider context from the report “10. That there are continued shortages in psychiatric care provision .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide evidence in accordance with the duty of candour
Wider context from the report “1. That CNWL failed in its duty of candour in relation to provision of evidence 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient training of SPA call handlers in patient identification and information seeking
Wider context from the report “3. That SPA call handlers were not sufficiently trained in how to identify patients by using computer searches and by not seeking information appropriately for example by using the international phonetic alphabet and using the word for the month in a person’s date of birth .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of psychiatric liaison clinicians to consider diagnoses made by other doctors
Wider context from the report “6. That the psychiatric liaison nurses and psychiatric liaison doctors should have regard to and specifically consider diagnoses made by other doctors for example those who see such patients repeatedly in A&E 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient use of protective film over glass in areas where patients are at increased risk of smashing windows
Wider context from the report “9. That the use of film over glass in areas where patients are at increased risk of smashing windows should be more widespread in the NHSE estate .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient psychiatric service response capacity out of hours for section 136 usage
Wider context from the report “7. That most section 136 usage is out of hours when there is less resource to respond from psychiatric services .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify CNWL staff operating outside policy
Wider context from the report “5. That CNWL were and may still be unaware that CNWL staff operate outside policy .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain safer staffing levels and a full liaison psychiatry staff complement at St Mary’s Hospital.
Verbatim wording from the response “• Whilst there is a national challenge to recruit and retain Registered Mental Health Nurses (RMN’s), CNWL has maintained safer staffing levels and provided a full liaison psychiatry staff complement at all times at the St Marys Hospital site.” Source location Response from Central and NW London NHS
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 Reinforce openness and transparency for staff attending court as witnesses through witness support.
Verbatim wording from the response “• We have spoken to the witnesses about your concern and are confident that they understand the importance of being open and transparent when giving evidence. We will reinforce this message as part of the support provided to all witnesses who attend court to give evidence.” Source location Response from Central and NW London NHS
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 Operate the Lighthouse assessment centre for mental health patients attending the emergency department.
Verbatim wording from the response “• A weekly meeting between the acute hospital clinicians at St Marys and CNWL now occurs. A joint venture between the two organisations for mental health patients attending the emergency department in the form of an assessment centre for mental health patients (The Lighthouse), at St Marys Hospital opened in the autumn of 2023 and has seen improved communication and partnership working.” Source location Response from Central and NW London NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue recruiting and retaining staff, monitor recruitment and vacancies, and implement supportive initiatives.
Verbatim wording from the response “• At CNWL, we recognise the fluid nature of this situation and affirm our dedication to consistently recruiting and retaining our valuable staff. We are committed to continuously monitoring recruitment and vacancies, as well as implementing supportive initiatives.” Source location Response from Central and NW London NHS
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 Provide SPA call handlers with induction guidance, phonetic-alphabet prompts and a minimum-question checklist for identifying patients and callers.
Verbatim wording from the response “• SPA has developed an induction pack, which specifically includes guidance on various ways of searching or identifying patient via system one/SPINE. All SPA staff now use phonetic alphabet when clarifying patients or callers’ details. On each desk within SPA there is a list of the phonetic alphabet, to support and prompt staff to ensure they have the correct spelling. SPA also has a checklist for call handlers, which prompts them to ask certain questions as a minimum, so information is not missed during calls.” Source location Response from Central and NW London NHS
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 Strengthen liaison clinicians’ consultation and collaboration with other doctors and use feedback from A&E doctors on diagnoses and interventions.
Verbatim wording from the response “• We appreciate there is a need to ensure that Psychiatric Liaison nurses and Liaison doctors have regard to and consider diagnoses made by other doctors who see a patient repeatedly in A&E. CNWL will ensure that the established channels of communications are strengthened through improved consultation and collaboration of patient care and a feedback mechanism is used where A&E doctors provide input on the effectiveness of psychiatric diagnoses and interventions at the weekly meeting referred to above,” Source location Response from Central and NW London NHS
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 Trust disputes failing its duty of candour, stating it provided evidence and received no requests for clarification or further evidence.
Verbatim wording from the response “• CNWL is very sorry that the Learned Coroner considers that CNWL did not provide evidence in accordance with its duty of candour. The Trust has always taken its duty of candour very seriously.” Source location Response from Central and NW London NHS
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 Trust disputes shortages in psychiatric care provision at its St Mary’s site, stating it maintained safer staffing and a full liaison psychiatry complement.
Verbatim wording from the response “• Whilst there is a national challenge to recruit and retain Registered Mental Health Nurses (RMN’s), CNWL has maintained safer staffing levels and provided a full liaison psychiatry staff complement at all times at the St Marys Hospital site.” Source location Response from Central and NW London NHS
Open published response
21 Aug 2023 Jacqueline Elizabeth Smith · Prevention of Future Deaths report West London
View report summary
Concerns raised 4 Lack of clear options and forward planning after failure of an assistance plan View source Insufficient staff training for dealing with complex hoarder cases View source Council hoarder-support guidance failing to support tenant assistance View source Failure to request required fire and environmental health assessments 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
Jacqueline Elizabeth Smith · 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
Jacqueline Elizabeth Smith took her own life by overdosing on prescribed medication at home and died in Hillingdon Hospital on 12 August 2022. She had poor physical health and considerable anxiety while seeking council assistance with hoarded possessions, and a mental health assessment was not performed after she contacted a crisis telephone service. The inquest identified concerns including insufficient staff training for complex hoarder cases, missing safety assessments, an unsuitable council flow chart, and a lack of clear options after the initial assistance plan failed.
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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear options and forward planning after failure of an assistance plan
Wider context from the report “(4) It was entirely unclear what options were available (if any) when the first plan of assistance completely failed , leaving the vulnerable tenant excluded from her property with no forward plan .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff training for dealing with complex hoarder cases
Wider context from the report “(1) The inquest identified that there was insufficient staff training to deal with complex hoarder cases .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Council hoarder-support guidance failing to support tenant assistance
Wider context from the report “(3) The council "flow chart" was clearly not fit for purpose to assist staff in progressing hoarder support and assistance and was focussed on enforcement procedures rather than tenant support . The inquest was advised that the council's approach was not enforcement, but their documentation did not support this .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to request required fire and environmental health assessments
Wider context from the report “(2) Other safety assessments such as a fire assessment and/or environmental health assessment were not requested despite their being a clear need.
” Open source report
16 Aug 2023 Kelvin Igweani · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 1 Failure to provide clear information and direction on obtaining emergency mental health assessment and care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kelvin Igweani · 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
Kelvin Igweani died from gunshot wounds after police forced entry into a flat where he had barricaded himself with a two-year-old boy during a severe mental health episode. The report identifies a concern that, despite repeated attempts by his mother to obtain help, unclear information and direction about accessing emergency mental health assessment and care meant Kelvin did not receive that support.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear information and direction on obtaining emergency mental health assessment and care
Wider context from the report “Through Kelvin's period of deteriorating mental health, which was obvious to those who knew him, his mother made repeated attempts to secure mental health assessment and care for him.
She was not directed clearly by the professionals she did have contact with, to take him to the Emergency Department for assistance. There was a gap which Kelvin fell through and he did not receive either mental health assessment or care. It was not possible to say that the failure to receive assessment or care resulted in Kelvin attempting to take the lives of others and succeeding in taking the life of his male neighbour.
It was clear that the lack of clear information and direction in regard to how to obtain that mental health assessment or care contributed to Kelvin not presenting for assessment which may possibly have averted the tragic events which unfolded on the 26th June 2021. This in turn raises the prospect that others, in similar predicaments may also be unable to obtain the care required.
” 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 Supply GP surgeries with posters explaining access to mental health services through the emergency department.
Verbatim wording from the response “We will also cascade a learning leaflet to local GPs via the Primary Care Network (PCN) alliance that we attend jointly with representatives from our local GPs and we will supply posters to GP surgeries to be displayed in their waiting areas informing how those presenting with acute mental health crisis can access mental health services via the ED at MKUH.” Source location Response from Central and North West London NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Trust website’s information on accessing urgent mental health support.
Verbatim wording from the response “We acknowledge your concerns and confirm that we have reviewed the information available on our website. This advises that urgent mental health support can be provided via our Single Point of Access service (SPA) 24 hours a day, 7 days a week which is accessible on telephone number: ████████ The Single Point of Access gives advice on how to access local mental health services in Milton Keynes, this may include going to A&E.” Source location Response from Central and North West London NHS Foundation Trust
Open published response
14 Mar 2023 Nicola Norman · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 3 Failure to routinely notify the patient’s GP and treating mental health services of SPA contacts View source Failure to routinely pass mental-health-related SPA calls to a suitably qualified clinician for mental health assessment and risk assessment View source Failure to routinely discuss SPA contacts with a supervising clinician when mental health symptoms or suicidality are raised 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
Nicola Norman · 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
Nicola Norman died on 20 January 2020, aged 42, after being found dead hanging at her mother’s address. Before her death, she contacted the Single Point of Access while highly anxious, reported feeling a burden and later reported an overdose and cutting her wrists. The principal concerns were that these contacts were not routinely discussed with a supervising clinician, passed to a suitably qualified clinician for assessment, or notified to her GP and mental health services.
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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely notify the patient’s GP and treating mental health services of SPA contacts
Wider context from the report “3. That SPA contacts are not routinely notified to the patient’s GP and any mental health services providing care for the patient .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely pass mental-health-related SPA calls to a suitably qualified clinician for mental health assessment and risk assessment
Wider context from the report “2. That such calls are not routinely passed on to a suitably qualified clinician able to undertake mental health assessment and assess risk for the patient .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely discuss SPA contacts with a supervising clinician when mental health symptoms or suicidality are raised
Wider context from the report “1. That SPA contacts are not routinely discussed with a supervising clinician , ss should have but did not happen in Ms Norman’s case, where mental health symptoms and especially where suicidality is raised by the caller.
” Open source report
15 Nov 2022 Ronald Alfred KELLY · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 2 Lack of automatic follow-up for patients discharged home who may need support and care View source Failure to action appropriate referrals for district nurse visits and assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ronald Alfred KELLY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ronald Alfred KELLY, aged 91, was found hanging on 19 September 2022 after recently being discharged from hospital and struggling to cope. The concerns included his discharge following surgery without a care package or follow-up, a rejected district nurse referral that was not actioned, and the apparent absence of a system for automatically following up patients discharged home who may need support and care. The inquest concluded that Mr Kelly died from suicide.
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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of automatic follow-up for patients discharged home who may need support and care
Wider context from the report “1. That a 91-year-old man was discharged from hospital following surgery, having refused to wait over the weekend for a care package to be put in place and there was no follow-up arranged to either assist him with his care or to ensure that he was coping .
2. That when the GP practice made a subsequent referral for a visit and assessment by the district nurse it was rejected on the basis that the appropriate referral was to “home first”. The GP forwarded the referral but nothing was actioned.
3. There does not appear to be any system to ensure that a patient discharged home possibly needing support and care are automatically followed up.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to action appropriate referrals for district nurse visits and assessments
Wider context from the report “1. That a 91-year-old man was discharged from hospital following surgery, having refused to wait over the weekend for a care package to be put in place and there was no follow-up arranged to either assist him with his care or to ensure that he was coping.
2. That when the GP practice made a subsequent referral for a visit and assessment by the district nurse it was rejected on the basis that the appropriate referral was to “home first” . The GP forwarded the referral but nothing was actioned.
3. There does not appear to be any system to ensure that a patient discharged home possibly needing support and care are automatically followed up.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the referral process with staff to identify learning.
Verbatim wording from the response “Since Mr Kelly’s death, the service has undertaken a review session with staff to identify learning about our referral process. We will amend the Standard Operating Procedure to ensure that we instigate tighter follow up when we request additional information on referrals.” Source location Response from Central and North West London NHS Foundation Trust
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 Amend the Standard Operating Procedure to require tighter follow-up when additional referral information is requested.
Verbatim wording from the response “Since Mr Kelly’s death, the service has undertaken a review session with staff to identify learning about our referral process. We will amend the Standard Operating Procedure to ensure that we instigate tighter follow up when we request additional information on referrals.” Source location Response from Central and North West London NHS Foundation Trust
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 MKUH was responsible for the inpatient discharge process because CNWL received no referral and was not involved in the inpatient care.
