6 Mar 2026 Asher Blackman · Prevention of Future Deaths report North London
View report summary
Concerns raised 3 Failure to record next of kin details in the initial assessment View source Failure to record what to do when the district nurse cannot gain access View source Failure of the no-access policy to include police involvement where the patient's life may be at risk View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Asher Blackman · 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
Asher Blackman died in hospital on 21 September 2025 after collapsing at home, where he was found to be profoundly hypoglycaemic. Concerns included the District Nurses’ failure to record next-of-kin details or procedures for inability to gain access, and a no-access policy that did not address police involvement where the patient’s life might be at risk.
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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 London Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record next of kin details in the initial assessment
Wider context from the report “That the initial assessment for Mr Blackman by the District Nurses did not record his next of kin details or what to do should the district nurse not be able to gain access.
The policy following no access did not take into account the need for police involvement where the life of the patient may be at risk through non access.
” Open source report × Source evidence
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 London Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record what to do when the district nurse cannot gain access
Wider context from the report “That the initial assessment for Mr Blackman by the District Nurses did not record his next of kin details or what to do should the district nurse not be able to gain access .
The policy following no access did not take into account the need for police involvement where the life of the patient may be at risk through non access.
” Open source report × Source evidence
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 London Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the no-access policy to include police involvement where the patient's life may be at risk
Wider context from the report “That the initial assessment for Mr Blackman by the District Nurses did not record his next of kin details or what to do should the district nurse not be able to gain access.
The policy following no access did not take into account the need for police involvement where the life of the patient may be at risk through non access.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct Trust-wide engagement events to review no-access clinical practice and reinforce comprehensive records and emergency-contact documentation.
Verbatim wording from the response “On behalf of Central London Community Healthcare NHS Trust (CLCH), I would like to express again our sincere condolences to Mr Blackman’s family. The Trust has carefully reviewed the matters raised in your report and, to ensure that we fully reflect on and learn from the events leading to the death of Mr Blackman, has undertaken a programme of Trust-wide engagement events. These sessions have been designed to review clinical practice and the application of the ‘No Access: Not Seen: Disengagement Policy’, ensuring that current approaches to managing situations where clinical staff are unable to gain access to a patient appropriately identify and assess all potential risks, and that proportionate mitigations are implemented to meet individual patient need.” Source location Response from Central London Community Healthcare 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 Update electronic patient records with prompts and alerts supporting completion and verification of next-of-kin and emergency-contact information.
Verbatim wording from the response “In addition, the Trust has a long-term plan to improve visibility of this information on the system, and we are working with the Information Management Team to update the electronic patient record system to include prompts and alerts to support completion and verification of this information.” Source location Response from Central London Community Healthcare 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 Undertake a comprehensive review to strengthen the no-access policy’s emphasis on immediate escalation for patients at significant clinical risk.
Verbatim wording from the response “Notwithstanding the existence of this Trust policy, the Trust is currently undertaking a comprehensive review informed by recent staff engagement activities. This review is intended to strengthen the policy by placing greater emphasis on the immediate escalation of a “no access” visit where a patient is assessed as being at significant clinical risk, including cases requiring critical interventions such as blood glucose monitoring and insulin administration.” Source location Response from Central London Community Healthcare 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 Review District Nursing referral forms, initial assessment documentation, and clinical-system configurations for contact-information capture and visibility.
Verbatim wording from the response “The Trust has undertaken a review of District Nursing referral forms, initial assessment documentation, and clinical system configurations to ensure that:” Source location Response from Central London Community Healthcare NHS 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 Implemented improvements to no-access arrangements and the proportionate PSIRF response directly address the reported concerns and strengthen patient safeguards.
Verbatim wording from the response “Central London Community Healthcare NHS Trust has formally reviewed the incident in accordance with its Patient Safety Incident Response Framework (PSIRF) and has identified opportunities to enhance existing processes. The Trust is assured that the actions implemented to embed improvements within the No Access: Not Seen: Disengagement arrangements, together with the proportionate PSIRF response, directly address the concerns raised in your report and significantly strengthen safeguards for patients receiving community nursing services.” Source location Response from Central London Community Healthcare NHS 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 The existing policy already provides for police involvement where non-access creates immediate, escalating or significant risks to patient safety or life.
