Concerns raised 3 Failure to provide an interpreter during ante- and post-natal visits for a woman who did not speak English View source Failure to establish the contents of an infant’s bottle feed View source Lack of culturally informed professional curiosity in infant feeding assessment 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
Izzah Fatima Ali · 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
Izzah Fatima Ali, a nine-month-old infant, died after developing profound iron-deficiency anaemia associated with consumption of cow’s milk. The report identified concerns about healthcare professionals failing to establish what was in her bottles, insufficient consideration of cultural practices, and the repeated absence of an interpreter during ante- and post-natal visits.
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 Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an interpreter during ante- and post-natal visits for a woman who did not speak English
Wider context from the report “1) A theme that emerged during the evidence was the repeated reference to Izzah being ‘bottle-fed’ without further inquiry. In this country, bottle-fed infers ‘formula-fed’ but it is a presumption and in this case it was a wrongly assumed presumption. As one witness observed: ‘bottle-fed’ does not explain what was in the bottle. It could be a formula preparation, equally, it could be expressed breast milk. In this case, it was cow’s milk but until Izzah’s last admission into hospital no healthcare professional established that crucial fact.
That reflects a failure to recognise that ‘bottle-fed’ is an incomplete description and requires an additional question of what is in the bottle.
It also reflects a lack of appreciation around different cultural practices: while it may be assumed that cow’s milk would not be given to an infant under one in this country, it does not automatically follow that the same is true in other countries, for example, Pakistan. There was, in my judgment, an element of assumption made here which could alternatively be described as a lack of professional curiosity.
- A second concern that emerged was that during both ante- and post-natal visits to a woman who did not speak English, no interpreter was involved , contrary to guidance .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish the contents of an infant’s bottle feed
Wider context from the report “1) A theme that emerged during the evidence was the repeated reference to Izzah being ‘bottle-fed’ without further inquiry . In this country, bottle-fed infers ‘formula-fed’ but it is a presumption and in this case it was a wrongly assumed presumption. As one witness observed: ‘bottle-fed’ does not explain what was in the bottle . It could be a formula preparation, equally, it could be expressed breast milk. In this case, it was cow’s milk but until Izzah’s last admission into hospital no healthcare professional established that crucial fact .
That reflects a failure to recognise that ‘bottle-fed’ is an incomplete description and requires an additional question of what is in the bottle .
It also reflects a lack of appreciation around different cultural practices: while it may be assumed that cow’s milk would not be given to an infant under one in this country, it does not automatically follow that the same is true in other countries, for example, Pakistan. There was, in my judgment, an element of assumption made here which could alternatively be described as a lack of professional curiosity.
- A second concern that emerged was that during both ante- and post-natal visits to a woman who did not speak English, no interpreter was involved, contrary to guidance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of culturally informed professional curiosity in infant feeding assessment
Wider context from the report “1) A theme that emerged during the evidence was the repeated reference to Izzah being ‘bottle-fed’ without further inquiry. In this country, bottle-fed infers ‘formula-fed’ but it is a presumption and in this case it was a wrongly assumed presumption. As one witness observed: ‘bottle-fed’ does not explain what was in the bottle. It could be a formula preparation, equally, it could be expressed breast milk. In this case, it was cow’s milk but until Izzah’s last admission into hospital no healthcare professional established that crucial fact.
That reflects a failure to recognise that ‘bottle-fed’ is an incomplete description and requires an additional question of what is in the bottle.
It also reflects a lack of appreciation around different cultural practices : while it may be assumed that cow’s milk would not be given to an infant under one in this country, it does not automatically follow that the same is true in other countries , for example, Pakistan. There was, in my judgment, an element of assumption made here which could alternatively be described as a lack of professional curiosity .
- A second concern that emerged was that during both ante- and post-natal visits to a woman who did not speak English, no interpreter was involved, contrary to guidance.
” 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 Instruct staff to record specific feeding details when nutrition may be linked to a child’s attendance.
Verbatim wording from the response “Our Minor Injuries Unit staff have asked to ensure that, should there be any concern about a child’s nutrition and if it is considered this could be linked to an attendance, staff should ask for specific details, including what is being fed.” Source location Response from Cornwall Partnership NHS Trust
Open published response
Concerns raised 7 Failure to assess need for hospital conveyance during nurse clinician review View source Failure to establish ambulance staff role and assessment status View source Failure to undertake sufficiently broad triage investigation View source Failure to include available family members in clerking patients with dementia View source Failure to confirm ambulance staff clinical grade during introductions View source Failure to ensure reliable sharing of ambulance clinical information between organisations View source Failure to conduct an independent physical assessment View source See 4 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
Require LML staff to complete and hand over patient clinical records for every journey, including separate records for outbound and return transfers.
Stated completedThe respondent said that this action was complete when they made their response on 14 October 2025. View source
Action
Share CFT’s MIU ambulance-receiving procedure with LML and reinforce ambulance-based assessment, handover, family involvement and suitability decisions through staff communications and learning forums.
Stated completedThe respondent said that this action was complete when they made their response on 14 October 2025. View source
Action
Require CFT MIU teams to assess ambulance arrivals and obtain handover, history and records before accepting or booking patients into the unit.
Stated completedThe respondent said that this action was complete when they made their response on 14 October 2025. View source
Action
Disseminate inquest learning on ambulance patient assessment, family and carer involvement, handover and safe escalation through CFT meetings, forums, staff communications and governance groups.
Stated completedThe respondent said that this action was complete when they made their response on 14 October 2025. View source
Action
Require LML crews to provide records promptly alongside structured verbal handover, disseminate the policy to staff, and audit a sample of records monthly against national standards.
Stated completedThe respondent said that this action was complete when they made their response on 14 October 2025. View source
Action
Require LML staff to identify their name, clinical role, scope and limitations, and wear correct clinical-grade epaulettes during patient and inter-organisational encounters.
Stated completedThe respondent said that this action was complete when they made their response on 14 October 2025. View source
Action
Reinforce clear staff introductions through LML’s mandatory annual face-to-face training, including role-specific discussion and scenario practice.
Stated completedThe respondent said that this action was complete when they made their response on 14 October 2025. View source
Action
Require LML staff to involve relatives and carers throughout assessment and care, documenting and justifying any proportionate exclusion.
Stated completedThe respondent said that this action was complete when they made their response on 14 October 2025. View source
Action
Reinforce CFT requirements to obtain complete histories and documentation, exercise professional curiosity, and independently assess patients rather than rely on previous assessments or handovers.
Stated completedThe respondent said that this action was complete when they made their response on 14 October 2025. View source
Action
Require CFT MIU clinicians to complete a full physical assessment after ambulance-based triage and continue monitoring implementation through documentation audits and observations of care.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 October 2025. View source See 7 more actions
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AI-generated summary
Brian Ingram · 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 Ingram, an 85-year-old man with dementia and vascular Parkinsonism, fell and was taken to a minor injuries unit after a delay. His hip fracture was not identified there, and he was discharged before later admission to hospital, where he underwent surgery and died. Concerns included the lack of a physical assessment, failure to identify groin pain and obtain a hip x-ray, assumptions about the ambulance staff’s clinical role, exclusion of his family member, and information-sharing between organisations.