Verbatim wording from the response “In response to your first point, we did not receive a referral for Mr Kelly either before or at the point of discharge and were not involved in his care whilst he was an inpatient at MKUH. We note that MKUH have provided a full response in relation to the discharge process, which they kindly shared with us.” Source location Response from Central and North West London NHS Foundation Trust
Open published response
21 Oct 2022 Daniel John O’Sullivan · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 7 Delays in alerting police when psychiatric patients fail to return from leave View source Poor contemporaneous documentation of unescorted leave View source Failure of Serious Incident Investigations to investigate missing records and interview relevant witnesses View source Failure to formulate Care and Treatment plans identifying core treatment needs View source Failure to update suicide self-harm risk assessments View source Vulnerability of psychiatric patients on voluntary leave to self-harm and predation View source Failure of Serious Incident Investigations to investigate care and treatment plan deficiencies and make recommendations View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Daniel John O’Sullivan · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daniel John O’Sullivan was found deceased on 27 March 2019 while a voluntary psychiatric patient at St Charles Hospital, after leaving the hospital unescorted and failing to return. The principal concerns were failures to update his self-harm risk assessment, formulate a care and treatment plan, document unescorted leave, and promptly notify police when he did not return. The report also raised concerns that the hospital’s serious incident investigation did not identify or investigate these issues adequately.
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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in alerting police when psychiatric patients fail to return from leave
Wider context from the report “2) My second concern is the poor contemporaneous documentation of the grant of unescorted leave from the hospital and the time taken to alert the police when Daniel failed to return on 26/3/19 by 21:00 pm. A ward nurse eventually contacted the police after midnight.
i) I am concerned that an earlier call to the police may have prevented the death, because Daniel was recorded on General Security Zone (GSZ) cameras at 22:21 leaving Vauxhall bridge, and returning, on foot at 23:48. An earlier call might have enabled police to intervene before he was able to commence the actions which ended his life.
ii) The ward manager claimed in evidence that he had instructed others to call the police when Daniel failed to return at 21:00. However, this was not documented anywhere in the medical records and a leave book with handwritten entries went missing after the death. The missing leave book was not investigated by the SII.
iii) A nurse who called the police, sometime before 00:30 according to the medical records, at 01:10 according to police records, was not interviewed by the SII.
I found these investigative deficits troubling because the learning of lessons in patient care depends, in part, on an early SII by the hospital concerned so that risks to patient safety can be identified to enable recommendations and improvements long before an inquest conclusion.
The delay in reporting the failure to return to the Ward was a factor that contributed to the dangerous situation already created by rescinding s.2.
I am nonetheless concerned that, in general, psychiatric patients being tested on voluntary leave are a vulnerable group and as such failures to return should be reported with expedition not only because they may be a danger to themselves, but also due to a risk of being preyed upon by others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor contemporaneous documentation of unescorted leave
Wider context from the report “2) My second concern is the poor contemporaneous documentation of the grant of unescorted leave from the hospital and the time taken to alert the police when Daniel failed to return on 26/3/19 by 21:00 pm. A ward nurse eventually contacted the police after midnight.
i) I am concerned that an earlier call to the police may have prevented the death, because Daniel was recorded on General Security Zone (GSZ) cameras at 22:21 leaving Vauxhall bridge, and returning, on foot at 23:48. An earlier call might have enabled police to intervene before he was able to commence the actions which ended his life.
ii) The ward manager claimed in evidence that he had instructed others to call the police when Daniel failed to return at 21:00. However, this was not documented anywhere in the medical records and a leave book with handwritten entries went missing after the death. The missing leave book was not investigated by the SII.
iii) A nurse who called the police, sometime before 00:30 according to the medical records, at 01:10 according to police records, was not interviewed by the SII.
I found these investigative deficits troubling because the learning of lessons in patient care depends, in part, on an early SII by the hospital concerned so that risks to patient safety can be identified to enable recommendations and improvements long before an inquest conclusion.
The delay in reporting the failure to return to the Ward was a factor that contributed to the dangerous situation already created by rescinding s.2.
I am nonetheless concerned that, in general, psychiatric patients being tested on voluntary leave are a vulnerable group and as such failures to return should be reported with expedition not only because they may be a danger to themselves, but also due to a risk of being preyed upon by others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Serious Incident Investigations to investigate missing records and interview relevant witnesses
Wider context from the report “2) My second concern is the poor contemporaneous documentation of the grant of unescorted leave from the hospital and the time taken to alert the police when Daniel failed to return on 26/3/19 by 21:00 pm. A ward nurse eventually contacted the police after midnight.
i) I am concerned that an earlier call to the police may have prevented the death, because Daniel was recorded on General Security Zone (GSZ) cameras at 22:21 leaving Vauxhall bridge, and returning, on foot at 23:48. An earlier call might have enabled police to intervene before he was able to commence the actions which ended his life.
ii) The ward manager claimed in evidence that he had instructed others to call the police when Daniel failed to return at 21:00. However, this was not documented anywhere in the medical records and a leave book with handwritten entries went missing after the death. The missing leave book was not investigated by the SII.
iii) A nurse who called the police, sometime before 00:30 according to the medical records, at 01:10 according to police records, was not interviewed by the SII.
I found these investigative deficits troubling because the learning of lessons in patient care depends, in part, on an early SII by the hospital concerned so that risks to patient safety can be identified to enable recommendations and improvements long before an inquest conclusion.
The delay in reporting the failure to return to the Ward was a factor that contributed to the dangerous situation already created by rescinding s.2.
I am nonetheless concerned that, in general, psychiatric patients being tested on voluntary leave are a vulnerable group and as such failures to return should be reported with expedition not only because they may be a danger to themselves, but also due to a risk of being preyed upon by others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to formulate Care and Treatment plans identifying core treatment needs
Wider context from the report “1) On completion of the inquest, I found the decision to rescind detention under s.2 on 25/3/19 was undermined in two essential respects:
a) A failure to update a suicide self-harm risk assessment.
b) A failure to formulate a Care and Treatment plan identifying core treatment needs.
A Serious Incident Investigation (SII), commissioned by CNWL, completed on 9/9/2019, investigated the Risk Assessment and made recommendations which I heard from a CNWL witness had subsequently been implemented and I am satisfied that his risk to life has been satisfactorily reduced.
However, I remain concerned that the Care and Treatment plan aspect was not identified by the SII and as such no recommendations were identified and followed up.
The psychiatrist who rescinded s.2, on 25/3/2019, was unable to participate in the inquest through illness.
As a result, I instructed an independent expert psychiatrist who gave evidence that there had been no treatment plan addressing Daniel’s core treatment needs.
The core treatment needs were that Daniel required antipsychotic medication to control his delusional beliefs and psychological intervention to address his substance misuse which exacerbated his delusional beliefs.
The expert also identified from statements and medical records that Daniel lacked insight into his mental health conditions and thereby lacked capacity. The treatment Daniel required was twofold. Assertive treatment of the delusional disorder with antipsychotics, whilst detained under s.2, to achieve stability, coupled with psychological therapy to address the illicit drug use.
I heard evidence that antipsychotics could not commence until the results of liver function tests were available, but this did not persuade the expert, that recession of s.2 was correct.
The psychiatrist who rescinded s.2 on 25/3/19 was interviewed by the SII but the care and treatment plan aspect was not explored by that investigation.
My concern is that failures in the formulation of a Care and Treatment Plan made a significant contribution to the death and this failing was not exposed until the inquest when it could have been identified much earlier by the SII in September 2019.
The fact that a Care and Treatment plan was not formulated gives me concern that the mistake could be repeated in future and my concern is compounded by the SII failing to investigate and make recommendations arising from this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to update suicide self-harm risk assessments
Wider context from the report “1) On completion of the inquest, I found the decision to rescind detention under s.2 on 25/3/19 was undermined in two essential respects:
a) A failure to update a suicide self-harm risk assessment.
b) A failure to formulate a Care and Treatment plan identifying core treatment needs.
A Serious Incident Investigation (SII), commissioned by CNWL, completed on 9/9/2019, investigated the Risk Assessment and made recommendations which I heard from a CNWL witness had subsequently been implemented and I am satisfied that his risk to life has been satisfactorily reduced.
However, I remain concerned that the Care and Treatment plan aspect was not identified by the SII and as such no recommendations were identified and followed up.
The psychiatrist who rescinded s.2, on 25/3/2019, was unable to participate in the inquest through illness.
As a result, I instructed an independent expert psychiatrist who gave evidence that there had been no treatment plan addressing Daniel’s core treatment needs.
The core treatment needs were that Daniel required antipsychotic medication to control his delusional beliefs and psychological intervention to address his substance misuse which exacerbated his delusional beliefs.
The expert also identified from statements and medical records that Daniel lacked insight into his mental health conditions and thereby lacked capacity. The treatment Daniel required was twofold. Assertive treatment of the delusional disorder with antipsychotics, whilst detained under s.2, to achieve stability, coupled with psychological therapy to address the illicit drug use.
I heard evidence that antipsychotics could not commence until the results of liver function tests were available, but this did not persuade the expert, that recession of s.2 was correct.
The psychiatrist who rescinded s.2 on 25/3/19 was interviewed by the SII but the care and treatment plan aspect was not explored by that investigation.
My concern is that failures in the formulation of a Care and Treatment Plan made a significant contribution to the death and this failing was not exposed until the inquest when it could have been identified much earlier by the SII in September 2019.
The fact that a Care and Treatment plan was not formulated gives me concern that the mistake could be repeated in future and my concern is compounded by the SII failing to investigate and make recommendations arising from this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Vulnerability of psychiatric patients on voluntary leave to self-harm and predation
Wider context from the report “2) My second concern is the poor contemporaneous documentation of the grant of unescorted leave from the hospital and the time taken to alert the police when Daniel failed to return on 26/3/19 by 21:00 pm. A ward nurse eventually contacted the police after midnight.
i) I am concerned that an earlier call to the police may have prevented the death, because Daniel was recorded on General Security Zone (GSZ) cameras at 22:21 leaving Vauxhall bridge, and returning, on foot at 23:48. An earlier call might have enabled police to intervene before he was able to commence the actions which ended his life.
ii) The ward manager claimed in evidence that he had instructed others to call the police when Daniel failed to return at 21:00. However, this was not documented anywhere in the medical records and a leave book with handwritten entries went missing after the death. The missing leave book was not investigated by the SII.
iii) A nurse who called the police, sometime before 00:30 according to the medical records, at 01:10 according to police records, was not interviewed by the SII.
I found these investigative deficits troubling because the learning of lessons in patient care depends, in part, on an early SII by the hospital concerned so that risks to patient safety can be identified to enable recommendations and improvements long before an inquest conclusion.
The delay in reporting the failure to return to the Ward was a factor that contributed to the dangerous situation already created by rescinding s.2.
I am nonetheless concerned that, in general, psychiatric patients being tested on voluntary leave are a vulnerable group and as such failures to return should be reported with expedition not only because they may be a danger to themselves, but also due to a risk of being preyed upon by others .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Serious Incident Investigations to investigate care and treatment plan deficiencies and make recommendations
Wider context from the report “1) On completion of the inquest, I found the decision to rescind detention under s.2 on 25/3/19 was undermined in two essential respects:
a) A failure to update a suicide self-harm risk assessment.
b) A failure to formulate a Care and Treatment plan identifying core treatment needs.
A Serious Incident Investigation (SII), commissioned by CNWL, completed on 9/9/2019, investigated the Risk Assessment and made recommendations which I heard from a CNWL witness had subsequently been implemented and I am satisfied that his risk to life has been satisfactorily reduced.
However, I remain concerned that the Care and Treatment plan aspect was not identified by the SII and as such no recommendations were identified and followed up.
The psychiatrist who rescinded s.2, on 25/3/2019, was unable to participate in the inquest through illness.
As a result, I instructed an independent expert psychiatrist who gave evidence that there had been no treatment plan addressing Daniel’s core treatment needs.
The core treatment needs were that Daniel required antipsychotic medication to control his delusional beliefs and psychological intervention to address his substance misuse which exacerbated his delusional beliefs.