Verbatim wording from the response “The No Access: Not Seen: Disengagement Policy states that, while police involvement is not routine, it is both justified and expected where a failure to gain access gives rise to immediate or escalating concerns regarding patient safety or risk to life. The policy further provides for escalation to emergency services, including the police, where urgent visual confirmation of a patient’s wellbeing is required; where access is obstructed by others and there are genuine concerns regarding safety; or where non-access indicates a risk of significant harm or death.” Source location Response from Central London Community Healthcare NHS Trust
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11 Jul 2025 Norah McGLYNN aka Noreen Philomena McGLYNN · Prevention of Future Deaths report Inner North London
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Concerns raised 1 Unavailability of rehydration at home 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
Norah McGLYNN aka Noreen Philomena McGLYNN · 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
Noreen McGlynn developed throat and urinary tract infections, was prescribed amoxicillin, suffered an anaphylactic reaction and died three days later from her underlying conditions. The concern was whether rehydration could have been provided at home when she became severely dehydrated, potentially avoiding hospital admission for her and others in the future.
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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 London Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of rehydration at home
Wider context from the report “I heard at inquest that, even before her anaphylaxis Ms McGlynn was waiting for an ambulance to take her to hospital. This was on the advice of two GPs and with the agreement of her daughter.
However, Noreen McGlynn’s family did not want her to go to hospital. They believed that she had a better chance of remaining well out of hospital. (The challenges that hospital admission present to the elderly are very well recognised.) And if she were now dying, family knew that Ms McGlynn would want to die at home. Her living situation was very supportive. She was a widow but she had an excellent full time carer and a loving, extremely engaged family, with her daughter living near by.
The reason that family now favoured hospital admission was because Ms McGlynn had become so dehydrated. They recognised that this was life threatening and likely to make her feel unwell. If the rapid response team from the Central London Community Healthcare NHS Trust who visited, or the GPs from Mountfield Surgery, had been able to offer rehydration at home , this would have been a far preferable course of action for Noreen McGlynn and for her loved ones.
Could such rehydration at home have been offered?
Could it be offered to others in the future?
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation UCR clinicians cannot prescribe IV fluids because prescribing them falls outside their current scope of practice.
Verbatim wording from the response “The current service specification commissioned by Barnet Clinical Commissioning Group for Urgent Community Response (UCR) services does include the administration of IV fluids. It states that treatment at home may be appropriate for serious illnesses when it aligns with the patient’s preferences. Although this is included in the service specification, decisions around commencing IV fluid infusion need to be made with the clear understanding that the diagnostic and support services available in the community may not match those provided in a hospital setting, including considerations of the need for continuous observations during infusion. For IV fluids to be initiated a medical doctor would need to prescribe the fluids and equipment (whilst UCR clinicians may be non-medical prescribers, prescribing IV fluids falls outside of their current scope of practice).” Source location Response from Central London Community Healthcare NHS 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 Patients requiring IV rehydration or showing physical deterioration are generally conveyed to hospital under the existing deteriorating patient procedure.
Verbatim wording from the response “Typically, patients requiring IV rehydration or showing any signs of physical deterioration are conveyed to A&E or secondary care for its administration. This approach is also in accordance with our deteriorating patient procedure which states that if a patient’s condition is causing concern, then action needs to be taken either through an assessment by a doctor, appropriately qualified senior clinician, advanced practitioner or the patient should be transferred to A&E or secondary care for further care.” Source location Response from Central London Community Healthcare NHS 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 A medical doctor, such as the SPOA doctor or GP, must decide whether IV fluids are needed and prescribe them.
Verbatim wording from the response “The current service specification commissioned by Barnet Clinical Commissioning Group for Urgent Community Response (UCR) services does include the administration of IV fluids. It states that treatment at home may be appropriate for serious illnesses when it aligns with the patient’s preferences. Although this is included in the service specification, decisions around commencing IV fluid infusion need to be made with the clear understanding that the diagnostic and support services available in the community may not match those provided in a hospital setting, including considerations of the need for continuous observations during infusion. For IV fluids to be initiated a medical doctor would need to prescribe the fluids and equipment (whilst UCR clinicians may be non-medical prescribers, prescribing IV fluids falls outside of their current scope of practice).” Source location Response from Central London Community Healthcare NHS Trust
Open published response
5 Dec 2022 Richard Thomas SHANNON · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 9 Failure to consider documented pressure-ulcer risk when issuing care instructions View source Failure to adequately investigate safeguarding explanations and evidence View source Failure to implement system, training and partnership changes after safeguarding investigation View source Failure to involve district nursing team in discharge planning View source Failure to arrange pressure-relieving bed and mattress replacement before discharge View source Failure to provide required personal hygiene and catheter care during home visits View source Failure to issue and disseminate daily skin-integrity checking instructions to all carers View source Omission of daily skin-integrity checking instruction from discharge assessment form View source Failure to establish daily skin-integrity monitoring responsibility View source See 6 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
Richard Thomas SHANNON · 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
Richard Thomas Shannon was discharged from hospital on 5 January 2022 with an almost completely healed sacral pressure ulcer and was readmitted on 13 January with a severe, necrotic ulcer. The report states that inadequate monitoring of his skin integrity and failures in discharge planning and coordination among hospital, nursing, social care and care-provider services were substantive concerns. He died as a consequence of the severe pressure ulcer, with the medical cause of death including infected sacral pressure ulcer and coccyx osteomyelitis.