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 Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess need for hospital conveyance during nurse clinician review
Wider context from the report “5) The nurse clinician was asked to review the x-ray only . There did not appear to have been any check as to whether Brian needed to be conveyed to RCHT which may have been appropriate if the complaint of groin pain had been noted.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish ambulance staff role and assessment status
Wider context from the report “6) The nurse clinician did not know the ambulance staff were ECAs and had wrongly assumed they were paramedics and had conducted their own assessment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake sufficiently broad triage investigation
Wider context from the report “4) Brian was seen by a triage nurse who ordered a knee x-ray only .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include available family members in clerking patients with dementia
Wider context from the report “2) Brian had dementia and so a family member accompanied him to the MIU. That family member was, however, asked to remain in the ambulance while Brian was clerked in. This caused or contributed to an omission to record groin pain as a presenting complaint. In evidence, it was suggested this was a hang over from COVID but it appears a practice that may need to be re-visited, especially where a patient presents with dementia and may not be able to provide a full or accurate history .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to confirm ambulance staff clinical grade during introductions
Wider context from the report “1) The family was under the impression that Brian was attended upon by paramedics rather than ECAs. It was accepted in evidence that proper introductions should be made when meeting a new family to include confirmation of a staff member’s clinical grade .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure reliable sharing of ambulance clinical information between organisations
Wider context from the report “3) The inquest was told that it will ordinarily be a SWAST ambulance that attends the MIU and there is a process whereby an ACRF can be sent electronically with the relevant past medical history. On this occasion, an LML ambulance attended whose staff work from written Patient Clinical Records. There was a conflict in the evidence as to whether a PCR was provided to MIU staff . One had to be subsequently requested by CPFT to review what had happened on the day . It may be appropriate to review how information is shared between different organisations .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct an independent physical assessment
Wider context from the report “7) The nurse clinician did not conduct his own physical assessment or speak to the available family member to confirm the relevant history and presenting complaints.
” 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 LML staff to complete and hand over patient clinical records for every journey, including separate records for outbound and return transfers.
Verbatim wording from the response “3.1.1 Crews will usually ring ahead prior to arriving at the door of a MIU or UTC.” Source location Response from Cornwall Partnership 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 Share CFT’s MIU ambulance-receiving procedure with LML and reinforce ambulance-based assessment, handover, family involvement and suitability decisions through staff communications and learning forums.
Verbatim wording from the response “2.3 Whilst CFT was not aware that Mr Ingram’s daughter was waiting in the ambulance in this case, we appreciate that had our Minor Injuries Unit (MIU) staff come to the ambulance to carry out an initial assessment of Mr Ingram and consider his suitability for review and/or treatment in the MIU, they would have discovered her waiting there, and had the opportunity to take any relevant history. It is established MIU practice to assess patients in the ambulance, prior to checking them in. This is expressly stated in the MIU Operational Policy, which sets out the procedure for patients being brought into the MIU by ambulance, as follows:” Source location Response from Cornwall Partnership 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 Require CFT MIU teams to assess ambulance arrivals and obtain handover, history and records before accepting or booking patients into the unit.
Verbatim wording from the response “2.6 There has been a team-wide communication to all MIU staff, reiterating the requirement for all patients arriving by ambulance (SWAST or otherwise), to be physically assessed and have a handover and history taken in the back of the ambulance, before the patient is accepted into the MIU. It has been clarified that the patient should only be booked in to the MIU, once the clinician has confirmed their acceptance with the admin team. Patients arriving by ambulance are not to be booked in until they have been assessed as suitable for treatment at the MIU.” Source location Response from Cornwall Partnership 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 Disseminate inquest learning on ambulance patient assessment, family and carer involvement, handover and safe escalation through CFT meetings, forums, staff communications and governance groups.
Verbatim wording from the response “2.5 The facts relating to Mr Ingram’s inquest have also been used as a case study and presented at the Learning from Experience (LFE) Forum, a meeting attended by all MIU clinical leads, to discuss any collective issues to be addressed, and to share learning and best practice across CFT. It was reiterated at the LFE Forum, that in accordance with policy, all patient arrivals via ambulance should be initially assessed in the ambulance, and a full assessment of the patient should be carried out by an MIU clinician (discussed further below).” Source location Response from Cornwall Partnership 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 Require LML crews to provide records promptly alongside structured verbal handover, disseminate the policy to staff, and audit a sample of records monthly against national standards.
Verbatim wording from the response “3.5 LML crews have also been reminded to ensure that PCRs are shared with the receiving destination in a timely manner and used alongside a structured verbal handover at every transfer of care. Documentation should never replace verbal communication; both are essential for continuity, safety, and clarity. This has been codified in a new policy, which has communicated to staff and reinforced by:” Source location Response from Cornwall Partnership 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 Require LML staff to identify their name, clinical role, scope and limitations, and wear correct clinical-grade epaulettes during patient and inter-organisational encounters.
Verbatim wording from the response “1.1 Since the inquest, LML has issued an organisation-wide memorandum concerning the mandatory requirement for all staff to clearly identify themselves to all patients, families and partner agencies. This information must include” Source location Response from Cornwall Partnership 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 Reinforce clear staff introductions through LML’s mandatory annual face-to-face training, including role-specific discussion and scenario practice.
Verbatim wording from the response “1.2 LML delivers three mandatory, annual face-to-face training days for staff, to ensure their competence and alignment to organisational standards. On each day of this training, the importance of clear introductions is reiterated to staff, and put in practice through group discussions and acting out scenarios.” Source location Response from Cornwall Partnership 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 Require LML staff to involve relatives and carers throughout assessment and care, documenting and justifying any proportionate exclusion.
Verbatim wording from the response “2.2 It was suggested in evidence at the inquest, that the practice of asking a family member to remain in the ambulance, may have been a remnant of procedure adopted during the COVID-19 pandemic. LML has reflected upon the decision of the ECA ambulance crew in this case, which was not in line with their policy. Following the inquest, LML has:” Source location Response from Cornwall Partnership 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 Reinforce CFT requirements to obtain complete histories and documentation, exercise professional curiosity, and independently assess patients rather than rely on previous assessments or handovers.
Verbatim wording from the response “3.8 From the perspective of CFT, all MIU staff have been reminded that the PCR, whether this is in paper form or any electronic PCR, should be received from the ambulance crew before the patient is booked in. Learning has been identified following the inquest in relation to patient handover at the MIU. It is acknowledged by CFT that there was an over-reliance on a verbal handover from the ambulance crew (believed by MIU staff to be paramedics), which had an impact on the initial assessment by the MIU practitioner. All staff have been reminded of the importance of taking a full patient history and all available patient documentation, prior to accepting the patient on to the MIU. This learning and required actions have been shared with staff via email and have featured on the agenda of MIU staff meetings over the last 12 months.” Source location Response from Cornwall Partnership 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 Require CFT MIU clinicians to complete a full physical assessment after ambulance-based triage and continue monitoring implementation through documentation audits and observations of care.
Verbatim wording from the response “7.1 We recognise that this was an important missed opportunity. CFT has taken clear and decisive steps to ensure that all staff are aware of the requirement to carry out a full physical assessment when patients are brought to the MIU (assuming they are initially deemed to be suitable following an ambulance-based triage). This has been communicated in MIU team meetings, LFE Forums, clinical supervision meetings, and across CQaGG and other patient safety forums attended by team leads across the spectrum of community services. CFT will continue to monitor the implementation of this learning, when carrying out documentation audits and observations of care, as part of our ASPIRE accreditation requirements.” Source location Response from Cornwall Partnership 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 Adopting an electronic patient-record system was not financially viable for a medium-sized ambulance provider.
Verbatim wording from the response “3.2 In Mr Ingram’s case, the ambulance which attended the call was a private ambulance provided by LML, whose staff work from written Patient Clinical Records (PCR). The possibility of LML adopting a similar electronic system of recording PCRs was discussed, however the associated set-up and maintenance costs were not considered financially viable for a medium sized ambulance provider. There was a conflict in the evidence at the inquest as to whether a PCR was provided to MIU staff. During discussions between the parties following the inquest, it was considered that the ECAs who brought Mr Ingram into the MIU may have retained his PCR, rather than left it with the MIU, because they were intending to wait for him to be x-rayed and then take him back home.” Source location Response from Cornwall Partnership NHS Foundation Trust
Open published response
Concerns raised 2 Failure to ensure follow-up by the operating orthopaedic team for complications at the surgical site View source Failure to give sufficient weight to continuity of clinical care in transfer decisions 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
Norma Ann Patricia Tellam · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Norma Ann Patricia Tellam suffered a fall causing a proximal femoral fracture and underwent surgery, followed by rehabilitation and further surgery after problems developed with the metalwork. She later suffered an upper gastrointestinal bleed and died on 16 April 2023. Concerns included transfers between hospitals that did not give sufficient weight to continuity of clinical care and did not return her to the hospital responsible for her orthopaedic follow-up.