The expert also identified from statements and medical records that Daniel lacked insight into his mental health conditions and thereby lacked capacity. The treatment Daniel required was twofold. Assertive treatment of the delusional disorder with antipsychotics, whilst detained under s.2, to achieve stability, coupled with psychological therapy to address the illicit drug use.
I heard evidence that antipsychotics could not commence until the results of liver function tests were available, but this did not persuade the expert, that recession of s.2 was correct.
The psychiatrist who rescinded s.2 on 25/3/19 was interviewed by the SII but the care and treatment plan aspect was not explored by that investigation.
My concern is that failures in the formulation of a Care and Treatment Plan made a significant contribution to the death and this failing was not exposed until the inquest when it could have been identified much earlier by the SII in September 2019.
The fact that a Care and Treatment plan was not formulated gives me concern that the mistake could be repeated in future and my concern is compounded by the SII failing to investigate and make recommendations arising from this issue .
” 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 Develop Quick Reference Guides supporting staff use of the electronic clinical record system and care-planning templates.
Verbatim wording from the response “A number of changes have occurred within the Trust and more locally at St Charles Mental Health Unit since the incident in March 2019. The Trust began using SystmOne as its electronic clinical system in February 2019. As staff transitioned to the new electronic clinical record system they were learning about the operation and functionality of the system, and this also involved use of templates within the system and recording of information. It is fair to say that in March 2019 St Charles Mental Health Unit was at the start of the process of using SystmOne. Three and a half years later staff are now proficient in its use. This has been assisted by the use of Quick Reference Guides (QRG) developed to support staff.” Source location Response from Central and North West London NHS Foundation Trust
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 Establish hourly ward accounting of patients during each shift, with responsibility allocated to the nurse in charge.
Verbatim wording from the response “Each patient is allocated a nurse for each shift. The nurse is responsible for completing the leave form for their identified patients and these forms are then uploaded by administration staff to the patient clinical record. The Nurse in Charge of each shift has the responsibility of ensuring that every patient is accounted for hourly. This task is allocated at the beginning of each shift and is recorded hourly, on a separate reporting sheet for every 24-hour period.” Source location Response from Central and North West London NHS Foundation Trust
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 Introduce Advanced Clinical Practitioners to support care planning, risk management and identification of Care and Treatment Plan deficiencies.
Verbatim wording from the response “In addition, St Charles Mental Health Unit has recruited and trained Advanced Clinical Practitioners (ACPs). One of the roles of the ACP is to support the MDT and in particular the nursing team with specific interventions, care planning and risk management. This includes reviewing the Care and Treatment Plan and highlighting any deficiencies.” Source location Response from Central and North West London NHS Foundation Trust
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 Update the Missing Informal Patient Policy to specify police-contact information required in SystmOne and Datix records.
Verbatim wording from the response “In response to the audit the following further actions were agreed:” Source location Response from Central and North West London NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Datix recording of police contact during AWOL incidents to monitor reporting timeliness and escalate unnecessary delays.
Verbatim wording from the response “In response to the audit the following further actions were agreed:” Source location Response from Central and North West London NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Clinical Risk Assessment and Safety Policy and mandate its associated e-learning for staff.
Verbatim wording from the response “The Clinical Risk Assessment and Safety Policy was reviewed in April 2021 which includes an e-learning package introduced in October 2020 which is now a mandatory requirement for staff to complete.” Source location Response from Central and North West London NHS Foundation Trust
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 Record each informal-leave episode on a paper form and upload it to the clinical record.
Verbatim wording from the response “Each episode of leave is also now recorded on a paper document which is then scanned and uploaded onto the clinical record system each week.” Source location Response from Central and North West London NHS Foundation Trust
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 Increase qualified ward staffing to support formulation and negotiation of Care and Treatment Plans.
Verbatim wording from the response “Approximately 18 months ago St Charles Mental Health Unit saw an increase in qualified staff for each ward at the Unit. This has provided additional opportunity for staff to spend one to one time formulating and negotiating Care and Treatment plans, aimed at reducing any identified risks and promoting patient recovery.” Source location Response from Central and North West London NHS Foundation Trust
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 Update the Missing Informal Patient Policy with a risk-assessment checklist and flow chart for managing patients who fail to return from leave.
Verbatim wording from the response “The Missing Informal Patient Policy was updated in March 2020. It now requires a checklist to be completed which was not in the previous version. This is a risk assessment checklist that is now used by staff for managing informal leave from the wards. The checklist records the time that the patient leaves the ward and expected time of return (which is agreed in advance with the patient). There is also a risk assessment and an action plan for completion to mitigate against any risk identified. The Missing Informal Patient Policy also now provides a useful flow chart with the steps that are required to be taken in the event of someone not returning at the agreed time. The approach is balanced by the perceived risk.” Source location Response from Central and North West London NHS Foundation Trust
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 Accredit the serious incident review process through SIRAN, revising policies, templates and review arrangements to meet best practice.
Verbatim wording from the response “At the beginning of 2020, the Trust sought to incorporate best practice in its management of serious incidents, which would result in improvement and effectiveness of the process and evidenced through Accreditation. Following several months of readiness activity including auditing and self-evaluation, workshops with Divisional representatives, implementation of agreed actions, revision of templates and redrafting of our policy, we succeeded through SIRAN. At the time of the changes, the Trust also introduced a forum to support reviewers/investigators of serious incidents to enhance understanding of the Root Cause Analysis (RCA) process.” Source location Response from Central and North West London NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Patient Safety Incident Response Framework through a fortnightly working group and human-factors education incorporating learning from this case.
Verbatim wording from the response “In August 2022, NHS England launched the Patient Safety Incident Response Framework (PSIRF), which NHS organisations are expected to implement over the next year. This new framework phases out the RCA methodology, introducing human factors and system-based approaches instead. As rolling out of human factors training had already commenced in the Trust prior to publication of the new framework, the Trust is ahead in its preparations in this regard. A working group is in place and meeting fortnightly to drive implementation of the new process. Education is a significant part of this work and training procured will take learning from this case into account.” Source location Response from Central and North West London NHS Foundation Trust
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 Provide RCA methodology training to staff and establish a forum supporting serious-incident reviewers and investigators.
Verbatim wording from the response “At the beginning of 2020, the Trust sought to incorporate best practice in its management of serious incidents, which would result in improvement and effectiveness of the process and evidenced through Accreditation. Following several months of readiness activity including auditing and self-evaluation, workshops with Divisional representatives, implementation of agreed actions, revision of templates and redrafting of our policy, we succeeded through SIRAN. At the time of the changes, the Trust also introduced a forum to support reviewers/investigators of serious incidents to enhance understanding of the Root Cause Analysis (RCA) process.” Source location Response from Central and North West London NHS Foundation Trust
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 Provide a dedicated Safeguarding Adult and Mental Capacity Lead Practitioner to support capacity-assessment training and Care and Treatment Plan completion.
Verbatim wording from the response “The St Charles Mental Health Unit site also has a Safeguarding Adult & Mental Capacity Lead Practitioner who provides dedicated support to the unit with training for the assessment of capacity which informs care plans and a part of training will remind staff how this should feed into the Care and Treatment Plan and dynamic plans.” Source location Response from Central and North West London NHS Foundation Trust
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 Create a dedicated serious incident review post in the incident division.
Verbatim wording from the response “On the specific issue of skills and competency to undertake reviews/investigations, 88 members of staff have been trained in RCA methodology in the last 2 years (since 2020). This methodology equips reviewers with the skill to probe and draw out care and service delivery problems and guides them to elicit lessons. In addition, the Division in which the incident occurred now has a dedicated serious incident review post, offering additional skills and support in this process.” Source location Response from Central and North West London NHS Foundation Trust
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 Police reporting after voluntary-leave failures need not be immediate or automatic; individualized risk assessment and ward-team discussion determine the response.
Verbatim wording from the response “The timing of contact with the police if a patient fails to return is not standardised or mandated within the Missing Informal Patient Policy. This should be reviewed as part of planning for leave and incorporated into the plan for leave as agreed with the patient. Assessment of capacity and assessment of risk form part of the overall decision making and will be informed by the views of the multidisciplinary team and the aims and intended outcomes as provided for in the care plan. Although police involvement is sometimes necessary it is not always the default position when a patient fails to return the ward. Failure to return should prompt a discussion between the members of the ward team, involving the RC as necessary.” Source location Response from Central and North West London NHS Foundation Trust
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 care-plan formulation, monitoring and review processes, including multiple checks and balances, are considered robust and sufficient.
Verbatim wording from the response “We are satisfied that the process now regarding formulation, monitoring and review of the Care and Treatment Plan is a robust one with appropriate checks and balances to promote the support and interventions our vulnerable patients require. As with all aspects of care and treatment of our patients, our processes are constantly under review, and we will continue to drive towards excellence and to achieve the best possible outcomes for our patients.” Source location Response from Central and North West London NHS Foundation Trust
Open published response
20 Oct 2022 Clifford William ROSE · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 1 Failure to carry out detailed needs assessments of very vulnerable and elderly patients face-to-face 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
Clifford William ROSE · 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
Clifford William Rose died on 10 August 2022 after a serious infection developed from a burn caused by an electric blanket, followed by amputation of his leg. The inquest identified failures in assessing his care needs and escalating concerns about his deteriorating health and self-neglect. It also found that telephone assessments had incorrectly indicated he could dress himself and was eating and drinking regularly.
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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out detailed needs assessments of very vulnerable and elderly patients face-to-face
Wider context from the report “During the course of the evidence at the inquest it became apparent that detailed assessments of the needs of very vulnerable and perhaps elderly patients are being carried out over the telephone . In this particular case, it lead to the deceased confirming that he was able to dress himself and that he was eating and drinking regularly. This was far from the correct position. I believe that consideration should be given to put in place a system whereby all assessments are carried out face-to-face and where appropriate should involve another member of the family.
” Open source report
24 Jun 2022 ZSOLT KIRJAK · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 5 Insufficient suicide risk assessment View source Lack of enquiry into previous self-harm and associated injury View source Incomplete psychiatric assessment View source Failure to provide the patient's wife an opportunity to contribute to clinical and risk assessments and management planning View source Failure of treatment planning to manage patient risks 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
ZSOLT KIRJAK · 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
ZSOLT KIRJAK died on 14 March 2021 after driving his car to a location following prolonged tinnitus, lack of sleep, anxiety and suicidal thoughts. The report raises concerns that his psychiatric assessment and suicide risk assessment were incomplete, that relevant previous self-harm was not adequately investigated, and that it was unclear whether his wife was given an opportunity to contribute to his assessments and management plan.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient suicide risk assessment
Wider context from the report “2. The Psychiatric assessment 4 (four) days prior to the Patient’s death was incomplete, partially with regards to his psychiatric history (including previous attempts at self harm and the documented recent attempt by the patient to give himself a stroke), substance use and medical history. Correspondingly, there was an insufficient risk assessment that did not include or appraise the Patient’s risk factors for suicide . The treatment plan prescribed did not manage the Patient’s risks.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of enquiry into previous self-harm and associated injury
Wider context from the report “3. There was a lack of enquiry by any of the clinicians who had seen the patient into the Patient’s previous attempt to give himself a stroke and a subsequently acquired eye injury. It is very unusual for a patient to attempt to give oneself a stroke and would reasonably be expected to warrant a detailed assessment because it implies a high degree of harm and lethality.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete psychiatric assessment
Wider context from the report “2. The Psychiatric assessment 4 (four) days prior to the Patient’s death was incomplete, partially with regards to his psychiatric history (including previous attempts at self harm and the documented recent attempt by the patient to give himself a stroke), substance use and medical history. Correspondingly, there was an insufficient risk assessment that did not include or appraise the Patient’s risk factors for suicide. The treatment plan prescribed did not manage the Patient’s risks.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the patient's wife an opportunity to contribute to clinical and risk assessments and management planning
Wider context from the report “4. Though there was contact between the LPS clinician and the Patient’s wife, there is no evidence as to whether the Patient’s wife was given the opportunity to contribute to his clinical and risk assessments and corresponding management plan .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of treatment planning to manage patient risks
Wider context from the report “2. The Psychiatric assessment 4 (four) days prior to the Patient’s death was incomplete, partially with regards to his psychiatric history (including previous attempts at self harm and the documented recent attempt by the patient to give himself a stroke), substance use and medical history. Correspondingly, there was an insufficient risk assessment that did not include or appraise the Patient’s risk factors for suicide. The treatment plan prescribed did not manage the Patient’s risks.