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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 London Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider documented pressure-ulcer risk when issuing care instructions
Wider context from the report “5. The City of Westminster social worker considering the Discharge to Assess form did not consider any part of the form other than the specific instructions . She did not include in her thinking the record a little further down the same page that Professor Shannon had a grade 2 pressure ulcer and was at high risk of developing pressure ulcers.
She told me that she was a social worker and not medically trained to read the Discharge to Assess form. However, she accepted that the form clearly stated that Professor Shannon had a grade 2 pressure ulcer and was at high risk of pressure ulcers.
She said that she did not issue a specific instruction to Kapital to check skin integrity every day.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central London Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately investigate safeguarding explanations and evidence
Wider context from the report “7. The City of Westminster undertook a safeguarding investigation after Professor Shannon’s death.
In that investigation, intended to learn lessons for the benefit of others, the City of Westminster investigator accepted, as the social worker had at the time, the explanation given by Kapital that the towels had been brought to the property after the carer’s first visit that morning and therefore had not been available to the carer. The investigator did not interview the Kapital carer. He accepted at inquest that he should have done.
There was no evidence to support Kapital’s assertion and it was in fact completely inaccurate.
” Open source report × Source evidence
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 London Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement system, training and partnership changes after safeguarding investigation
Wider context from the report “8. The safeguarding investigation was concluded by the social worker from Westminster at the end of June 2022, but I was told that there have been no changes made to systems or training in the intervening five months . The social worker has recently emailed partner agencies suggesting a meeting, but no such meeting has taken place .
Apparently, no lessons have been learnt.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central London Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve district nursing team in discharge planning
Wider context from the report “1. The discharge team at University College Hospital (UCH) did not seek a pressure relieving bed and mattress to replace Professor Shannon’s own before he was discharged on 5 January.
This was because his sacral pressure ulcer was almost fully healed and so they did not consider it necessary. However, he was at risk of further pressure ulcers and so it was a measure that should have been sought. The changing of a bed is more difficult to organise once the patient is home and sleeping in it.
If the Central London Community Healthcare district nursing team at Soho Centre for Health and Care (the district nurses) had been invited and had attended the UCH discharge planning meeting , it is much more likely that this measure would have been considered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central London Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange pressure-relieving bed and mattress replacement before discharge
Wider context from the report “1. The discharge team at University College Hospital (UCH) did not seek a pressure relieving bed and mattress to replace Professor Shannon’s own before he was discharged on 5 January.
This was because his sacral pressure ulcer was almost fully healed and so they did not consider it necessary. However, he was at risk of further pressure ulcers and so it was a measure that should have been sought. The changing of a bed is more difficult to organise once the patient is home and sleeping in it.
If the Central London Community Healthcare district nursing team at Soho Centre for Health and Care (the district nurses) had been invited and had attended the UCH discharge planning meeting, it is much more likely that this measure would have been considered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central London Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide required personal hygiene and catheter care during home visits
Wider context from the report “6. When a district nurse arrived at the home the morning after discharge, she found that Professor Shannon’s catheter bag was so full it had become detached, and he had demonstrably and significantly soiled himself.
He had been in this condition when a Kapital carer had visited earlier that same morning, but the carer had not cleaned him or changed the catheter bag .
It took the district nurse three hours properly to take care of her patient’s needs. Carers from Kapital had been booked to visit Professor Shannon’s home for an hour four times each day by the City of Westminster. One of their specific tasks was to attend to the personal hygiene needs of this elderly and vulnerable man who was unable to attend to them himself.