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 Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure follow-up by the operating orthopaedic team for complications at the surgical site
Wider context from the report “1. Although Mrs Tellam was under the care of Royal Cornwall Hospital and awaiting a post operation follow up, when clinical staff at Liskeard Community Hospital had concerns about a possible infection at the site of the surgery Mrs Tellam was taken to Derriford Hospital rather than to the orthopaedic team at the Royal Cornwall Hospital who had recently operated on her .
2. When Mrs Tellam had recovered from a chest infection she was transferred from Derriford to Liskeard Community Hospital for further rehabilitation rather than to the Royal Cornwall Hospital for follow up on the developing problems with the fixing metalwork at the site of the hip surgery .
3. Decisions relating to the transfer of Mrs Tellam between Liskeard Community Hospital and Derriford Hospital did not give sufficient weight to continuity of clinical care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to give sufficient weight to continuity of clinical care in transfer decisions
Wider context from the report “1. Although Mrs Tellam was under the care of Royal Cornwall Hospital and awaiting a post operation follow up, when clinical staff at Liskeard Community Hospital had concerns about a possible infection at the site of the surgery Mrs Tellam was taken to Derriford Hospital rather than to the orthopaedic team at the Royal Cornwall Hospital who had recently operated on her.
2. When Mrs Tellam had recovered from a chest infection she was transferred from Derriford to Liskeard Community Hospital for further rehabilitation rather than to the Royal Cornwall Hospital for follow up on the developing problems with the fixing metalwork at the site of the hip surgery.
3. Decisions relating to the transfer of Mrs Tellam between Liskeard Community Hospital and Derriford Hospital did not give sufficient weight to continuity of clinical care.
” Open source report
Concerns raised 5 Failure to clearly record treatment plans between transferring and receiving clinical staff View source Lack of clear, detailed and direct doctor-to-doctor handovers between hospitals View source Failure to properly record handovers in medical notes View source Failure to agree treatment plans between transferring and receiving clinical staff View source Errors in writing prescriptions for intravenous fluids 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
Paul Byron Holmes · 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
Paul Byron Holmes sustained fractured ribs and a fractured sternum in a road traffic collision on 4 April 2022, followed by hospitalisation, delirium, dehydration and declining health. He died at home on 29 May 2022 after returning for palliative care. Concerns included inadequate doctor-to-doctor handover and recording of the treatment plan during a hospital transfer, and a prescription error that delayed intravenous fluids.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly record treatment plans between transferring and receiving clinical staff
Wider context from the report “(2) A treatment plan including the need to continue to treat Paul for dehydration and what to do in the event of deterioration was not agreed and recorded clearly between clinical staff of both hospitals
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear, detailed and direct doctor-to-doctor handovers between hospitals
Wider context from the report “(1) There was no clear, detailed and direct handover between doctors of the two hospitals
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly record handovers in medical notes
Wider context from the report “(3) Any handover which did take place was not properly recorded in Paul's medical notes
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to agree treatment plans between transferring and receiving clinical staff
Wider context from the report “(2) A treatment plan including the need to continue to treat Paul for dehydration and what to do in the event of deterioration was not agreed and recorded clearly between clinical staff of both hospitals
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Errors in writing prescriptions for intravenous fluids
Wider context from the report “(4) An error in the writing out of a prescription for intravenous fluids at the Royal Cornwall meant that the administration of hydrating fluids at Liskeard Community Hospital was delayed.
” Open source report
Concerns raised 3 Insufficient training on the risks of hypovolaemia in anticoagulated patients View source Failure to undertake observations following changes in patient presentation View source Failure to record observations following changes in patient presentation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Valerie Ann Simmons · 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
Valerie Ann Simmons developed a large left-thigh haematoma after receiving Fragmin while receiving anticoagulation therapy, was later admitted to hospital, deteriorated and died on 11 January 2023. Concerns included the absence of recorded observations after a change in her presentation and the need for further training on the risks of hypovolaemia in an anticoagulated patient.
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 Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient training on the risks of hypovolaemia in anticoagulated patients
Wider context from the report “Further training related to the risks of hypovolaemia in an anti-coagulated patient would be beneficial .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake observations following changes in patient presentation
Wider context from the report “Where there was a change in a patient’s presentation, it would be expected that a set of observations would be undertaken and recorded in a patient’s notes ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record observations following changes in patient presentation
Wider context from the report “Where there was a change in a patient’s presentation, it would be expected that a set of observations would be undertaken and recorded in a patient’s notes ;
” 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 Develop and share a learning-from-experience poster with community nursing teams on observations, deterioration recognition and documentation.
Verbatim wording from the response “We recognise that policy updates and training changes can take time. To reassure the family, as part of our meetings, we have undertaken learning from experience to develop a poster which will be shared across all community nursing teams demonstrating the importance of recognising the signs of a deteriorating patient and highlighting the importance of taking and recording basic observations when there is change in clinical presentation.” Source location Response from Cornwall Partnership NHS 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 Obtain investment for additional CASP training capacity and deliver three to four extra sessions annually for registered community nurses.
Verbatim wording from the response “On review of training for community nursing, we have identified that the community assessment of sick patient training, (CASP) is a mandatory training requirement for the acute care at home and home first teams only. As a result of learning from this incident, the group has recommended that CASP would be an advantageous course to be added to the registered community nurse’s mandatory training, particularly as the acuity of patients in the community is increasing.” Source location Response from Cornwall Partnership NHS 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 Amend the INR point-of-care-testing SOP and training video to cover anticoagulant-related bleeding complications and prompt observations after clinical deterioration.
Verbatim wording from the response “members of the community nursing team who have been specifically trained and assessed as competent in the use of the INR POCT device, and who can demonstrate an understanding of the role of INR testing including a basic interpretation of the INR result. Practitioners must demonstrate competence and be signed off before performing this role. However, on review of the SOP and training video, conducted in response to the Regulation 28 report, we have identified that it does not include awareness on the tendency of patients taking anticoagulants to have bleeding complications such as haematomas, or how to manage the side effects/consequences for example hypovolaemia. (A haematoma is a collection of blood which is located outside the blood vessels. They can be found under the skin within a soft tissue and display as a purple-coloured bruise.” Source location Response from Cornwall Partnership NHS Foundation Trust
Open published response
Concerns raised 1 Failure to complete the process for implementing the proposed changes without undue delay 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
Christopher Stevens · 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
Christopher Stevens had a history of serious overdose attempts and was admitted to a mental health ward as an informal patient. While the ward was understaffed, he was allowed to take unescorted leave without a nurse completing a risk assessment, and his body was found three days later. The principal concerns were failures in reviewing records, assessing leave-related risk, recognising his non-return promptly, and completing proposed process changes without undue delay.
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 Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete the process for implementing the proposed changes without undue delay
Wider context from the report “Although Chris’s death occurred in February 2022, it also became clear that the process had not been completed . It was hoped this could be achieved by the end of July this year but the inquest was told there would need to be consideration of the proposals by the different consultants now involved . I was concerned to ensure that the process was completed without undue delay and it is with this in mind that I now write to you.
” Open source report
Concerns raised 3 Failure to meaningfully involve families and carers in the discharge process View source Failure to establish a detailed plan for managing acute deterioration View source Failure to document the rationale for discharge safety decisions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kirsty Marie Doodes · 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
Kirsty Marie Doodes, who had a history of mental ill-health, was discharged from hospital on 18 March 2020 and later deteriorated at home. She died from her injuries on 27 March 2020 after being taken to hospital. The concerns included insufficient note-keeping, inadequate detail about the future care plan and management of acute deterioration, and insufficient involvement of her carer in the discharge process.
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 Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to meaningfully involve families and carers in the discharge process
Wider context from the report “iii) Lack of involvement of family/carer in discharge process
The Trust’s own discharge policy states:
3. Principles
The decision to discharge someone from hospital must be in keeping with the Care Programme Approach (CPA), (DH 1991, 2008) and governed by the following principles:
The patient, carer and / or advocate, must be actively involved in all aspects of the discharge plan, where practicable. Arrangements for discharge should be negotiated with everyone likely to be concerned with the service user’s aftercare.