” Open source report
14 Dec 2021 Hedley Frederick ROBINSON · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 2 Failure to discuss S. 136 Mental Health Act assessments with relevant police officers and other involved care professionals View source Failure to ensure that S. 136 Mental Health Act assessments use full information held by relevant services 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
Hedley Frederick ROBINSON · 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
Hedley Frederick ROBINSON died on 14 April 2019 after sustaining multiple stab wounds inflicted in Newport Pagnell on 24 March 2019. The concern identified was that a Mental Health Act section 136 assessment was conducted without full information or discussion with relevant senior police officers and others involved in the assailant’s care, prompting concern about the operation of section 136 procedures in Milton Keynes.
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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss S. 136 Mental Health Act assessments with relevant police officers and other involved care professionals
Wider context from the report “I am concerned that the S. 136 Mental Health Act assessment was conducted without full information held by CNWL or discussion with senior police officers and others who had been involved in the care of the deceased’s assailant . There needs to be an urgent review of the operation of S. 136 procedures in Milton Keynes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that S. 136 Mental Health Act assessments use full information held by relevant services
Wider context from the report “I am concerned that the S. 136 Mental Health Act assessment was conducted without full information held by CNWL or discussion with senior police officers and others who had been involved in the care of the deceased’s assailant. There needs to be an urgent review of the operation of S. 136 procedures in Milton Keynes.
” Open source report
28 Mar 2021 Bathsheba Shepherd · Prevention of Future Deaths report London (West)
View report summary
Concerns raised 2 Failure of GP registration processes to enable registration without relevant documentary proof View source Failure to resolve the interagency Care Programme Approach process 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
Bathsheba Shepherd · 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
Bathsheba Bianca Kay Shepherd, known as Kay, was fatally stabbed by her housemate at some point between 10 and 11 November 2015 and was pronounced deceased on 11 November 2015. The report identified concerns about her being housed with a dangerous and vulnerable housemate, failures in risk assessment and rehousing, and her lack of GP registration and associated support.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of GP registration processes to enable registration without relevant documentary proof
Wider context from the report “(2) I was concerned by evidence in the course of the Inquest that the disengagement of a person with known psychological illness from the process of registration with a GP by her failure to obtain relevant documentary proof to enable registration meant that she could not be registered . Registration with a regular GP would in my mind have provided additional support to her. This may have enabled her to raise concerns or fears relating to her accommodation and housemate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to resolve the interagency Care Programme Approach process
Wider context from the report “(1) I was concerned to find that even though 5 years had elapsed between Kay’s death and the hearing of the Inquest the issue of the way in which the Care Programme Approach was being conducted between the local authority and the NHS Trust was still the subject of discussion and had not been resolved to the satisfaction of the manager responsible for the process . The delay in my view represents a threat to the lives of others in similar situations .
” Open source report
6 Jul 2020 Prince Kwabena Fosu · Prevention of Future Deaths report West London
View report summary
Concerns raised 2 Failure to report detainee concerns simultaneously to the Home Office contract monitor and healthcare managers at the IRC View source Failure to recognise when to refer cases to healthcare View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Prince Kwabena Fosu · 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 Fosu was being held in a single cell at Harmondsworth IRC when he was found unresponsive on 30 October 2012. The inquest jury found that control points protecting vulnerable detainees were grossly ineffective and that there had been failures across agencies to recognise, monitor and respond to his deteriorating condition. The stated concerns included recognising when to refer detainees to healthcare and ensuring that concerns were reported simultaneously to healthcare managers and the Home Office contract monitor.
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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to report detainee concerns simultaneously to the Home Office contract monitor and healthcare managers at the IRC
Wider context from the report “2. IMB- The current practise remains to refer concerns around detainees only to the Home Office contract monitor. I see no good reason not to, in addition and simultaneously, report concerns to the healthcare managers at the IRC. In recording this concern I have in mind the jury’s determinations and findings in the record of inquest which highlight ineffective joint working across all agencies. Simultaneous reporting of issues would lessen the prospect of a healthcare related issue slipping through the net and not being addressed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise when to refer cases to healthcare
Wider context from the report “1. CNWL - All staff who would be expected to refer cases to healthcare need as much assistance as possible in order to discharge that responsibility effectively. It is recognised CNWL is the new healthcare provider and did not provide healthcare in 2012. It is also recognised that CNWL have improved the training on how to make a referral. However, there was knowledge on how to make a referral in 2012 and the jury have highlighted the failures that still occurred , leading to the death of Mr Fosu . My concern centres on improving the recognition of when to make a referral as opposed to knowing the mechanics of making a referral once a decision has been made to refer. By way of respectful analogy, medical practitioners referring cases to a coroner know how to make a referral but now have guidance in legislation as to when to refer. The Trust should give serious consideration to developing a guide to all staff on when to refer cases to healthcare. This should be achievable without being either over-prescriptive or over-restrictive.
” 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 Draft guidance on conditions and symptoms indicating referral to the Mental Health Team.
Verbatim wording from the response “Thirdly, the Offender Care directorate is drafting guidance on when a patient should be referred to the mental health team, including conditions and symptoms. This guidance will be added to the Offender Care Mental Health and Learning Disability Operating Policy. The Offender Care Mental Health and Learning Disability Operating Policy is applicable to all CNWL staff and sub-contractors in offender care settings and provides an overview of services and expectations of how these services will be delivered. The policy is also shared with commissioners, partner agencies, prisons and Immigration Removal Centre staff. Including the guidance on when to refer to the mental health team within this document ensures it is available to all relevant parties.” Source location 2020-0148-Response-from-Central-and-North-West-London-NHS-Foundation-Trust.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate the referral guidance as a standalone document to CNWL staff and partner agencies across relevant IRC and prison services.
Verbatim wording from the response “In addition to embedding this guidance into the Offender Care Mental Health and Learning Disability Operating Policy, we will also be circulating it as a standalone document to all CNWL staff and to all partner agencies in the IRC and across the prisons in which we provide healthcare by the end of November 2020.” Source location 2020-0148-Response-from-Central-and-North-West-London-NHS-Foundation-Trust.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add referral guidance to the Offender Care Mental Health and Learning Disability Operating Policy.
Verbatim wording from the response “Thirdly, the Offender Care directorate is drafting guidance on when a patient should be referred to the mental health team, including conditions and symptoms. This guidance will be added to the Offender Care Mental Health and Learning Disability Operating Policy. The Offender Care Mental Health and Learning Disability Operating Policy is applicable to all CNWL staff and sub-contractors in offender care settings and provides an overview of services and expectations of how these services will be delivered. The policy is also shared with commissioners, partner agencies, prisons and Immigration Removal Centre staff. Including the guidance on when to refer to the mental health team within this document ensures it is available to all relevant parties.” Source location 2020-0148-Response-from-Central-and-North-West-London-NHS-Foundation-Trust.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adapt mental health awareness training to explain when staff should refer patients to the Mental Health Team.
Verbatim wording from the response “Firstly, mental health awareness training already taking place in the Immigration Removal Centre (IRC) and already available to Care and Custody staff as well as healthcare has been adapted to include specific information detailing when a referral should be made to the Mental Health Team. Included within the training package is an overview of what mental health is, the main groups of mental disorders and slides covering depression, bipolar, anxiety, panic attacks, Post-Traumatic Stress Disorder, Personality disorders, schizophrenia, treatment and referrals. For each of these conditions, there is a summary of how the conditions present, what staff should look out for and the action that they should take. The training recommends that if staff recognise any of these conditions they should refer the patient to the mental health team.” Source location 2020-0148-Response-from-Central-and-North-West-London-NHS-Foundation-Trust.pdf
Open published response
21 Feb 2020 Andrew Goldstraw · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 5 Failure of SystmOne search functions to extract key mental health risk information View source Failure to identify documented suicide and deliberate self-harm risk information View source SystmOne failing to facilitate retrieval of key suicide and deliberate self-harm risk information View source Failure to maintain accurate and usable summary and active-problem risk information View source Lack of effective SystmOne training and competency in suicide and deliberate self-harm risk assessment View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew Goldstraw · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrew Goldstraw was found hanging in a cell at HM Prison, Winchester, on 14 November 2018, having taken his own life using a ligature made from torn bed linen. The report raised concerns that relevant information about his previous suicidal ideation and self-harm attempts was difficult for healthcare staff to identify in SystmOne, that the system could hinder effective risk assessment, and that staff training may have been inadequate. The inquest jury found that an ACCT should have been opened and that its absence would have more than minimally helped to prevent his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of SystmOne search functions to extract key mental health risk information
Wider context from the report “B. SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT. Too much reliance is placed on the individual prisoners presentation and how he answers a series of pre-set questions.
C. At best, SystmOne makes it difficult for a mental health nurse to ascertain the relevant information and at worst it actively misleads them. For example, a search can be made of the "journal" section but this would rely on the exact words being searched (such as "suicide" or "deliberate self-harm") and it would then be necessary to go through the various entries (in Mr Goldstraw's case spread over 111 pages) using the "Key Word Search" function. Further, the functions that would (on the face of it) serve to assist in this situation (such as the "Summary" page or "Active Problems" section) were not populated with the information relevant to an accurate assessment. It was conceded by the legal representatives acting on behalf of CNWL that the "Summary" section is "very limited in its contents" and is not routinely used by healthcare staff within the prison in order to gain an insight into a prisoner's past medical history.
D. The "Active Problems" section of SystmOne is subdivided in to a number of distinct areas and it appears to be wholly inadequate in terms of identifying key areas of concern such as the risk of suicide or deliberate self-harm. The only information contained in the "Active Problems" section of SystmOne in Mr Goldstraw's case was four years out of date. None of the relevant information was contained in "Active Problems" but a great deal of irrelevant information was there!
E. The "Communications" section of SystmOne contains a chronological record of correspondence with the hospital, GP surgery and psychiatric units. However, the "Key Word Search" facility does not function at all and short of going through all of the correspondence there is no way of identifying the key information needed to undertake an effective risk assessment. The "Communications" section in Mr Goldstraw's case amounted to 83 pages. Although the relevant information concerning Mr Goldstraw's mental health issues was contained within the "Communications" section of SystmOne there was no way of easily extracting it .
F. Accordingly, a busy, under pressure mental health nurse or doctor is very likely to struggle to find the relevant entries using SystmOne, which may explain why (in Mr Goldstraw's case) too much reliance was placed on how he presented during interview. A prisoner who chooses not to disclose his true state of mind or suicidal ideation is unlikely to come to the notice of the healthcare staff whose job it is to identify the risk that he may pose to himself because SystmOne does not facilitate this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify documented suicide and deliberate self-harm risk information
Wider context from the report “A. The computer system used by CNWL is known as SystmOne. Healthcare staff working on Reception when Mr Goldstraw first arrived at the prison had access to his previous medical notes and history (around 240 pages in all) stored on SystmOne. The records contained numerous references to suicidal ideation and previous attempts at deliberate self-harm. Mr Goldstraw had attempted to take his own life on several previous occasions, the most recent of which was only three months prior to his arrival at the prison. However, despite a proliferation of entries making reference to his mental health history the mental health nurse who had access to SystmOne was seemingly unaware of the relevant entries . Had he been, he said he would have opened an ACCT.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation SystmOne failing to facilitate retrieval of key suicide and deliberate self-harm risk information
Wider context from the report “B. SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT . Too much reliance is placed on the individual prisoners presentation and how he answers a series of pre-set questions.
C. At best, SystmOne makes it difficult for a mental health nurse to ascertain the relevant information and at worst it actively misleads them. For example, a search can be made of the "journal" section but this would rely on the exact words being searched (such as "suicide" or "deliberate self-harm") and it would then be necessary to go through the various entries (in Mr Goldstraw's case spread over 111 pages) using the "Key Word Search" function. Further, the functions that would (on the face of it) serve to assist in this situation (such as the "Summary" page or "Active Problems" section) were not populated with the information relevant to an accurate assessment. It was conceded by the legal representatives acting on behalf of CNWL that the "Summary" section is "very limited in its contents" and is not routinely used by healthcare staff within the prison in order to gain an insight into a prisoner's past medical history.