The Kapital carer’s explanation for leaving him in this condition was that there was no soap or towel in the property. This excuse struck me as demonstrating an appalling lack of humanity and I was shocked to hear of it.
In fact, Professor Shannon was obviously dearly loved, and his friends had done everything they could to make his home ready for him, including stocking his bathroom with soap and towels readily found by the district nurse. Apparently, the Kapital carer had simply not opened the bathroom cupboard.
” Open source report × Source evidence
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 London Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to issue and disseminate daily skin-integrity checking instructions to all carers
Wider context from the report “3. The district nurses expected the carers employed by Kapital Care UK Limited (the Kapital carers) and commissioned by social services at the City of Westminster Council (social services) to check the skin integrity every day. However, there is no record that they issued such an instruction .
Even if individual district nurses had sought to issue such an instruction to Kapital carers, the district nurses only attended the home once a day and did not always meet the carers. When the nurses did meet the carers, they rarely saw the same carer twice.
Individual district nurses could not ensure that such an instruction was issued to all carers who attended Professor Shannon. This instruction had to be given at a higher level and passed on to each and every Kapital carer.
” Open source report × Source evidence
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 London Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Omission of daily skin-integrity checking instruction from discharge assessment form
Wider context from the report “4. Upon discharge, a Discharge to Assess form was completed by therapists (I am unclear whether occupational or physiotherapists) at UCH and sent to social services at the City of Westminster. The form raised a number of concerns, but did not specifically instruct that carers should check skin integrity every day. That was an omission.
” Open source report × Source evidence
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 London Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish daily skin-integrity monitoring responsibility
Wider context from the report “2. Upon discharge, UCH sent a referral to the district nurses. This included notification of a grade 2 pressure ulcer and a high risk of pressure ulcers in the future. Professor Shannon had three significant risk factors. He was immobile, he had diabetes, and he had already suffered a pressure ulcer.
The UCH nurses expected the district nurses to check the skin integrity every day. The district nurses did not intend to include this in their daily tasks when they attended the home to assist with insulin administration for diabetic control and with catheter care.
If the district nurses had been invited and had attended the UCH discharge planning meeting, this misunderstanding could easily have been identified and the true position understood by all.
” 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 Share safeguarding escalation learning with relevant staff so similar incidents automatically trigger Trust safeguarding-team escalation and local-authority follow-up.
Verbatim wording from the response “• We have shared learning from this with staff involved and across the organization to ensure that such an incident will automatically trigger an internal escalation to our safeguarding team in the Trust who will follow this up with the local authority.” Source location Response from Central London Community Healthcare
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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 Establish a dedicated telephone number and contact time for discussing hospital discharges.
Verbatim wording from the response “• We have enhanced lines of communication between our teams, by setting up a specific phone number and time when the nurses will be able to discuss hospital discharges.” Source location Response from Central London Community Healthcare
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 Offer additional pressure-ulcer care training to care organisations where required.
Verbatim wording from the response “• Central London Community Healthcare NHS Trust Academy will also offer further training where it is required to care organisations” Source location Response from Central London Community Healthcare
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 Update home-held care-plan templates with clear carer instructions, escalation criteria and community nurse contact details.
Verbatim wording from the response “• We have updated the care plans template for care plans that are held in the patients’ home to ensure that they contain clear instructions for the carers where required. This documentation now also includes clear escalation criteria and contact details for the community nurses.” Source location Response from Central London Community Healthcare
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 Embed the practice changes in operational procedures for all community teams.
Verbatim wording from the response “In addition, CLCH will ensure the changes to practice are embedded in operational procedures for all our community teams and this work will be completed by 31st March 2023.” Source location Response from Central London Community Healthcare
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 Improve discharge information for carers, including holistic care instructions and equipment needed to reduce pressure damage.
Verbatim wording from the response “• The Central London Community Healthcare NHS Trust District Nursing Team has worked with University College Hospital NHS Trust and The City of Westminster to review and improve the quality of information we share with carers, prior to a vulnerable adult being discharged from hospital. This includes giving clear instructions regarding holistic care requirements and the equipment needed to reduce the risk of pressure damage.” Source location Response from Central London Community Healthcare
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 Invite District Nurses to University College Hospital NHS Trust meetings for complex discharges.