████████ was Kirsty’s carer. He had not been ‘actively involved in all aspects of the discharge plan.’ He had a phone call to come and collect her and on arriving at the hospital he found her bag to be packed. He did not feel as though he was given any choice.
I acknowledged at inquest that there were extenuating circumstances in that Kirsty’s discharge coincided with the first national lockdown during the COVID pandemic. Nevertheless, I think it is appropriate to bring to your attention whether there is a need to remind clinicians to involve families and carers in a meaningful way during the discharge process.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish a detailed plan for managing acute deterioration
Wider context from the report “i) Insufficiency of note-keeping.
ii) ████████
The note made by Dr ████████ in the RiO records was described by an independent expert, Dr ████████, as extremely brief. I accept that medical notes should not be defensive in nature but there is nothing at all in it to justify the view expressed that Kirsty was safe to go home. In a context where she has, over a very recent period, attempted to ████████ on five occasions, the rationale explaining how it was felt she was safe to go home should, in my view, have been set out.
Of perhaps more significance is that there was nothing in the note to assist clinicians with understanding how the future care plan was to be organised . That was in a context where a national lockdown was imminent. Given the unprecedented circumstances, it seems apparent to me that there was all the more reason to provide detail in this regard. The fact it was not set out, it seems to me, implies that there was doubt on the part of Dr ████████ about the plan to continue treating Kirsty was to be organised. My fear is that this simply passed the burden of the management of the risk to ████████.
This reached an entirely foreseeable crisis in the early hours of 23 March. Kirsty had deteriorated to the point she was described as very suicidal. ████████ was exhausted from his desperate efforts to keep his safe. He rang the ward for assistance. There was no one available to help him. ████████ was advised to call the emergency services. He rang the police who told him to ring the ambulance service who told him to ring the CMHT in the morning. This should not have happened. A detailed plan with how to manage an acute deterioration could have prevented it .
At the time, Doctor ████████ was effectively carrying the burden of two consultant psychiatrists in that Dr ████████ was away from work. I indicated at inquest that if this was due to under-resourcing of the Trust, I would write to those responsible for funding. I was advised that, in fact, the problem may be due to a scarcity of consultant psychiatrists nationally. I would be grateful if you could please let me know the position.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document the rationale for discharge safety decisions
Wider context from the report “i) Insufficiency of note-keeping.
ii) ████████
The note made by Dr ████████ in the RiO records was described by an independent expert, Dr ████████, as extremely brief. I accept that medical notes should not be defensive in nature but there is nothing at all in it to justify the view expressed that Kirsty was safe to go home . In a context where she has, over a very recent period, attempted to ████████ on five occasions, the rationale explaining how it was felt she was safe to go home should, in my view, have been set out .
Of perhaps more significance is that there was nothing in the note to assist clinicians with understanding how the future care plan was to be organised. That was in a context where a national lockdown was imminent. Given the unprecedented circumstances, it seems apparent to me that there was all the more reason to provide detail in this regard. The fact it was not set out, it seems to me, implies that there was doubt on the part of Dr ████████ about the plan to continue treating Kirsty was to be organised. My fear is that this simply passed the burden of the management of the risk to ████████.
This reached an entirely foreseeable crisis in the early hours of 23 March. Kirsty had deteriorated to the point she was described as very suicidal. ████████ was exhausted from his desperate efforts to keep his safe. He rang the ward for assistance. There was no one available to help him. ████████ was advised to call the emergency services. He rang the police who told him to ring the ambulance service who told him to ring the CMHT in the morning. This should not have happened. A detailed plan with how to manage an acute deterioration could have prevented it.
At the time, Doctor ████████ was effectively carrying the burden of two consultant psychiatrists in that Dr ████████ was away from work. I indicated at inquest that if this was due to under-resourcing of the Trust, I would write to those responsible for funding. I was advised that, in fact, the problem may be due to a scarcity of consultant psychiatrists nationally. I would be grateful if you could please let me know the position.
” 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 Consider including a concise template for documenting inpatient discharge decisions in the discharge policy review.
Verbatim wording from the response “Sadly, services are finite and we have to balance the extent to which we prioritise the most comprehensive documentation, against the time available for clinical care with patients and their families. As part of our plan to improve mental health services we will be reviewing our accepted documentation standards, with the aim of supporting and directing our clinicians to spend the maximum amount of time providing compassionate, person-centred care, while minimising what may ultimately be, unhelpfully defensive documentation. This approach will also allow clinicians as much time as possible to have difficult discussions with families and carers, for example around discharges from hospital. As such, consideration will be given as part of the review of the discharge policy (described above) to include a template for documenting inpatient discharge decisions.” Source location 2021-0343-Response-from-Cornwall-Partnership-NHS-Foundation-Trust_Published
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 accepted clinical documentation standards to maximise clinicians’ time for compassionate, person-centred care and discussions with families and carers.
Verbatim wording from the response “Sadly, services are finite and we have to balance the extent to which we prioritise the most comprehensive documentation, against the time available for clinical care with patients and their families. As part of our plan to improve mental health services we will be reviewing our accepted documentation standards, with the aim of supporting and directing our clinicians to spend the maximum amount of time providing compassionate, person-centred care, while minimising what may ultimately be, unhelpfully defensive documentation. This approach will also allow clinicians as much time as possible to have difficult discussions with families and carers, for example around discharges from hospital. As such, consideration will be given as part of the review of the discharge policy (described above) to include a template for documenting inpatient discharge decisions.” Source location 2021-0343-Response-from-Cornwall-Partnership-NHS-Foundation-Trust_Published
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’s mental health acute ward discharge policy and prioritise vital discharge steps and multidisciplinary roles and responsibilities.
Verbatim wording from the response “With the above factors in mind, we have identified learning for us in that we need to support our clinicians to improve the discharge process and we therefore intend to review the Trust’s mental health acute ward discharge policy to support this.” Source location 2021-0343-Response-from-Cornwall-Partnership-NHS-Foundation-Trust_Published
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 on reducing hospital length of stay towards the national average while following best evidence and allowing families time to understand discharge decisions.
Verbatim wording from the response “Additionally, we are committed to working on the length of stay in our hospitals in an attempt to ensure that it is closer to the national average whilst continuing to work in line with best evidence such as the NICE Guidelines. This will often (and perhaps more frequently) mean that families and carers may find the rationale for discharge contrary to their wishes and/or counterintuitive. For this reason, time to enable families to work through, question and hopefully accept this will need to be prioritised as although Mr Doodes was involved in his wife’s discharge planning, we recognise that he did not feel as supportive of the plan as we would have liked.” Source location 2021-0343-Response-from-Cornwall-Partnership-NHS-Foundation-Trust_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Finite services and limited clinical time prevent consistently prioritising comprehensive documentation alongside direct patient and family care.
Verbatim wording from the response “Sadly, services are finite and we have to balance the extent to which we prioritise the most comprehensive documentation, against the time available for clinical care with patients and their families. As part of our plan to improve mental health services we will be reviewing our accepted documentation standards, with the aim of supporting and directing our clinicians to spend the maximum amount of time providing compassionate, person-centred care, while minimising what may ultimately be, unhelpfully defensive documentation. This approach will also allow clinicians as much time as possible to have difficult discussions with families and carers, for example around discharges from hospital. As such, consideration will be given as part of the review of the discharge policy (described above) to include a template for documenting inpatient discharge decisions.” Source location 2021-0343-Response-from-Cornwall-Partnership-NHS-Foundation-Trust_Published
Open published response
23 Mar 2020 Lewis Charles Francis · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 2 Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum View source Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment 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
Lewis Charles Francis · 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
Lewis Charles Francis was arrested after stabbing his mother while acutely psychotic and was remanded to HM Prison Exeter after no ready medium secure mental health hospital transfer facility was available. He died at the prison on 24 April 2017 by suicide as a result of suspension by a ligature. Concerns included the lack of a ready transfer mechanism from police custody to medium secure mental health facilities, and insufficient understanding of the needs and vulnerabilities of prisoners on the autistic spectrum.
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 Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum
Wider context from the report “(2) Evidence at the inquest suggested that there was an insufficient understanding of the special needs and vulnerabilities of those prisoners who are within the autistic spectrum
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment
Wider context from the report “(1) At present there is no mechanism for the ready transfer of a person in police custody within the police areas of Devon and Cornwall, Avon and Somerset, Wiltshire and Gloucestershire from police custody to a medium secure mental health facility for assessment / treatment under sections 2 and 3 of the Mental Health Act 1983 where such a person is suspected of or charged with a serious crime. Such an arrangement exists in the West Midlands where a Memorandum of Understanding has been developed and agreed between relevant agencies.
” Open source report
Concerns raised 3 Failure to complete formal carer assessments View source Lack of regular case-coordinator contact View source Failure to regularly update care plans and risk assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dr Geraint Brierley Hughes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Dr Geraint Brierley Hughes was stabbed once in the chest by his wife at their home on 15 November 2013 and died. The substantive concerns included that a formal carer’s assessment had not been completed and that the case coordinator had not maintained regular contact, resulting in care plans and risk assessments not being regularly updated.
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 Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete formal carer assessments
Wider context from the report “In the Trust’s own Serious Incident Report and the separately conducted Domestic Homicide Review, it was noted that a formal carer’s assessment had not been completed with Doctor Hughes . It was noted that while this could not be said to have been causative of the outcome, nevertheless, it represented a departure from best practice .
I was advised that the Trust’s electronic case management system (Rio) was now capable of customisation and had been adapted to ensure that a carer’s assessment was mandatory in cases where domestic abuse was present.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of regular case-coordinator contact
Wider context from the report “The reviews into the circumstances of this death had also identified a lack of regular contact by the case coordinator . In turn, this meant that care plans and risk assessments were not regularly updated. Of note, this has not been identified in the usual supervisory reviews.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to regularly update care plans and risk assessments
Wider context from the report “The reviews into the circumstances of this death had also identified a lack of regular contact by the case coordinator. In turn, this meant that care plans and risk assessments were not regularly updated . Of note, this has not been identified in the usual supervisory reviews.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor Community Mental Health Team compliance using dashboards, reports and monthly performance meetings.
Verbatim wording from the response “The Trust’s Community Mental Health Teams monitor compliance through a compliance dashboard. Individual members of the team can access their own compliance report. The compliance report details information including days since last appointment; care plan date and the number of days since the care plan was created; risk assessment date and days since last risk assessment. Where a care assessment or risk assessment is out of date this is highlighted in the compliance report in red providing a visual tool to assist with assessing compliance. Team managers also discuss compliance with individual team members within supervision.” Source location 2019-0268-Response-by-Cornwall-Partnership-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 Request monthly community mental health reports on carers’ assessments offered and accepted.
Verbatim wording from the response “The Trust’s Carers Policy is currently being reviewed via the Trust’s Carers Committee which meets monthly and this provides a valuable forum for carers and for the Trust to consider improvements. The Trust’s Carers Lead requests monthly reports from the community mental health services in relation to the number of assessments offered and accepted. The Trust’s community mental health service are also proposing that the role of carers is to be part of the Trust’s 2021 quality account priority to continue to improve engagement with carers.” Source location 2019-0268-Response-by-Cornwall-Partnership-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 Carers Policy and train staff on carers’ rights, assessments and related processes.
Verbatim wording from the response “The Trust’s Carers Policy sets out how the Trust assesses, supports and responds to the needs of carers and records this information in RiO (electronic patient record system). The term “carer” refers to “someone who provides practical unpaid help or emotional support to family members, neighbours or friends who use the services of Cornwall Partnership NHS Foundation Trust” as defined in the Care Act 2014. The Policy has been produced by the Trust in consultation with patient and carer representatives and applies across all services. Training has been provided to staff on carers’ rights and processes.” Source location 2019-0268-Response-by-Cornwall-Partnership-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 structured recording and oversight of staff supervision under the revised Supervision Policy.
Verbatim wording from the response “Supervision has always been available to staff but we now have better recording of supervision with much more structure and focus than previously. The Trust’s Supervision Policy was reviewed and re-written in May 2018 to provide a framework for the delivery of comprehensive, consistent and good quality supervision for all our staff. The policy deals with the three elements of a comprehensive supervision structure; managerial supervision, caseload supervision and clinical/ professional supervision. As a minimum caseload supervision should include a review of record keeping quality; frequency of contact; access to appropriate treatment; any cases currently subject to or which may be referred to Adult Safeguarding; any Child Safeguarding concerns; use of Routine Enquiry; non-attendance and subsequent management of cases; self-neglect and complex cases with multiple services are engaged.” Source location 2019-0268-Response-by-Cornwall-Partnership-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 Review the Trust’s Carers Policy through the monthly Carers Committee.
Verbatim wording from the response “The Trust’s Carers Policy is currently being reviewed via the Trust’s Carers Committee which meets monthly and this provides a valuable forum for carers and for the Trust to consider improvements. The Trust’s Carers Lead requests monthly reports from the community mental health services in relation to the number of assessments offered and accepted. The Trust’s community mental health service are also proposing that the role of carers is to be part of the Trust’s 2021 quality account priority to continue to improve engagement with carers.” Source location 2019-0268-Response-by-Cornwall-Partnership-NHS-Trust
Open published response
Concerns raised 4 Failure to develop and implement the delivery plan in relation to the existing CMHT-Addaction service level agreement View source Failure of the working relationship between CMHT and Addaction View source Failure to operate the Cornwall dual diagnosis policy effectively View source Inadequate interface between Addaction and community mental-health teams 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
PAUL MATTHEW GILLAM · 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
Paul Matthew Gillam was found dead at home after consuming alcohol, drugs and six pills of unknown composition. The inquest recorded that he died on 3 June 2018 from the toxic effects of a reckless overdose of non-prescription drugs. The principal concerns related to communication and working arrangements between Addaction and the Community Mental Health Team (CMHT), including the implementation of their service-level agreement and delivery 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 Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to develop and implement the delivery plan in relation to the existing CMHT-Addaction service level agreement
Wider context from the report “(2) The development and implementation of the delivery plan in relation to the existing service level agreement between CMHT and Addaction .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the working relationship between CMHT and Addaction
Wider context from the report “(3) The working relationship between CMHT and Addaction .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to operate the Cornwall dual diagnosis policy effectively
Wider context from the report “(1) The operation of the Cornwall dual diagnosis policy and the interface between Addaction and CMHT .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate interface between Addaction and community mental-health teams
Wider context from the report “(1) The operation of the Cornwall dual diagnosis policy and the interface between Addaction and CMHT .
” Open source report
Concerns raised 3 Requirement for substance misuse treatment before mental health treatment View source Lack of access to mental health support for people with drug dependency View source Discharge from CMHT after two missed appointments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Marcus HANCE · 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
Marcus Hance died on 13 October 2017 from the synergistic effect of a reckless overdose of illicit and therapeutic drugs, in the context of a history of drug abuse. Concerns included the separation of support for substance misuse from support for associated mental health issues, the approach that substance misuse should be addressed before mental health treatment, and his discharge from the Community Mental Health Team after two missed appointments.
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 Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Requirement for substance misuse treatment before mental health treatment
Wider context from the report “(2) The approach to cases of dual diagnosis, that substance misuse should be addressed before any mental health treatment could proceed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of access to mental health support for people with drug dependency
Wider context from the report “(1) Marcus was in a position where he was getting support with his drug dependency from the drug and alcohol team but was not able to access support for the mental health issues which were associated with the drug dependency .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Discharge from CMHT after two missed appointments
Wider context from the report “(3) The discharge from CMHT on failing to attend two appointments .
” 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 Work in partnership with NHS Kernow on ongoing reviews of the Dual Diagnosis strategy, service interdependencies, and service specifications.
Verbatim wording from the response “Thank you for providing me with the response provided by NHS Kernow Clinical Commissioning Group, commissioners of mental health services, confirming the on-going review in relation to the Dual Diagnosis strategy; the review of the interdependencies between Outlook Southwest and the Trust and the review of a number of service specifications between NHS Kernow and the Trust.” Source location 2018-0173-Response-by-Cornwall-NHS-Trust
Open published response
Concerns raised 3 Failure to communicate relevant patient information between GP and mental health services View source Lack of access to relevant records across healthcare providers View source Lack of clarity about crisis response pathways and service roles View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David John Buttriss · 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 John Buttriss died at home on 9 May 2016 after cutting himself during a mental health crisis, despite medical assistance and resuscitation. The report identified communication problems between the GP and mental health services, separate healthcare record systems that limited access to relevant information, and a lack of clarity about the appropriate crisis-response pathway and the roles of different mental health teams.
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 Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate relevant patient information between GP and mental health services
Wider context from the report “1. Mr Buttriss had contact with a number of health agencies in the weeks prior to his death including the Community Mental Health, Home Treatment team, GP, Out of Hours GP and Paramedics. It was clear from the evidence at the inquest that
• There were Communication issues between the GP and mental health service. The mental health services had requested a patient profile from the GP on 14.5.16 which was not received. The Patient’s GP did not advise mental health services that Mr Buttriss had a mental health history pre-2009 when spoken to following his first self-referral on 14.5.16. It was not known whether this may have affected the decisions the mental health professionals took but it did and meant that his mental health issues were not known to the Cornwall Mental Health Service when they were contacted at the time of crisis
• The health care records for the GP and the Mental Health services are held on different health care record systems held by the different healthcare providers. This meant that the GP did not have access to the mental health service records at the time of the consultation on by ████████ on 25th April nor did the mental health workers have information about the appointment with ████████ nor were they aware of the medication issues. The Out of Hours GP, ████████ did not have access to either the mental health or GP records and was in a difficult position when deciding how to deal with Mr Buttriss especially with regards to prescribing and sign posting to mental health professionals when she saw him in acute crisis on the 7th May.
• It was clear from the evidence of the Paramedic and ████████ and the parents that there was lack of clarity of the appropriate method or pathway to deal with Mr Butriss on the night of 7th May when he was in crisis. The paramedic did speak to the Home Treatment Team for advice but as Mr Buttriss was reluctant to engage no intervention was made. There appeared to be confusions between the role of the Community Mental Health Service and the Home Treatment Team and the Home Treatment Team Out of Hours 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 Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of access to relevant records across healthcare providers
Wider context from the report “1. Mr Buttriss had contact with a number of health agencies in the weeks prior to his death including the Community Mental Health, Home Treatment team, GP, Out of Hours GP and Paramedics. It was clear from the evidence at the inquest that
• There were Communication issues between the GP and mental health service. The mental health services had requested a patient profile from the GP on 14.5.16 which was not received. The Patient’s GP did not advise mental health services that Mr Buttriss had a mental health history pre-2009 when spoken to following his first self-referral on 14.5.16. It was not known whether this may have affected the decisions the mental health professionals took but it did and meant that his mental health issues were not known to the Cornwall Mental Health Service when they were contacted at the time of crisis
• The health care records for the GP and the Mental Health services are held on different health care record systems held by the different healthcare providers. This meant that the GP did not have access to the mental health service records at the time of the consultation on by ████████ on 25th April nor did the mental health workers have information about the appointment with ████████ nor were they aware of the medication issues. The Out of Hours GP, ████████ did not have access to either the mental health or GP records and was in a difficult position when deciding how to deal with Mr Buttriss especially with regards to prescribing and sign posting to mental health professionals when she saw him in acute crisis on the 7th May.
• It was clear from the evidence of the Paramedic and ████████ and the parents that there was lack of clarity of the appropriate method or pathway to deal with Mr Butriss on the night of 7th May when he was in crisis. The paramedic did speak to the Home Treatment Team for advice but as Mr Buttriss was reluctant to engage no intervention was made. There appeared to be confusions between the role of the Community Mental Health Service and the Home Treatment Team and the Home Treatment Team Out of Hours 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 Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about crisis response pathways and service roles
Wider context from the report “1. Mr Buttriss had contact with a number of health agencies in the weeks prior to his death including the Community Mental Health, Home Treatment team, GP, Out of Hours GP and Paramedics. It was clear from the evidence at the inquest that
• There were Communication issues between the GP and mental health service. The mental health services had requested a patient profile from the GP on 14.5.16 which was not received. The Patient’s GP did not advise mental health services that Mr Buttriss had a mental health history pre-2009 when spoken to following his first self-referral on 14.5.16. It was not known whether this may have affected the decisions the mental health professionals took but it did and meant that his mental health issues were not known to the Cornwall Mental Health Service when they were contacted at the time of crisis
• The health care records for the GP and the Mental Health services are held on different health care record systems held by the different healthcare providers. This meant that the GP did not have access to the mental health service records at the time of the consultation on by ████████ on 25th April nor did the mental health workers have information about the appointment with ████████ nor were they aware of the medication issues. The Out of Hours GP, ████████ did not have access to either the mental health or GP records and was in a difficult position when deciding how to deal with Mr Buttriss especially with regards to prescribing and sign posting to mental health professionals when she saw him in acute crisis on the 7th May.
• It was clear from the evidence of the Paramedic and ████████ and the parents that there was lack of clarity of the appropriate method or pathway to deal with Mr Butriss on the night of 7th May when he was in crisis . The paramedic did speak to the Home Treatment Team for advice but as Mr Buttriss was reluctant to engage no intervention was made. There appeared to be confusions between the role of the Community Mental Health Service and the Home Treatment Team and the Home Treatment Team Out of Hours provision.
” 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 Develop and provide patients with Safety Plans containing warning signs, coping strategies, crisis contacts, care-team details and carer guidance.
Verbatim wording from the response “In addition new Safety Plans have been developed to be completed and provided to patients containing detailed crisis information for patients and their relatives, friends and carers. The plans confirm the name of team providing the care and the name of their care co-ordinator as well as the best number to contact the team and crisis numbers. The plan encourages carers to share any concerns and participate in the care and also explains that a “Nearest Relative” can speak to an Approved Mental Health Professional about their rights as a nearest relative. The plan is completed with the patient and sets out their warning signs; coping strategies and professionals or agencies to contact in a crisis.” Source location 2018-0010-Response-by-Cornwall-NHS-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 Use a Community Mental Health Nurse Consultant to liaise with GP practices on assessment services, team responsibilities, information sharing and raising concerns.
Verbatim wording from the response “In addition ████████, in her new role as Community Mental Health Nurse Consultant, has begun working with a number of local GP practices. This has involved meeting GPs to discuss the new assessment service; the role and remit of Community Mental Health Teams and ways to improve information sharing and raising patients of concern. This is an ongoing piece of work to continue to improve liaison between services.” Source location 2018-0010-Response-by-Cornwall-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 Send patients and GPs written assessment outcomes describing the formulation and recommendations, with advice and signposting where secondary services are unsuitable.
Verbatim wording from the response “Once the assessment has taken place and a decision made by the multi-disciplinary team as to the appropriateness for secondary mental health services a letter is sent to the patient and their GP focusing on the formulation and recommendation of the assessment. If the individual is not suitable for secondary services then advice, guidance and signposting is offered.” Source location 2018-0010-Response-by-Cornwall-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 Review out-of-hours services to determine whether changes to Home Treatment Teams are needed.
Verbatim wording from the response “The Trust is reviewing the Out of Hours services and this is likely to result in changes to the Home Treatment Teams within the next 6 months. Once changes have been confirmed the Trust plans to meet with external providers to confirm the changes and clarify the role of the Home Treatment Teams.” Source location 2018-0010-Response-by-Cornwall-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 Update the public website with crisis information explaining daytime and out-of-hours mental health services, helplines and team contact numbers.
Verbatim wording from the response “In direct response to your Regulation 28 report the Trust has changed the Trust’s internet page. There is now a designated section headed “I need help now” providing mental health crisis information. The internet page is accessible to all members of the public including patients and health professionals and provides information explaining the roles and responsibilities of daytime and out of hours mental health services as well as details of a number of helplines and resources available to support those in crisis. Contact telephone numbers are also provided for the Trust’s Home Treatment Teams and Community Mental Health Teams.” Source location 2018-0010-Response-by-Cornwall-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 an assessment service with designated referral administrators who request a Patient Profile from the GP for every Adult Mental Health Services referral.
Verbatim wording from the response “The Trust has implemented a new assessment service replacing the Single Point of Access to ensure that access to mental health services is consistent and effective. Each locality area now has a designated referral administrator to manage all referrals into Adult Mental Health Services and the administrator requests a copy of the Patient Profile from the patient’s GP for every referral received. Since the implementation of the assessment service some GPs now routinely provide the Patient Profile together with the referral.” Source location 2018-0010-Response-by-Cornwall-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 Written confirmation of assessment outcomes to GPs and ongoing liaison are considered sufficient for communication about referrals.
Verbatim wording from the response “From the Trust’s perspective the outcome of an assessment with Adult Mental Health Services is confirmed in writing to GPs and on-going liaison work with GPs will also improve communication and information sharing.” Source location 2018-0010-Response-by-Cornwall-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 Existing secure RiO access arrangements are considered sufficient for sharing health records with other agencies.
Verbatim wording from the response “The Trust already works with other agencies to allow secure health record sharing. Agencies are requested to complete an application form for access to RiO, the Trust’s electronic health record system. The application form is a standard form which requires specific information detailing the individual, their role, employing organisation and the legal basis for access as well as confirmation of Information Governance training. The Trust has allowed access to RiO to a number of agencies including Cornwall Council, acute hospitals and GPs.” Source location 2018-0010-Response-by-Cornwall-NHS-Trust
Open published response
Concerns raised 4 Failure to notify family, occupational therapists and carers of new equipment deliveries View source Lack of training for family, carers and district nurses before use of new equipment View source Failure to carry out appropriate risk assessments before use of new equipment View source Lack of formal protocols for notifying district nurses of falls or changes in fall risk View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dorothea Jean Parr · 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
Dorothea Parr fell from a newly delivered electric riser-recliner chair at home on 21 March 2016, sustained a fractured neck of femur, and died of pneumonia on 28 March 2016. The report raised concerns that the chair was delivered without notifying her family, carers, or district nurses, limiting opportunities for training and risk assessment. It also identified a lack of formal procedures for notifying district nurses about falls, changes in presentation, or new equipment.
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 Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to notify family, occupational therapists and carers of new equipment deliveries
Wider context from the report “At the inquest the evidence showed that the electric armchair had been ordered by the Occupational Therapist and delivered by Tremorvah Industries (Mobility) at short/no notice to Mrs Parr’s address on 21st March 2016. No notification was given to the son – who had requested to be present when it was delivered nor to the Occupational Therapist or Kerrier Home Care Ltd who provided the carers who would assist Mrs Parr in using the new chair. This meant there was limited or no opportunity for the family and carers or district nurses to be trained for or appropriate risk assessments to be carried out prior to the use of the new equipment or at the time of the first use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training for family, carers and district nurses before use of new equipment
Wider context from the report “At the inquest the evidence showed that the electric armchair had been ordered by the Occupational Therapist and delivered by Tremorvah Industries (Mobility) at short/no notice to Mrs Parr’s address on 21st March 2016. No notification was given to the son – who had requested to be present when it was delivered nor to the Occupational Therapist or Kerrier Home Care Ltd who provided the carers who would assist Mrs Parr in using the new chair. This meant there was limited or no opportunity for the family and carers or district nurses to be trained for or appropriate risk assessments to be carried out prior to the use of the new equipment or at the time of the first use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out appropriate risk assessments before use of new equipment
Wider context from the report “At the inquest the evidence showed that the electric armchair had been ordered by the Occupational Therapist and delivered by Tremorvah Industries (Mobility) at short/no notice to Mrs Parr’s address on 21st March 2016. No notification was given to the son – who had requested to be present when it was delivered nor to the Occupational Therapist or Kerrier Home Care Ltd who provided the carers who would assist Mrs Parr in using the new chair. This meant there was limited or no opportunity for the family and carers or district nurses to be trained for or appropriate risk assessments to be carried out prior to the use of the new equipment or at the time of the first use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of formal protocols for notifying district nurses of falls or changes in fall risk
Wider context from the report “The District Nurse Manger explained that it was the role of the District Nurses to carry out the Falls Risk Assessment for clients living in the community at risk of falling. The District Nurses were very dependent on other agencies to inform them of falls or changes to the risk of falls e.g. the delivery of the electric chair or changes in presentation which increase the risk of falls e.g. confusion. In this case District nurses were not informed of the fall on 21st March from the new electric chair and no requirement for this to be done and so there was a lost opportunity to provide input – which in this case could have been to deactivate the electric armchair while the carers were not present. Although there were informal procedures in place for district nurse notification, there were no formal protocols or procedures in place.
” 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 Implement and embed the community slips, trips and falls policy, including falls risk assessments, care plans, incident reporting, and shared learning.
Verbatim wording from the response “Standards for Better Health state that NICE clinical and public health guidance should be disseminated and implemented at all levels through a robust framework. The implementation of this policy will ensure that NICE guidance and NSF standards are being followed throughout the county for the management of falls.” Source location 2016-0466-Response-by-Cornwall-Partnership-NHS-Trust.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The embedded community falls policy and its risk-assessment requirements are considered sufficient, so no further action will be taken.
Verbatim wording from the response “Standards for Better Health state that NICE clinical and public health guidance should be disseminated and implemented at all levels through a robust framework. The implementation of this policy will ensure that NICE guidance and NSF standards are being followed throughout the county for the management of falls.” Source location 2016-0466-Response-by-Cornwall-Partnership-NHS-Trust.pdf
Open published response
Concerns raised 8 Failure to maintain consistent and adequately justified clinical records View source Failure to safely manage patients with apparent capacity who decline treatment or care despite deterioration View source Failure to ensure consistency in treatment decisions View source Failure to record concerns about self-harm risk in patients with apparent capacity View source Delays in Community Mental Health team assessment after referral View source Failure to share relevant self-harm concerns with family or friends reporting deterioration View source Incomplete serious incident review lacking formal interviews of relevant clinicians View source Failure to account safely for inconsistent patient presentations in risk assessment View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Danny Sweet · 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
Danny Sweet, who had a long history of mental health issues, took a staggered paracetamol overdose on 23 October 2015 and died the next day in Treliske Hospital. Concerns included the rapid transfer and discharge between mental health services despite earlier consideration of informal admission, difficulties assessing his inconsistent presentation, inconsistent treatment decisions and records, and an incomplete Serious Incident Report.
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 Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain consistent and adequately justified clinical records
Wider context from the report “I raise also whether there should be training to ensure that the entries in the notes and records are consistent . By way of illustration, where ████████ and ████████ decide to discharge Mr Sweet from their respective caseloads, they should justify those decisions in light of ████████'s earlier concern that Mr Sweet may need an informal admission into hospital .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to safely manage patients with apparent capacity who decline treatment or care despite deterioration
Wider context from the report “Mr Sweet’s case raises a more general issue namely, how the Trust deals with patients (within the confines of the Law as currently drawn) who appear to have capacity and yet decline treatment/care even where family/friends state their condition is deteriorating .
I recognise this is a difficult issue. I wonder, however, whether in such situations, clinicians should record in the notes and records their concerns that patients have capacity and yet may go on to self-harm. Furthermore, I feel it may be worth reviewing if clinicians should share those concerns with family/friends who try and bring to attention the patient’s deteriorating condition. I recognise there will be an obvious need to respect the rules on confidentiality.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure consistency in treatment decisions
Wider context from the report “I wondered if it may be appropriate to reflect on how to deal with patients who present in an inconsistent manner. In particular, I questioned whether it was appropriate simply to presume the best case scenario.
I was further concerned whether or not it was appropriate for a check to be built into the assessment process to ensure consistency in treatment decisions . There appeared to be obvious inconsistencies first in the concern of ████████and the decision the very next day to discharge Mr Sweet from the caseload of the HTT and secondly, in the decision of ████████to refer to CMHT yet ████████discharging Mr Sweet from caseload after a first assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record concerns about self-harm risk in patients with apparent capacity
Wider context from the report “Mr Sweet’s case raises a more general issue namely, how the Trust deals with patients (within the confines of the Law as currently drawn) who appear to have capacity and yet decline treatment/care even where family/friends state their condition is deteriorating.
I recognise this is a difficult issue. I wonder, however, whether in such situations, clinicians should record in the notes and records their concerns that patients have capacity and yet may go on to self-harm . Furthermore, I feel it may be worth reviewing if clinicians should share those concerns with family/friends who try and bring to attention the patient’s deteriorating condition. I recognise there will be an obvious need to respect the rules on confidentiality.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in Community Mental Health team assessment after referral
Wider context from the report “I was concerned, however, that the very day after a Consultant Psychiatrist contemplated informal admission into hospital, a nurse from the HTT felt able to refer Mr Sweet to the Community Mental Health team where he was not seen for a month .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant self-harm concerns with family or friends reporting deterioration
Wider context from the report “Mr Sweet’s case raises a more general issue namely, how the Trust deals with patients (within the confines of the Law as currently drawn) who appear to have capacity and yet decline treatment/care even where family/friends state their condition is deteriorating.
I recognise this is a difficult issue. I wonder, however, whether in such situations, clinicians should record in the notes and records their concerns that patients have capacity and yet may go on to self-harm. Furthermore, I feel it may be worth reviewing if clinicians should share those concerns with family/friends who try and bring to attention the patient’s deteriorating condition . I recognise there will be an obvious need to respect the rules on confidentiality.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete serious incident review lacking formal interviews of relevant clinicians
Wider context from the report “A final matter that came out of the inquest was that the Serious Incident Report was incomplete . In particular, neither ████████ nor ████████ had been formally interviewed as part of the review process . You may feel that there would be merit in getting the respective clinicians from the relevant departments (Hospital Liaison, HTT and CMHT) together to see if there are any lessons to be learned.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to account safely for inconsistent patient presentations in risk assessment
Wider context from the report “I wondered if it may be appropriate to reflect on how to deal with patients who present in an inconsistent manner . In particular, I questioned whether it was appropriate simply to presume the best case scenario .
I was further concerned whether or not it was appropriate for a check to be built into the assessment process to ensure consistency in treatment decisions. There appeared to be obvious inconsistencies first in the concern of ████████and the decision the very next day to discharge Mr Sweet from the caseload of the HTT and secondly, in the decision of ████████to refer to CMHT yet ████████discharging Mr Sweet from caseload after a first assessment.
” 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 Ensure all key clinicians within investigation terms of reference participate in future Serious Incident investigations.
Verbatim wording from the response “The Trust acknowledges that the Serious Incident Report is incomplete. There are learning points for the Trust in relation to Serious Incident Investigations and the Trust’s Director of Quality and Governance/Executive Nurse, ████████ will take this forward. We will ensure that in the future all key clinicians, within the Terms of Reference, are involved in future investigations. We have also identified the importance of providing feedback to staff interviewed for the purposes of the investigation.” Source location 2016-0275-Response-by-Cornwall-NHS-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 Hold a Learning from Experience meeting with relevant clinical staff to consider developing a care pathway, engaging family and friends, and producing an action plan.
Verbatim wording from the response “It is impossible to ensure consistency in treatment decisions because assessments are “of the moment” and there has to be flexibility for clinicians as situations can change. However, the Trust does recognise that there does need to be a clearly defined pathway decided at the initial presentation. The action that will be taken is that there will be a Learning from Experience meeting. We will ensure that clinical staff, across all services involved in the care of Mr Sweet, participate in the meeting. The meeting will be overseen by ████████ Inpatient Clinical Director and Consultant in Rehabilitation Psychiatry. One of the purposes of the meeting will be to consider developing the pathway.” Source location 2016-0275-Response-by-Cornwall-NHS-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 Launch a Trust-wide review of clinical risk assessments for people presenting with suicidal thoughts or acts, including use of the STORM assessment.
Verbatim wording from the response “We agree that it is appropriate to reflect on how to deal with patients who present in an inconsistent manner. It is not appropriate to presume the best case scenario and clinical staff are trained to use structured risk assessments. However we propose to launch a review into the clinical risk assessment of people who present with suicidal thoughts or acts across each of our services and in particular the Trust’s use of the STORM” Source location 2016-0275-Response-by-Cornwall-NHS-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 the Trust’s Serious Incident investigation process.
Verbatim wording from the response “In summary there will be action taken by the Trust by way of a Learning from Experience Meeting to consider ways of developing a pathway; how to engage friends and family and to allow a further period of reflection. It is expected that an action plan will be developed at the Learning from Experience meeting. There will also be a review of the clinical risk assessments of people who present with suicidal thoughts or acts by the end of February 2017 and we will review the Trust’s Serious Investigation process.” Source location 2016-0275-Response-by-Cornwall-NHS-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 Continue rolling out the SBAR structured record-keeping tool across all services.
Verbatim wording from the response “The Trust does provide training to staff in relation to record keeping and the importance of recording the rationale for decisions. We are already enhancing the record keeping of staff by implementing the “SBAR” (Situation, Background, Assessment, Recommendation) tool as standard in record keeping. This has been introduced to staff on our psychiatric inpatient wards and we will continue to filter this through across all services. We are therefore making efforts and taking action to introduce a more structured format to our records. This action is on-going.” Source location 2016-0275-Response-by-Cornwall-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 Consistency in treatment decisions cannot be ensured because assessments are moment-specific and require clinical flexibility.
Verbatim wording from the response “It is impossible to ensure consistency in treatment decisions because assessments are “of the moment” and there has to be flexibility for clinicians as situations can change. However, the Trust does recognise that there does need to be a clearly defined pathway decided at the initial presentation. The action that will be taken is that there will be a Learning from Experience meeting. We will ensure that clinical staff, across all services involved in the care of Mr Sweet, participate in the meeting. The meeting will be overseen by ████████ Inpatient Clinical Director and Consultant in Rehabilitation Psychiatry. One of the purposes of the meeting will be to consider developing the pathway.” Source location 2016-0275-Response-by-Cornwall-NHS-Trust
Open published response
Concerns raised 5 Failure to ensure availability of psychiatric beds in Cornwall View source Failure to ensure procedures prioritise high-risk patients on psychological therapy waiting lists View source Failure to ensure adequate resource allocation to the home treatment team View source Failure to manage waiting lists for individual psychological therapy safely View source Failure to ensure an appropriate threshold for offering home treatment support 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
Simon Jonathon Klemberg · 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
Simon Jonathon Klemberg died in the early hours of 7 June 2015 following a reckless and impulsive overdose of prescription medication taken to address acute head pain, possibly related to his psychological condition. He had serious mental health problems, and individual psychological therapy recommended in February 2015 was delayed and never commenced. The report raised concerns about psychiatric bed availability, resources and thresholds for the home treatment team, and the prioritisation of high-risk patients awaiting psychological therapy.
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 Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure availability of psychiatric beds in Cornwall
Wider context from the report “(1) To review the availability of beds for psychiatric patients in Cornwall . Kernow Clinical Commissioning group (KCCG) to respond
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure procedures prioritise high-risk patients on psychological therapy waiting lists
Wider context from the report “(4) To review procedures for prioritizing high risk patients in waiting lists for psychological therapy . Cornwall Partnership NHS Foundation Trust (CFT) to respond.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure adequate resource allocation to the home treatment team
Wider context from the report “(2) To review the allocation of resources to the home treatment team , with particular reference to the threshold for offering support. Both Kernow Clinical Commissioning group (KCCG) and Cornwall Partnership NHS Foundation Trust (CFT) to respond
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to manage waiting lists for individual psychological therapy safely
Wider context from the report “(3) To review the waiting lists for individual psychological therapy . Cornwall Partnership NHS Foundation Trust (CFT) to respond.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure an appropriate threshold for offering home treatment support
Wider context from the report “(2) To review the allocation of resources to the home treatment team, with particular reference to the threshold for offering support . Both Kernow Clinical Commissioning group (KCCG) and Cornwall Partnership NHS Foundation Trust (CFT) to respond
” 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