D. The "Active Problems" section of SystmOne is subdivided in to a number of distinct areas and it appears to be wholly inadequate in terms of identifying key areas of concern such as the risk of suicide or deliberate self-harm. The only information contained in the "Active Problems" section of SystmOne in Mr Goldstraw's case was four years out of date. None of the relevant information was contained in "Active Problems" but a great deal of irrelevant information was there!
E. The "Communications" section of SystmOne contains a chronological record of correspondence with the hospital, GP surgery and psychiatric units. However, the "Key Word Search" facility does not function at all and short of going through all of the correspondence there is no way of identifying the key information needed to undertake an effective risk assessment. The "Communications" section in Mr Goldstraw's case amounted to 83 pages. Although the relevant information concerning Mr Goldstraw's mental health issues was contained within the "Communications" section of SystmOne there was no way of easily extracting it.
F. Accordingly, a busy, under pressure mental health nurse or doctor is very likely to struggle to find the relevant entries using SystmOne, which may explain why (in Mr Goldstraw's case) too much reliance was placed on how he presented during interview. A prisoner who chooses not to disclose his true state of mind or suicidal ideation is unlikely to come to the notice of the healthcare staff whose job it is to identify the risk that he may pose to himself because SystmOne does not facilitate this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate and usable summary and active-problem risk information
Wider context from the report “B. SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT. Too much reliance is placed on the individual prisoners presentation and how he answers a series of pre-set questions.
C. At best, SystmOne makes it difficult for a mental health nurse to ascertain the relevant information and at worst it actively misleads them. For example, a search can be made of the "journal" section but this would rely on the exact words being searched (such as "suicide" or "deliberate self-harm") and it would then be necessary to go through the various entries (in Mr Goldstraw's case spread over 111 pages) using the "Key Word Search" function. Further, the functions that would (on the face of it) serve to assist in this situation (such as the "Summary" page or "Active Problems" section) were not populated with the information relevant to an accurate assessment . It was conceded by the legal representatives acting on behalf of CNWL that the "Summary" section is "very limited in its contents" and is not routinely used by healthcare staff within the prison in order to gain an insight into a prisoner's past medical history.
D. The "Active Problems" section of SystmOne is subdivided in to a number of distinct areas and it appears to be wholly inadequate in terms of identifying key areas of concern such as the risk of suicide or deliberate self-harm . The only information contained in the "Active Problems" section of SystmOne in Mr Goldstraw's case was four years out of date. None of the relevant information was contained in "Active Problems" but a great deal of irrelevant information was there!
E. The "Communications" section of SystmOne contains a chronological record of correspondence with the hospital, GP surgery and psychiatric units. However, the "Key Word Search" facility does not function at all and short of going through all of the correspondence there is no way of identifying the key information needed to undertake an effective risk assessment. The "Communications" section in Mr Goldstraw's case amounted to 83 pages. Although the relevant information concerning Mr Goldstraw's mental health issues was contained within the "Communications" section of SystmOne there was no way of easily extracting it.
F. Accordingly, a busy, under pressure mental health nurse or doctor is very likely to struggle to find the relevant entries using SystmOne, which may explain why (in Mr Goldstraw's case) too much reliance was placed on how he presented during interview. A prisoner who chooses not to disclose his true state of mind or suicidal ideation is unlikely to come to the notice of the healthcare staff whose job it is to identify the risk that he may pose to himself because SystmOne does not facilitate this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of effective SystmOne training and competency in suicide and deliberate self-harm risk assessment
Wider context from the report “G. There also appeared to be a lack of training in relation to the effective use of SystmOne . In particular, it was not clear whether any steps had been taken to ensure that the staff who were working at the prison at the time of Mr Goldstraw's death had been retrained or had their competencies assessed in light of the failures identified. There is a real concern that some staff are still failing adequately to carry out assessments of a prisoners risk of suicide / deliberate self-harm.
H. The Head of Healthcare at HM Prison, Winchester has indicated that she intends to provide (in conjunction with the Prison Governor) a joint learning bulletin to all staff, stressing the importance of sharing information, most notably in reception and during the early days in custody. However, this does not address the technical shortcomings of SystmOne which present a matter of considerable concern, even if healthcare staff undertake all reasonable steps to ascertain a prisoner's previous mental health history as part of the prison induction process.
” 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 Train all staff during induction to use SystmOne’s problem functionality and audit its use through quarterly care-quality meetings.
Verbatim wording from the response “This functionality has the potential to be very helpful if used appropriately as, for instance, every episode of self-harm could be linked to a problem “Self-harm” meaning all episodes are collated in one place. CNWL has sent out guidance to all staff on how to manage problems on SystmOne. Training will be provided on “problems” for every member of staff during their induction. The use of problems on SystmOne will be audited through the Offender Care, Care Quality Meetings initially on a quarterly basis to review progress of this function.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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 Distribute guidance to offender-care sites on using SystmOne searches to identify suicide and self-harm history.
Verbatim wording from the response “The Trust has sent out guidance to all offender care sites in relation to the search function. Whilst this is a function owned by SystmOne CNWL has given staff directions on how to best utilise this function. For instance, when trying to get a history of suicide attempts rather than searching suicide the clinician should search ‘suic’ which will bring up results for suicide, suicidal, suicidal thoughts.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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 Remind staff to use SystmOne search tools when information entered by other organisations is difficult to locate.
Verbatim wording from the response “We will also remind staff that other organisations use SystmOne and that they may not enter data in an easy to view way. Staff have been advised to use search functionality to find data that may have not been entered properly by staff from other organisations.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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 Deliver SystmOne training through induction and the Learning and Development Zone, including additional training identified through supervision.
Verbatim wording from the response “All staff are trained in SystmOne during their induction. SystmOne training is now available on the Trust’s Learning and Development Zone (LDZ) and all staff identified as requiring additional training (through six weekly supervision) will complete the SystmOne training on LDZ.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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 Provide reception-screening nurses with a guide explaining how to register patients and access previous medical records.
Verbatim wording from the response “A reception guide has been developed for all CNWL nursing staff undertaking reception screening. This includes clear guidance on how a staff member is able to access previous medical records when registering a patient within the prison. A patient must be registered with the prison by the nurse in the reception and then the records saved prior to the nursing staff having access to all the medical records. This is clearly outlined in the reception guidance document.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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 Audit mental-health risk assessments and resulting care plans quarterly and during the annual medical-records audit.
Verbatim wording from the response “Additionally, Offender Care is carrying out quarterly review of risk assessments. Mental Health risk assessments have been developed across CNWL offender care services and have been uploaded onto SystmOne. These risk assessments include a patient’s risk of harm to themselves and to others. These risk assessments should be updated whenever there is a recognised change in a patients risk and should form the basis of a care plan. Both risk assessments and the care plans they help formulate are audited every three months and also form part of the annual medical records audit to provide assurances that risks are being appropriately identified.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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 Distribute guidance and a standard process for reviewing, entering and linking diagnoses and problems in SystmOne.
Verbatim wording from the response “The usefulness of the “Problem section” is reliant on the information added to it by whichever establishment the patient is in. However, CNWL offender care have sent out a memo to all staff to inform them how to review problems which are on the SystmOne record. In addition, since this inquest, CNWL Offender Care have sent out the SystmOne guidance section in how to input diagnosis data and link it to consultations in a standard way across the service. This is referred to as “creating a problem”. To ensure this memo is acted upon, Offender Care will undertake a review of the use of problem section in conjunction with their annual medical records audit. This audit generates site specific action plans highlighting areas for improvement.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review use of SystmOne’s problem section through the annual medical-records audit and assign improvement actions where required.
Verbatim wording from the response “The usefulness of the “Problem section” is reliant on the information added to it by whichever establishment the patient is in. However, CNWL offender care have sent out a memo to all staff to inform them how to review problems which are on the SystmOne record. In addition, since this inquest, CNWL Offender Care have sent out the SystmOne guidance section in how to input diagnosis data and link it to consultations in a standard way across the service. This is referred to as “creating a problem”. To ensure this memo is acted upon, Offender Care will undertake a review of the use of problem section in conjunction with their annual medical records audit. This audit generates site specific action plans highlighting areas for improvement.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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 Require annual Suicide and Self Harm and ACCT training, with successful testing before staff are signed off as compliant.
Verbatim wording from the response “All staff are now required to complete annual Suicide and Self Harm training and annual ACCT training. In these training packages, identification of suicide and deliberate self- harm risk are covered and all staff have to successfully pass a test which covers these areas to be signed off as compliant.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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 Require reception-screening staff to complete modified training and confirm competence through induction sign-off and supervision.
Verbatim wording from the response “The Trust has modified its staff training to ensure this type of issue does not re-occur in the future. All staff are required to complete this training as part of their induction and to sign that they have completed the training and are competent to undertake reception screening. For existing staff this training and compliance issues will be discussed through management supervisions.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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 accuracy of SystmOne’s problem list depends on all providers updating records, not solely on CNWL.
Verbatim wording from the response “The Problem list is populated by staff who use SystmOne. CNWL are not the only provider who use SystmOne and therefore an accurate Problem list is dependent on” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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 SystmOne’s contract is managed by NHS England, while system developments are for NHS England and TPP to consider.
Verbatim wording from the response “SystmOne is the medical records system for all prisoners and this contract with TPP is managed by NHS England and not directly by CNWL. However, with internal training and audit we hope to be able to overcome a significant proportion of the limitations identified. We will also be raising the Coroner’s concerns and our work around with TPP so that they can consider them in any future developments of the system” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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 Clinicians are not reliant solely on patients’ disclosed answers or presentation when assessing suicide and self-harm risk.
Verbatim wording from the response “Whilst the risk assessment template on SystmOne does ask pre-set questions the clinician is not reliant solely on the information disclosed during the assessment. When completing the risk assessment there is a section on the right hand side of the template with previous values that have been entered in relation to these questions. This allows the clinician to have an understanding of previous answers to these questions and gives them some context when considering a response to a question. For instance if a patient’s response contradicts a previous statement they have made the staff will be able to ascertain this and ask appropriate follow up. When the cursor is put in the box relating to risk incidents and triggers previous entries about this come up on the right hand section of the template.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
Open published response
24 Sep 2019 Iain Neil MACINNES · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 1 Failure to keep patients’ families informed of significant changes in care 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
Iain Neil MACINNES · 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
Iain Neil MACINNES was found hanging at his home in Milton Keynes on 17 January 2019, after his mental health had deteriorated during December 2018. The report identified concerns that his family were not informed about his deterioration or transfer to the Acute Home Treatment Team, and that there was a failure to recognise the extent of his deterioration, resulting in lost opportunities for hospital admission.
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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to keep patients’ families informed of significant changes in care
Wider context from the report “During the course of the evidence it became apparent that, despite the fact that the deceased had indicated that he wanted information to be shared with his family and for them to be involved in his care, they were not informed that his condition had deteriorated and that he had been transferred to the Home Treatment Team although it was widely accepted that it is important that the family are involved in a patients treatment and care. The process for recording details of the family and for keeping them informed needs to be reviewed by the trust and proposals for reform considered.
” Open source report
28 Aug 2019 Amir Siman-Tov · Prevention of Future Deaths report London (West)
View report summary
Concerns raised 14 Failure to communicate and establish vomiting during return to the healthcare unit View source Failure to provide detailed written clinical information and directions on discharge View source Failure to use the code blue procedure to summon an immediate emergency ambulance View source Failure to administer naloxone in suspected opiate overdose View source Lack of authority to require healthcare staff participation in the ACDT process View source Failure of the Consultant Forensic Psychiatrist to read ACDT documents View source Failure to apply renal impairment information in codeine overdose assessment View source Failure of healthcare staff to understand and participate in the ACDT process View source Failure to position an unresponsive patient on the floor for effective resuscitation View source Failure of hospital clinicians to account for available medical monitoring and supervision when returning patients to Colnbrook IRC View source Unclear healthcare staff roles in the ACDT process View source Failure to provide explicit clinical direction and handover to night staff View source Inconsistent checks that detainees swallow issued medication View source Failure to wake, assess and take vital signs of a sleeping patient at risk View source See 11 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
Amir Siman-Tov · 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
Amir Siman-Tov died at Colnbrook Immigration Removal Centre on 17 February 2016 after taking an overdose of codeine. The concerns included inconsistent involvement of healthcare staff in the ACDT self-harm reduction process, inconsistent medication checks, inadequate hospital discharge information and handover, insufficient monitoring after his return, and shortcomings in the emergency response.
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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate and establish vomiting during return to the healthcare unit
Wider context from the report “9. During the journey back to the Colnbrook IRC Mr Siman-Tov vomited several times. He vomited on his return to the healthcare unit. The nurse on duty was not told by the escorting custody staff and did not ask about any vomiting in the returning minus. In oral evidence the nurse said that had he known of the vomiting then he would have returned Mr Siman-Tov to the hospital for further assessment. He did not know because he did not ask and was not told .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide detailed written clinical information and directions on discharge
Wider context from the report “8. On discharge Mr Siman-Tov in the early evening of the 16ᵗʰ February 2016 was returned to Colnbrook IRC with no accompanying clinical information at all and no advice or directions to the clinical staff at the Colnbrook IRC from the hospital . The only information provided was that one of the hospital doctors had spoken to one of the Colnbrook IRC on the telephone and that Mr Siman-Tov was “good to go”. Failure to provide detailed written information puts patients at risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use the code blue procedure to summon an immediate emergency ambulance
Wider context from the report “12. At approximately 3.10 on the 17ᵗʰ February 2016 Mr Siman-Tov was found to be unresponsive by custody officers. Medical assistance was called for but the required “code blue” for summoning an immediate emergency ambulance was not used .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to administer naloxone in suspected opiate overdose
Wider context from the report “14. An emergency bag was brought containing adrenaline autoinjector and also naloxone which Dr Harris said was a temporary antidote to opiates . A nurse gave an injection of adrenaline into the thigh “because he thought it might help”. Naloxone was not given , even though ████████ had required emergency admission the day prior because of an opiate overdose. This puts detainees at risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of authority to require healthcare staff participation in the ACDT process
Wider context from the report “4. The Centre Manager gave evidence that he recognised the importance of the ACDT process in keeping detainee’s safe and he actively encouraged as wide participation in the process as possible. He stated that he was only able to direct the custody staff and it was not in his power to direct that healthcare staff participated .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Consultant Forensic Psychiatrist to read ACDT documents
Wider context from the report “3. The Consultant Forensic Psychiatrist did not read the ACDT documents . This puts detainees at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to apply renal impairment information in codeine overdose assessment
Wider context from the report “6. Mr Siman-Tov was taken to the Hillingdon Hospital in the late morning following his overdose on the 16ᵗʰ February 2016. At the Hillingdon Hospital an assessment, examination and blood tests were taken. The blood tests indicated renal impairment. An information system TOXBASE is used in emergency departments to provide assistance to clinicians. Toxbase indicates that in renal impairment greater care must be taken in cases of codeine overdose. This was missed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of healthcare staff to understand and participate in the ACDT process
Wider context from the report “1. A GP who had seen Mr Siman-Tov during his stay at Colnbrook IRC told the jury that he never seen and was not aware of the content of ACDT documents and regarded the documents as a custody officer process. He told the Court that it was not customary for healthcare staff to attend or participate in the ACDT process . This puts detainees at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to position an unresponsive patient on the floor for effective resuscitation
Wider context from the report “13. Nursing and other staff arrived. A custody officer asked the nurse if Mr Siman-Tov should be moved to the floor for resuscitation. The nurse replied no. Dr Harris, an expert in Emergency Medicine said that he should have been moved to the floor for effective resuscitation . This puts detainees at risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital clinicians to account for available medical monitoring and supervision when returning patients to Colnbrook IRC
Wider context from the report “7. The hospital clinicians gave evidence which suggested that they were not fully aware of the level of medical monitoring and supervision available at Colnbrook IRC . Mr Siman-Tov had taken an overdose whilst supervised within that facility and a decision was made to return him to that environment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear healthcare staff roles in the ACDT process
Wider context from the report “2. The nurses who gave evidence similarly were uncertain of their role with respect to the ACDT process and had variable accounts of their involvement in the ACDT process . This puts detainees at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide explicit clinical direction and handover to night staff
Wider context from the report “10. Mr Siman-Tov’s care was then handed over to night staff. No explicit direction or handover was given . The explanation for this was that the observations should be second signature and did not need elaboration.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent checks that detainees swallow issued medication
Wider context from the report “5. Mr Siman-Tov expressed that he might save his medication and take as an overdose. There was conflicting evidence as to the rigour of the checks to ensure detainees had swallowed issued medicine at the time of dispensing and the nurses who gave evidence described different practices of observation . Mr Siman-Tov was able to collect sufficient codeine ultimately to be able to end his life. This lack of consistency of checks puts detainee’s at risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to wake, assess and take vital signs of a sleeping patient at risk
Wider context from the report “11. The night nurse on duty at around 2100 noted that Mr Siman-Tov was sleeping and snoring. He made no attempt to wake him, check him or take his vital signs . This put Mr Siman-Tov at risk .
” Open source report
29 Apr 2019 Georgia Sylvia Nelson · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 6 Lack of suitable housing for young patients with severe and enduring mental illness View source Failure to use inpatient opportunities to address care and treatment needs before discharge View source Failure to ensure proper discharge planning and referral for patients with mental illness View source Severe shortage of rehabilitation housing placements View source Lack of long-term supported housing placements for patients with severe and enduring mental illness View source Failure to actively consider rehabilitation as a discharge option where housing concerns exist View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 10
Action
Maintain discharge-planning policies and ward processes, including admission discharge planning, daily discharge-tool use, and pre-discharge communication with care coordinators and families.
Stated completedThe respondent said that this action was complete when they made their response on 14 June 2019. View source
Action
Follow new NICE rehabilitation guidance when considering rehabilitation during discharge planning.
Stated plannedThe respondent said that this action was planned when they made their response on 14 June 2019. View source
Action
Implement the piloted trauma-informed inpatient care approach across all sites.
Stated plannedThe respondent said that this action was planned when they made their response on 14 June 2019. View source
Action
Have Crisis and Home Treatment Teams attend each ward’s daily handover to contribute to discharge planning.
Stated completedThe respondent said that this action was complete when they made their response on 14 June 2019. View source
Action
Give every discharged patient a crisis contact and help information, together with details of their follow-up appointment.
Stated plannedThe respondent said that this action was planned when they made their response on 14 June 2019. View source
Action
Work with commissioners and the local authority to secure a wider choice of rehabilitation services for patients.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 June 2019. View source
Action
Deliver face-to-face contact with an identified worker within 72 hours for people leaving hospital.
Stated plannedThe respondent said that this action was planned when they made their response on 14 June 2019. View source
Action
Have community team leads attend daily bed-management huddles to support communication about forthcoming discharges.
Stated plannedThe respondent said that this action was planned when they made their response on 14 June 2019. View source
Action
Ensure community teams discuss all inpatients daily so they know patients’ progress and can contribute to admission goals.
Stated plannedThe respondent said that this action was planned when they made their response on 14 June 2019. View source
Action
Maximise available community support and interventions, including recovery, vocational, employment-support and peer-support services, within discharge planning.
Stated plannedThe respondent said that this action was planned when they made their response on 14 June 2019. View source See 7 more actions
×
AI-generated summary
Georgia Sylvia Nelson · 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
Georgia Sylvia Nelson, who had treatment-resistant schizophrenia and severe persistent symptoms, stepped in front of a train at Gloucester Road Underground Station on 11 May 2018 and was killed instantly. The report raised concerns about the lack of suitable long-term and rehabilitation housing for young people with severe mental illness, inadequate discharge planning, and missed opportunities to improve treatment and consider rehabilitation before discharge.
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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of suitable housing for young patients with severe and enduring mental illness
Wider context from the report “1. That there is no suitable housing specifically for young patients with severe and enduring mental illness in RBKC .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use inpatient opportunities to address care and treatment needs before discharge
Wider context from the report “5. That whilst mental health patients are in hospital all opportunities are used to improve their care and treatment and that where possible, they are not discharged before these have been appropriately addressed , rather than discharging them as soon as they are deemed no longer at active risk to themselves or others .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure proper discharge planning and referral for patients with mental illness
Wider context from the report “4. That there should be a system to ensure that there is proper discharge planning and referral on for all patients discharged after admission with mental illness .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Severe shortage of rehabilitation housing placements
Wider context from the report “3. There is a severe shortage of rehabilitation housing placements in RBKC for patients who require them .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of long-term supported housing placements for patients with severe and enduring mental illness
Wider context from the report “2. There are no long term placements, potentially life long, for any patients requiring supported housing in RBKC with such mental illness .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to actively consider rehabilitation as a discharge option where housing concerns exist
Wider context from the report “6. That rehabilitation should be more actively considered as a discharge option for patients especially where there are pre-admission concerns about their housing .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain discharge-planning policies and ward processes, including admission discharge planning, daily discharge-tool use, and pre-discharge communication with care coordinators and families.
Verbatim wording from the response “The Trust has specific policies (CPA Policy 2015 and the Discharge and Transfer of Patients, 2015) in place that set out the expectations and requirements of discharge planning and referral for patients leaving hospital are completed. These policies underpin the important principle of the need for community teams work to closely with inpatient teams to ensure that planning is carried out to ensure as seamless a transition as possible from our inpatient services to the community in recognition of the well-known vulnerability of this period.” Source location 2019-0140-Response-by-CNWL-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Follow new NICE rehabilitation guidance when considering rehabilitation during discharge planning.
Verbatim wording from the response “NICE are due to produce guidelines on Rehabilitation in adults with complex psychosis and related severe mental health conditions that we know are likely to propose a wider range of options to provide patients with rehabilitation not just in an inpatient setting. This is the national direction of travel, with patients being brought back from out of area placements to their local community and rehabilitation being provided in high supported accommodation or even in patients’ independent accommodation. We are working with our commissioner and local authority to ensure that services are commissioned for our patients that give the widest choice of rehabilitation options and keep up to date with modern ways of working. This will mean that as discharge planning starts at admission, we will follow the new NICE guidance on considering rehabilitation as appropriate.” Source location 2019-0140-Response-by-CNWL-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the piloted trauma-informed inpatient care approach across all sites.
Verbatim wording from the response “To ensure that this is the case we will:
- We have successfully piloted a new trauma-informed approach to in-patient care delivery in one of our units and this is being implemented across all sites. This will support the development of a more personalised approach to in-patient care
- The Crisis and Home Treatment Teams attending the handover meeting on each ward daily will ensure they are aware of any planned discharges and contribute to discharge planning for all patients on the wards
- Every community team has a daily ‘zoning’ meeting and we will ensure that all inpatients are discussed in the relevant team so community teams are aware of all current in-patients and their progress and can contribute meaningfully to the intended aim of the admission
- Community team leads will attend the daily bed management meeting huddles where forthcoming discharges are discussed to ensure they are” Source location 2019-0140-Response-by-CNWL-NHS-Trust
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 Have Crisis and Home Treatment Teams attend each ward’s daily handover to contribute to discharge planning.
Verbatim wording from the response “To further support this critical point in the pathway we will:
- The Crisis and Home Treatment Teams now attend the daily handover meeting on each ward to ensure they are aware of any planned discharges and contribute to discharge planning for all patients on the wards.
- Ensure we deliver on the National CQUIN that people leaving hospital have face to face contact within 72 hours of discharge by an identified worker.
- That all patients leave hospital with a clear plan of who to contact in crisis and where to get help if they need it as well as the details of the above appointment. This will help this critical period of adjustment and support longer term ongoing care and communication.
- Ensure the learning from this case is shared across all in-patient, crisis and community teams” Source location 2019-0140-Response-by-CNWL-NHS-Trust
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 Give every discharged patient a crisis contact and help information, together with details of their follow-up appointment.
Verbatim wording from the response “To further support this critical point in the pathway we will:
- The Crisis and Home Treatment Teams now attend the daily handover meeting on each ward to ensure they are aware of any planned discharges and contribute to discharge planning for all patients on the wards.
- Ensure we deliver on the National CQUIN that people leaving hospital have face to face contact within 72 hours of discharge by an identified worker.
- That all patients leave hospital with a clear plan of who to contact in crisis and where to get help if they need it as well as the details of the above appointment. This will help this critical period of adjustment and support longer term ongoing care and communication.
- Ensure the learning from this case is shared across all in-patient, crisis and community teams” Source location 2019-0140-Response-by-CNWL-NHS-Trust
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 Work with commissioners and the local authority to secure a wider choice of rehabilitation services for patients.
Verbatim wording from the response “NICE are due to produce guidelines on Rehabilitation in adults with complex psychosis and related severe mental health conditions that we know are likely to propose a wider range of options to provide patients with rehabilitation not just in an inpatient setting. This is the national direction of travel, with patients being brought back from out of area placements to their local community and rehabilitation being provided in high supported accommodation or even in patients’ independent accommodation. We are working with our commissioner and local authority to ensure that services are commissioned for our patients that give the widest choice of rehabilitation options and keep up to date with modern ways of working. This will mean that as discharge planning starts at admission, we will follow the new NICE guidance on considering rehabilitation as appropriate.” Source location 2019-0140-Response-by-CNWL-NHS-Trust
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 Deliver face-to-face contact with an identified worker within 72 hours for people leaving hospital.
Verbatim wording from the response “To further support this critical point in the pathway we will:
- The Crisis and Home Treatment Teams now attend the daily handover meeting on each ward to ensure they are aware of any planned discharges and contribute to discharge planning for all patients on the wards.
- Ensure we deliver on the National CQUIN that people leaving hospital have face to face contact within 72 hours of discharge by an identified worker.
- That all patients leave hospital with a clear plan of who to contact in crisis and where to get help if they need it as well as the details of the above appointment. This will help this critical period of adjustment and support longer term ongoing care and communication.
- Ensure the learning from this case is shared across all in-patient, crisis and community teams” Source location 2019-0140-Response-by-CNWL-NHS-Trust
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 Have community team leads attend daily bed-management huddles to support communication about forthcoming discharges.
Verbatim wording from the response “To ensure that this is the case we will:
- We have successfully piloted a new trauma-informed approach to in-patient care delivery in one of our units and this is being implemented across all sites. This will support the development of a more personalised approach to in-patient care
- The Crisis and Home Treatment Teams attending the handover meeting on each ward daily will ensure they are aware of any planned discharges and contribute to discharge planning for all patients on the wards
- Every community team has a daily ‘zoning’ meeting and we will ensure that all inpatients are discussed in the relevant team so community teams are aware of all current in-patients and their progress and can contribute meaningfully to the intended aim of the admission
- Community team leads will attend the daily bed management meeting huddles where forthcoming discharges are discussed to ensure they are” Source location 2019-0140-Response-by-CNWL-NHS-Trust
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 Ensure community teams discuss all inpatients daily so they know patients’ progress and can contribute to admission goals.
Verbatim wording from the response “To ensure that this is the case we will:
- We have successfully piloted a new trauma-informed approach to in-patient care delivery in one of our units and this is being implemented across all sites. This will support the development of a more personalised approach to in-patient care
- The Crisis and Home Treatment Teams attending the handover meeting on each ward daily will ensure they are aware of any planned discharges and contribute to discharge planning for all patients on the wards
- Every community team has a daily ‘zoning’ meeting and we will ensure that all inpatients are discussed in the relevant team so community teams are aware of all current in-patients and their progress and can contribute meaningfully to the intended aim of the admission
- Community team leads will attend the daily bed management meeting huddles where forthcoming discharges are discussed to ensure they are” Source location 2019-0140-Response-by-CNWL-NHS-Trust
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 Maximise available community support and interventions, including recovery, vocational, employment-support and peer-support services, within discharge planning.
Verbatim wording from the response “sighted on these and can support better communication
- We have a range of support and interventions for patients outside hospital settings which we will ensure are maximised in the discharge planning process. For example the Recovery College offers a range of person-centred interventions and the Trust has a well-developed Vocational service, offering Employment Support using the Individual Placement and Support Model, a User Employment Programme and a strong programme of Peer Support.” Source location 2019-0140-Response-by-CNWL-NHS-Trust
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 Housing provision for young people and rehabilitation placements is outside the Trust’s commissioning functions.
Verbatim wording from the response “Concerns 1, 2 and 3 are within the domain of the Royal Borough of Kensington & Chelsea, who develop and commission housing provision, including a range of supported accommodation. Whilst the Trust does not commission these services, as the major provider of NHS mental health care within the Borough, we do work closely with the local authority to inform and assist them in developing new services. We think however, they will want to respond to these 3 points separately as the responsible organisation, and we are aware they are currently in the process of responding to you in this respect.” Source location 2019-0140-Response-by-CNWL-NHS-Trust
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 Royal Borough of Kensington and Chelsea is responsible for developing and commissioning the relevant housing provision and should respond to these concerns.
Verbatim wording from the response “Concerns 1, 2 and 3 are within the domain of the Royal Borough of Kensington & Chelsea, who develop and commission housing provision, including a range of supported accommodation. Whilst the Trust does not commission these services, as the major provider of NHS mental health care within the Borough, we do work closely with the local authority to inform and assist them in developing new services. We think however, they will want to respond to these 3 points separately as the responsible organisation, and we are aware they are currently in the process of responding to you in this respect.” Source location 2019-0140-Response-by-CNWL-NHS-Trust
Open published response
27 Feb 2019 Peter George Garvin · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 5 Lack of joint-working arrangements between the NHS and private psychiatric consultants View source Discharge of NHS patients seeking private psychiatric care View source Delays in carer assessment during the patient treatment pathway View source Lack of doctor-to-doctor communication for prescribing View source Insufficient local psychiatric beds View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter George Garvin · 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
Peter George Garvin, who was under the care of a Community Mental Health Team while his medication was prescribed by his GP, entered the Regent’s Canal on 31 January 2018 with the intention of taking his own life. The report identifies concerns about communication between the CMHT and GP, insufficient local psychiatric beds, discharge from NHS care after seeking private psychiatric treatment, and the lack of an early carer’s 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of joint-working arrangements between the NHS and private psychiatric consultants
Wider context from the report “3. That if patients seek private psychiatric care they should not be discharged by the NHS. Instead a memorandum of understanding should be agreed between the NHS and Private psychiatric consultants to allow joint working and facilitate patient care . This should surely be possible along the lines of such agreements with GPs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Discharge of NHS patients seeking private psychiatric care
Wider context from the report “3. That if patients seek private psychiatric care they should not be discharged by the NHS . Instead a memorandum of understanding should be agreed between the NHS and Private psychiatric consultants to allow joint working and facilitate patient care. This should surely be possible along the lines of such agreements with GPs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in carer assessment during the patient treatment pathway
Wider context from the report “4. That carer’s assessment should be undertaken early in the patient treatment pathway .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of doctor-to-doctor communication for prescribing
Wider context from the report “1. That there should be a system of doctor to doctor communication to facilitate prescribing , for example through direct email contact.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient local psychiatric beds
Wider context from the report “2. That there should be sufficient local beds so that such a vulnerable person should not have to be hospitalised so very far from home.
” 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 Implement a staff protocol for coordinating NHS care with private psychiatric treatment and explaining the process to patients.
Verbatim wording from the response “Because of the Trust’s location and geography we can potentially be working with any number of private psychiatrists which would make it impossible to have a standard MOU agreed by all of them in advance. As an alternative, we have drawn up a protocol for our own staff, which sets out (a) how they should work with colleagues working in any private sector organisation and (b) how they should explain the process to their patients. This draws heavily on national guidance.” Source location 2019-0069-Response-by-CNWL-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A standard MOU with all private psychiatrists cannot be agreed because the Trust may work with numerous providers across its geography.
Verbatim wording from the response “Because of the Trust’s location and geography we can potentially be working with any number of private psychiatrists which would make it impossible to have a standard MOU agreed by all of them in advance. As an alternative, we have drawn up a protocol for our own staff, which sets out (a) how they should work with colleagues working in any private sector organisation and (b) how they should explain the process to their patients. This draws heavily on national guidance.” Source location 2019-0069-Response-by-CNWL-NHS-Trust
Open published response
25 Feb 2019 John William Pearce · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Overreliance on patient refusal of hospital care despite difficulty expressing himself View source Insufficient district nursing attendances after increased visit frequency was identified as necessary View source Failure to share wound photographs for timely escalation decisions View source Lack of clear escalation instructions for worsening open wounds View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 12
Action
Oversee reassessment of wound-care competence for all relevant staff.
Stated plannedThe respondent said that this action was planned when they made their response on 2 June 2019. View source
Action
Cascade a Trust-wide clinical message reminding community nursing teams about wound policy, consent, capacity, and escalation requirements.
Stated plannedThe respondent said that this action was planned when they made their response on 2 June 2019. View source
Action
Share learning from the case and work with Whittington NHS Trust to improve wound-care planning and visit-frequency decisions.
Stated in progressThe respondent said that this action was in progress when they made their response on 2 June 2019. View source
Action
Apply the Lower Limb and Leg Ulcer Management Policy to standardize wound management and escalation across the Trust.
Stated completedThe respondent said that this action was complete when they made their response on 2 June 2019. View source
Action
Reinforce the wound policy, escalation responsibilities, emergency-services role, qualified-nurse attendance, reassessment, and risk-factor management with the involved team.
Stated completedThe respondent said that this action was complete when they made their response on 2 June 2019. View source
Action
Tighten formal, regular mental-capacity assessment and accurate recording when consequential treatment decisions are made.
Stated in progressThe respondent said that this action was in progress when they made their response on 2 June 2019. View source
Action
Share case learning through the clinical-message process, a learning event, and the Pressure Ulcer Board.
Stated plannedThe respondent said that this action was planned when they made their response on 2 June 2019. View source
Action
Provide bespoke community training on capacity, best interests, and supporting clinical documentation.
Stated plannedThe respondent said that this action was planned when they made their response on 2 June 2019. View source
Action
Retrain team members to use the NEWS2 tool for identifying deterioration and seeking emergency help.
Stated plannedThe respondent said that this action was planned when they made their response on 2 June 2019. View source
Action
Consider adapting existing Mental Capacity Act training to support capacity and best-interests decisions when patients decline appropriate care.
Stated plannedThe respondent said that this action was planned when they made their response on 2 June 2019. View source
Action
Reinforce secure sharing of photographs and other information about deteriorating wounds with specialist services and GPs during escalation.
Stated in progressThe respondent said that this action was in progress when they made their response on 2 June 2019. View source
Action
Hold a follow-up meeting to assess embedded learning and systematic identification of deteriorating patients at handovers.
Stated plannedThe respondent said that this action was planned when they made their response on 2 June 2019. View source See 9 more actions
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AI-generated summary
John William Pearce · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John William Pearce was a frail 90-year-old man who developed a worsening left knee wound after an injury in April 2018 and died in hospital on 21 September 2018. The report identified concerns about delayed hospital referral, insufficient district nursing attendances, reliance on his reluctance to attend hospital, and inadequate systems for recognising and sharing information about worsening wounds.