Verbatim wording from the response “• The District Nurses are now invited to meetings with University College Hospital NHS Trust for any complex discharges.” Source location Response from Central London Community Healthcare
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 Share the pressure-ulcer care training proforma with Westminster adult social care to support consistent carer training.
Verbatim wording from the response “• To further enhance the level of pressure ulcer prevention knowledge in the local system, we have shared our pressure ulcer care training proforma from the Central London Community Healthcare NHS Trust Academy with Westminster adult social care to assist in ensuring that there is a clear standard of training delivered by the different care organisations which will support carers to deliver effective care.” Source location Response from Central London Community Healthcare
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 Update home-held care-plan templates with clear carer instructions, escalation criteria and community-nurse contact details.
Verbatim wording from the response “• We have updated the care plans template for care plans that are held in the patients’ home to ensure that they contain clear instructions for the carers where required. This documentation now also includes clear escalation criteria and contact details for the community nurses.” Source location Response from Central London Community Healthcare
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 Set up a dedicated telephone line and contact time for nurses to discuss hospital discharges.
Verbatim wording from the response “• We have enhanced lines of communication between our teams, by setting up a specific phone number and time when the nurses will be able to discuss hospital discharges.” Source location Response from Central London Community Healthcare
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 Continue collaborative safeguarding work with system partners to embed improvements in partnership working, discharge planning and holistic, personalised care.
Verbatim wording from the response “We will continue to work collaboratively through the safeguarding processes to further embed improvements outlined above and agreed with our system partners to strengthen partnership working and discharge planning to enable holistic and personalized care to be delivered.” Source location Response from Central London Community Healthcare
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 Share safeguarding learning with staff and introduce automatic internal safeguarding-team escalation for relevant incidents.
Verbatim wording from the response “• We have shared learning from this with staff involved and across the organization to ensure that such an incident will automatically trigger an internal escalation to our safeguarding team in the Trust who will follow this up with the local authority.” Source location Response from Central London Community Healthcare
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 Embed the practice changes in operational procedures for all community teams by 31 March 2023.
Verbatim wording from the response “In addition, CLCH will ensure the changes to practice are embedded in operational procedures for all our community teams and this work will be completed by 31st March 2023.” Source location Response from Central London Community Healthcare
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 and improve information shared with carers before vulnerable adults are discharged, including holistic-care instructions and pressure-damage prevention equipment.
Verbatim wording from the response “• The Central London Community Healthcare NHS Trust District Nursing Team has worked with University College Hospital NHS Trust and The City of Westminster to review and improve the quality of information we share with carers, prior to a vulnerable adult being discharged from hospital. This includes giving clear instructions regarding holistic care requirements and the equipment needed to reduce the risk of pressure damage.” Source location Response from Central London Community Healthcare
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 Invite district nurses to University College Hospital NHS Trust meetings for complex discharges.
Verbatim wording from the response “• The District Nurses are now invited to meetings with University College Hospital NHS Trust for any complex discharges.” Source location Response from Central London Community Healthcare
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 Share discharge communications and care plans with all providers involved in patients’ care.
Verbatim wording from the response “• All communications including care plans are now being shared with all providers involved in care at discharge to ensure consistency in care provision.” Source location Response from Central London Community Healthcare
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 Share the pressure-ulcer care training proforma with Westminster adult social care to support consistent carer training standards.
Verbatim wording from the response “• To further enhance the level of pressure ulcer prevention knowledge in the local system, we have shared our pressure ulcer care training proforma from the Central London Community Healthcare NHS Trust Academy with Westminster adult social care to assist in ensuring that there is a clear standard of training delivered by the different care organisations which will support carers to deliver effective care.” Source location Response from Central London Community Healthcare
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 Offer additional pressure-ulcer prevention training to care organisations where required.
Verbatim wording from the response “• Central London Community Healthcare NHS Trust Academy will also offer further training where it is required to care organisations” Source location Response from Central London Community Healthcare
Open published response
21 Feb 2020 Anita Loi · Prevention of Future Deaths report South London
View report summary
Concerns raised 2 Failure to engage with GPs in clinical review of unexpected deaths View source Failure to respond to community referrals for wound management View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Anita Loi · 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
Anita Loi, who had Type 1 diabetes, suffered a burn to her left leg in April 2019 that developed into an infected wound. Despite repeated referrals, the community nursing teams did not attend to management of the wound, and she later suffered cardiac arrest and died in hospital on 1 July 2019. The principal concerns were the lack of response to referrals and whether appropriate referral policies and procedures were in place.
