Croydon University Hospital

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First report 19 Sep 2025•Latest report 19 Sep 2025

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Croydon University Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. South London

    AI-generated summary

    Mr Luke John Chatterton · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mr Luke John Chatterton had a history of Clozapine-related constipation and developed vomiting, severe pain and suspected intestinal obstruction. He was discharged from the emergency department after an X-ray, later deteriorated and suffered a cardiac arrest, with delays in advanced life support before he died. The principal concerns were the safety and timeliness of resuscitation for detained mental health patients and the identification and escalation of risks associated with suspected obstruction in patients taking Clozapine.

    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 Croydon University Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a national formal guideline for management of bowel obstruction

    Wider context from the report

    “2. The acute Trust has taken a number of steps to facilitate identifying the risks of a patient who is referred with suspected obstruction. Outstanding is the development with the mental health Trust of an educational package and guidelines for managing suspected acute obstruction, including pseudo-obstruction (a complication of Clozapine) and recognizing the rare but potentially fatal risks of anti-psychotics. There is currently no national formal guideline on management of bowel obstruction. Given the rarity of antipsychotic induced acute obstruction, there seems to be merit in alerting national professional bodies to enable consideration to be given to the development of a guideline, which might identify the use of red flags to escalate and investigate those at most risk. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Croydon University Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in accessing advanced life support resuscitation for detained patients

    Wider context from the report

    “1. The delays in accessing advanced life support (ALS) resuscitation in the MH hospital were worse than expected in the community. London Ambulance Service target for Category 1 calls is 7 minutes and yet it took 37 minutes before the paramedics arrived. Despite concerns that resuscitation skills were better to maintain in a MH Trust, Adrenaline and IV lines were part of the system at the time. Initially no IV line could be found, then none could be inserted. 25 minutes of asystole elapsed before Adrenaline was administered. Evidence was heard that MH Trusts cannot safely provide advanced life support resuscitation unless they are co-located with an acute hospital site. The National Quality Standards in mental health in patient care requires calling 999 immediately and strongly recommends provision of IV-line insertion and drug administration and a team leader with ALS skills, but the Resuscitation Council has apparently approved the Trust policy. Thus, the safety of a patient detained by the State, who has a cardio-respiratory arrest, would seem to vary according to post code, some not being close to acute hospital standards, and might even be worse than in the community. Given that those who suffer psychosis have increased risks of premature death, including suicide and cardiovascular deaths, in part related to treatment, the State would seem to have a responsibility to mitigate these risks, when compulsorily detaining them. It raises the question as to whether patients with high risk should have the right to choose a site where there is co-location of acute services and whether units with high concentration of detained psychotics should and can be safely equipped to provide Advanced Life Support. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Croydon University Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of mental health hospitals to provide advanced life support resuscitation without acute hospital co-location

    Wider context from the report

    “1. The delays in accessing advanced life support (ALS) resuscitation in the MH hospital were worse than expected in the community. London Ambulance Service target for Category 1 calls is 7 minutes and yet it took 37 minutes before the paramedics arrived. Despite concerns that resuscitation skills were better to maintain in a MH Trust, Adrenaline and IV lines were part of the system at the time. Initially no IV line could be found, then none could be inserted. 25 minutes of asystole elapsed before Adrenaline was administered. Evidence was heard that MH Trusts cannot safely provide advanced life support resuscitation unless they are co-located with an acute hospital site. The National Quality Standards in mental health in patient care requires calling 999 immediately and strongly recommends provision of IV-line insertion and drug administration and a team leader with ALS skills, but the Resuscitation Council has apparently approved the Trust policy. Thus, the safety of a patient detained by the State, who has a cardio-respiratory arrest, would seem to vary according to post code, some not being close to acute hospital standards, and might even be worse than in the community. Given that those who suffer psychosis have increased risks of premature death, including suicide and cardiovascular deaths, in part related to treatment, the State would seem to have a responsibility to mitigate these risks, when compulsorily detaining them. It raises the question as to whether patients with high risk should have the right to choose a site where there is co-location of acute services and whether units with high concentration of detained psychotics should and can be safely equipped to provide Advanced Life Support. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Croydon University Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to identify the risks of deterioration and death from suspected acute obstruction in patients chronically on Clozapine

    Wider context from the report

    “2. The acute Trust has taken a number of steps to facilitate identifying the risks of a patient who is referred with suspected obstruction. Outstanding is the development with the mental health Trust of an educational package and guidelines for managing suspected acute obstruction, including pseudo-obstruction (a complication of Clozapine) and recognizing the rare but potentially fatal risks of anti-psychotics. There is currently no national formal guideline on management of bowel obstruction. Given the rarity of antipsychotic induced acute obstruction, there seems to be merit in alerting national professional bodies to enable consideration to be given to the development of a guideline, which might identify the use of red flags to escalate and investigate those at most risk. ”
    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

Data last updated 7 September 2026