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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Overreliance on patient refusal of hospital care despite difficulty expressing himself
Wider context from the report “I am concerned that:
(a) There was no clear instruction, protocol or system which assists nursing staff in dealing with elderly patients who suffer from open wounds which worsen over time, as to when the emergency services should be contacted. It is clear that the staff were following a Tissue Viability Nurse care plan, but no-one appeared to recognise the severity of the injury and the fact that tendons and bone were exposed;
(b) There were insufficient attendances on Mr Pearce by the District Nurse Team when it appeared to be decided that he would be visited at more frequent intervals;
(c) Too much emphasis was placed on Mr Pearce’s own view that he did not like hospitals and did not want to go there , even though he was noted to be an individual who had difficulty expressing himself ;
(d) There was no clear evidence that photographs taken of the wound were shared with other agencies or the deceased’s GP, such that another view could be taken of those wounds so as to consider whether the emergency services should become involved as a matter of urgency.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient district nursing attendances after increased visit frequency was identified as necessary
Wider context from the report “I am concerned that:
(a) There was no clear instruction, protocol or system which assists nursing staff in dealing with elderly patients who suffer from open wounds which worsen over time, as to when the emergency services should be contacted. It is clear that the staff were following a Tissue Viability Nurse care plan, but no-one appeared to recognise the severity of the injury and the fact that tendons and bone were exposed;
(b) There were insufficient attendances on Mr Pearce by the District Nurse Team when it appeared to be decided that he would be visited at more frequent intervals ;
(c) Too much emphasis was placed on Mr Pearce’s own view that he did not like hospitals and did not want to go there, even though he was noted to be an individual who had difficulty expressing himself;
(d) There was no clear evidence that photographs taken of the wound were shared with other agencies or the deceased’s GP, such that another view could be taken of those wounds so as to consider whether the emergency services should become involved as a matter of urgency.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share wound photographs for timely escalation decisions
Wider context from the report “I am concerned that:
(a) There was no clear instruction, protocol or system which assists nursing staff in dealing with elderly patients who suffer from open wounds which worsen over time, as to when the emergency services should be contacted. It is clear that the staff were following a Tissue Viability Nurse care plan, but no-one appeared to recognise the severity of the injury and the fact that tendons and bone were exposed;
(b) There were insufficient attendances on Mr Pearce by the District Nurse Team when it appeared to be decided that he would be visited at more frequent intervals;
(c) Too much emphasis was placed on Mr Pearce’s own view that he did not like hospitals and did not want to go there, even though he was noted to be an individual who had difficulty expressing himself;
(d) There was no clear evidence that photographs taken of the wound were shared with other agencies or the deceased’s GP , such that another view could be taken of those wounds so as to consider whether the emergency services should become involved as a matter of urgency .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear escalation instructions for worsening open wounds
Wider context from the report “I am concerned that:
(a) There was no clear instruction, protocol or system which assists nursing staff in dealing with elderly patients who suffer from open wounds which worsen over time, as to when the emergency services should be contacted . It is clear that the staff were following a Tissue Viability Nurse care plan, but no-one appeared to recognise the severity of the injury and the fact that tendons and bone were exposed ;
(b) There were insufficient attendances on Mr Pearce by the District Nurse Team when it appeared to be decided that he would be visited at more frequent intervals;
(c) Too much emphasis was placed on Mr Pearce’s own view that he did not like hospitals and did not want to go there, even though he was noted to be an individual who had difficulty expressing himself;
(d) There was no clear evidence that photographs taken of the wound were shared with other agencies or the deceased’s GP, such that another view could be taken of those wounds so as to consider whether the emergency services should become involved as a matter of urgency.
” 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 Oversee reassessment of wound-care competence for all relevant staff.
Verbatim wording from the response “All of our district nurses complete annual refresher training on wound care management. There is a competency framework in place for health care assistants and district nurse team leaders are responsible for ensuring that their staff are competent. In light of these findings, the Lead Nurse will oversee a programme for reassessment of competence and this will be completed for all staff by 1 June 2019.” Source location 2019-0068-Response-by-CNWL-NHS-Trust
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 Cascade a Trust-wide clinical message reminding community nursing teams about wound policy, consent, capacity, and escalation requirements.
Verbatim wording from the response “In addition, a Trust-wide clinical message will be cascaded out to all community nursing teams reminding them of the policy requirements, consent and capacity and escalation processes.” Source location 2019-0068-Response-by-CNWL-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning from the case and work with Whittington NHS Trust to improve wound-care planning and visit-frequency decisions.
Verbatim wording from the response “Whittington NHS Trust currently provide the specialist tissue viability service for complex wounds to Camden residents and were directly involved in the care delivered to Mr Pearce. As the specialist service, they advise our district nursing teams on the wound care plan and frequency of visits. We are therefore sharing, and working together, with the Whittington NHS Trust in the learning from this case.” Source location 2019-0068-Response-by-CNWL-NHS-Trust
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 Apply the Lower Limb and Leg Ulcer Management Policy to standardize wound management and escalation across the Trust.
Verbatim wording from the response “CNWL has a Lower Limb and Leg Ulcer Management Policy which was published in October 2018 and gives detailed instructions on the management of lower limb wounds, including traumatic non healing wounds as seen in this case. The purpose of the policy is to standardise lower limb and leg ulcer management strategies across the Trust in accordance with NICE (2016), Best Practice Statement (2016) and RCN (2006) guidance.” Source location 2019-0068-Response-by-CNWL-NHS-Trust
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 Reinforce the wound policy, escalation responsibilities, emergency-services role, qualified-nurse attendance, reassessment, and risk-factor management with the involved team.
Verbatim wording from the response “It is completely unacceptable that this policy was not consistently adhered to by the staff involved in Mr Pearce’s care. In response to this, the Divisional Director of Nursing and the Inner London Lead Nurse met with the team involved in this gentleman’s care on 19 March 2019 to discuss the findings of the PFD, reiterate the policy and assess any further support required in ensuring the above policy is followed in the future.” Source location 2019-0068-Response-by-CNWL-NHS-Trust
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 Tighten formal, regular mental-capacity assessment and accurate recording when consequential treatment decisions are made.
Verbatim wording from the response “We are tightening our process for ensuring that there is formal and regular mental capacity assessment at the point that treatment decisions of consequence are being made and recorded accurately in our clinical records.” Source location 2019-0068-Response-by-CNWL-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share case learning through the clinical-message process, a learning event, and the Pressure Ulcer Board.
Verbatim wording from the response “As identified above, the learning from this case will be shared across the Trust as part of our “clinical message of the week” process during the next month. The case will also be shared at a planned learning event with staff, GP and colleagues from Whittington Health on 9 May 2019.” Source location 2019-0068-Response-by-CNWL-NHS-Trust
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 Provide bespoke community training on capacity, best interests, and supporting clinical documentation.
Verbatim wording from the response “During May our Safeguarding Adults lead will also be providing additional bespoke training for capacity and best interest in community settings including supporting clinicians with necessary documentation.” Source location 2019-0068-Response-by-CNWL-NHS-Trust
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 Retrain team members to use the NEWS2 tool for identifying deterioration and seeking emergency help.
Verbatim wording from the response “CNWL has a deteriorating patient policy which identifies actions staff need to take to identify when patients clinical condition changes. The policy requires that staff in adult services use the National Early Warning Score (NEWS2) tool which directs staff to seek emergency help. CNWL will re-train members of the team in the use of this tool by the end of May 2019.” Source location 2019-0068-Response-by-CNWL-NHS-Trust
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 Consider adapting existing Mental Capacity Act training to support capacity and best-interests decisions when patients decline appropriate care.
Verbatim wording from the response “This case has highlighted the difficulties of safely managing patients who decline care against clinical advice. In cases where health workers believe the patient is making unwise decisions against hospital admission and more frequent visits in his/her own home, we provide specific safeguarding advice and will now consider how best to adapt our existing Mental Capacity Act (MCA) training to support the application of the MCA, and best interests need to be made on each occasion when the patient is declining appropriate clinical care.” Source location 2019-0068-Response-by-CNWL-NHS-Trust
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 Reinforce secure sharing of photographs and other information about deteriorating wounds with specialist services and GPs during escalation.
Verbatim wording from the response “Due to the GPs using a different recording system (EMIS), the GP would not automatically be able to access the photographs. We recognise that it is not practical or necessary to share all photographs of wounds automatically with every GP. As part of the escalation where a patient’s condition is seen to be deteriorating, the requirement for sharing information, including photographs, is expected and would take place via secure email. This has been reinforced to our staff as part of the meeting in March and will be again reinforced at the follow up session in May.” Source location 2019-0068-Response-by-CNWL-NHS-Trust
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 Hold a follow-up meeting to assess embedded learning and systematic identification of deteriorating patients at handovers.
Verbatim wording from the response “A further follow up meeting is planned with the team on 3 May 2019 to assess how the team have embedded learning from this incident to date including their local processes for ensuring that at handovers, deteriorating patients are identified in a systematic manner.” Source location 2019-0068-Response-by-CNWL-NHS-Trust
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 Automatic sharing of all wound photographs with every GP is not considered practical or necessary; photographs will be shared during deterioration escalation.
Verbatim wording from the response “Photographic evidence was regularly taken and consent to photography was recorded with all photographs being uploaded to the clinical recording system (Systmone). The process already in place ensures that any photographs can be reviewed by the Whittington NHS Trust who currently provides the specialist tissue viability service to Camden residents and were involved in the care delivered. As mentioned above, we are working with the Whittington to address the learning from this case and are due to meet with them on 9th May as highlighted above.” Source location 2019-0068-Response-by-CNWL-NHS-Trust
Open published response
24 Oct 2018 Maximilien Conrad Kohler · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 8 Inadequate NHS services for adults with ASD View source Lack of education for parents caring for children with ASD View source Severe shortage of inpatient psychiatric beds for children and adolescents View source Over-reliance on questionnaires impeding correct diagnosis View source Lack of support for parents caring for children with ASD View source Reduced training time for doctors causing delays in diagnosis and misdiagnosis View source NHS commissioning structure biased against services for chronic incurable conditions and ASD View source Over-reliance on questionnaires causing underestimation of self-harm risk View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Maximilien Conrad Kohler · 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
Maximilien Conrad Kohler, known as Max, was found hanging by a belt from a pull-up bar at his home on 5 May 2018 and died despite resuscitation. The report identified concerns about delayed or incorrect diagnosis, over-reliance on questionnaires in assessing diagnosis and self-harm risk, limited services and support for people with ASD and their parents, and shortages of NHS inpatient psychiatric beds for children and adolescents.
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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate NHS services for adults with ASD
Wider context from the report “6. That services for adults with ASD are even less well provided for by the NHS than those for children .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of education for parents caring for children with ASD
Wider context from the report “4. That there is a lack of support and education available for parents caring for children with ASD .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Severe shortage of inpatient psychiatric beds for children and adolescents
Wider context from the report “5. That there is a severe shortage of inpatient psychiatric beds for children and adolescents in the NHS .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on questionnaires impeding correct diagnosis
Wider context from the report “2. That over reliance in the current fashion on questionnaires used in diagnostics and management may impede rather than assist doctors and other clinicians, firstly to arrive at the correct diagnosis in the first place , and secondly to cause or contribute to underestimation or proper evaluation of the risk of self -harm in particular.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of support for parents caring for children with ASD
Wider context from the report “4. That there is a lack of support and education available for parents caring for children with ASD .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Reduced training time for doctors causing delays in diagnosis and misdiagnosis
Wider context from the report “1. That delays in diagnosis and misdiagnosis in medicine due to reduced time in training for doctors in general and psychiatry in particular , may imperil the lives of vulnerable patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation NHS commissioning structure biased against services for chronic incurable conditions and ASD
Wider context from the report “3. That the NHS care commissioning structure is biased against the commissioning of services for chronic incurable conditions in general and ASD in particular .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on questionnaires causing underestimation of self-harm risk
Wider context from the report “2. That over reliance in the current fashion on questionnaires used in diagnostics and management may impede rather than assist doctors and other clinicians, firstly to arrive at the correct diagnosis in the first place, and secondly to cause or contribute to underestimation or proper evaluation of the risk of self -harm in particular .
” Open source report
21 May 2018 Caroline Antoinette Scott · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 2 Failure of all medical services in Milton Keynes to fully understand the policy for emergency referrals View source Inadequate out-of-hours emergency service provision for mental health emergencies 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
Caroline Antoinette Scott · 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
Caroline Antoinette Scott, who had depression and thoughts of suicide, was found hanging at home on 30 May 2017 and died in hospital on 2 June 2017. The inquest identified a failure to carry out a mental health assessment after recognising that she was in crisis, resulting in a lost opportunity to refer her for treatment. Concerns were also raised about the adequacy of out-of-hours emergency mental health services and whether emergency referral policy was understood by all medical services in Milton Keynes.
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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of all medical services in Milton Keynes to fully understand the policy for emergency referrals
Wider context from the report “(2) That the policy for emergency referrals is not fully understood by all medical services in Milton Keynes
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate out-of-hours emergency service provision for mental health emergencies
Wider context from the report “(1) That the provision of out of hours emergency service for mental health emergencies is inadequate
” 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