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 London Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to engage with GPs in clinical review of unexpected deaths
Wider context from the report “(2) On 11 December 2019 the GP invited the District Nurses Team and Tissue Viability Nurses Team to attend a meeting at the surgery with the practice clinicians to review unexpected deaths and to discuss this case. Neither team attended the meeting and to date have not engaged with the GP in relation to this death despite a chasing letter .
” Open source report × Source evidence
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 London Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to respond to community referrals for wound management
Wider context from the report “(1) The Tissue Viability Nurse and District Nurses are a part of the same community team but no steps had been taken to attend to the management of Anita Loi’s leg wound despite repeated referrals by the GP and a call to the community team by the family .
” 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 Improve referral processes from primary care into District Nursing and Tissue Viability Nursing teams.
Verbatim wording from the response “1. We have undertaken an urgent review and are improving the referral processes from primary care into DN & TVN teams.” Source location 2020-0067-Response-from-Central-London-Community-Healthcare-NHS-Trust_Redacted.willbetrim.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement updated triage procedures requiring checks for other services and coordinated review of referrals received by multiple teams.
Verbatim wording from the response “We have updated our Triaging Standard Operating Procedures to ensure a robust process for the management and response to referrals. The procedure now ensures that Triage nurses check if patients are open to other CLCH services. If the referral received is for more than one service on the same day the triage nurse must make contact with that other service to initiate joint working and ensure that visits are allocated appropriately. When a referral is received by more than one service, a meeting is held to ensure that the patient’s referral, clinical history is reviewed jointly and a plan of action on how best to manage the patient’s care is determined.” Source location 2020-0067-Response-from-Central-London-Community-Healthcare-NHS-Trust_Redacted.willbetrim.pdf
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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 Establish multidisciplinary review processes for people referred to multiple teams.
Verbatim wording from the response “5. We will establish clear processes to be in place to review jointly as part of an MDT all people referred who are know to multiple teams to ensure timely joined up responsiveness.” Source location 2020-0067-Response-from-Central-London-Community-Healthcare-NHS-Trust_Redacted.willbetrim.pdf
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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 Develop electronic patient-record reminders in EMIS Health to improve referral management and responsiveness.
Verbatim wording from the response “2. We will commence work on our electronic patient record system to strengthen the reminder capability in EMIS Health, (Egton Medical Information Systems), to ensure that referrals are effectively managed and responsiveness is maximised.” Source location 2020-0067-Response-from-Central-London-Community-Healthcare-NHS-Trust_Redacted.willbetrim.pdf
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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 engagement with GP practice meetings and communication about patient-care discussions and unexpected deaths.
Verbatim wording from the response “I’m sorry that we missed the opportunity to engage in this meeting as a result of the issues outlined above. We acknowledge that engaging in this meeting would have been a good opportunity to review Mrs Loi’s care and we will put measures in place to ensure improved engagement with such meetings going forward. The Merton Community Service continue to attend practice meetings and will be strengthening the communication between the GP practices to ensure that discussions are held whenever there is any confusion surrounding a patient’s care or unexpected death.” Source location 2020-0067-Response-from-Central-London-Community-Healthcare-NHS-Trust_Redacted.willbetrim.pdf
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Attendance at the GP case-review meeting was not possible because the manager was on leave and the deputy was subsequently unavailable through sickness.
Verbatim wording from the response “████████ replied on 20 November 2019 advising that she would be unable to attend on that date as she would be on annual leave, however, she would enquire whether another manager would be able to attend in her place. ████████ informed ████████ that she would be unable to share the clinical records with him as there was no information sharing agreement in place with the GP practice at that time however information would be shared by the person attending the meeting.” Source location 2020-0067-Response-from-Central-London-Community-Healthcare-NHS-Trust_Redacted.willbetrim.pdf
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clinical records could not be shared with the GP practice because no information-sharing agreement was in place.
Verbatim wording from the response “████████ replied on 20 November 2019 advising that she would be unable to attend on that date as she would be on annual leave, however, she would enquire whether another manager would be able to attend in her place. ████████ informed ████████ that she would be unable to share the clinical records with him as there was no information sharing agreement in place with the GP practice at that time however information would be shared by the person attending the meeting.” Source location 2020-0067-Response-from-Central-London-Community-Healthcare-NHS-Trust_Redacted.willbetrim.pdf
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations