16 Mar 2026 DARREN ROBERT DICKSON · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 1 Failure to retain and prevent destruction of supervision records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
DARREN ROBERT DICKSON · 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
Darren Robert Dickson was found unresponsive at home on 5 February 2025 and died in hospital on 6 February 2025. Toxicology showed benzodiazepine and alcohol, which the report states led to his death on the balance of probabilities. The principal concern was that records had been overwritten and later destroyed, with insufficient reassurance that the trust’s policy addressed the retention and non-destruction of records.
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 Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to retain and prevent destruction of supervision records
Wider context from the report “I had evidence that Mr Dickson’s supervision records were being overwritten and the full nature of those records could not accurately be ascertained. Following Mr Dickson’s death, those supervision records were destroyed and were not available to me at the inquest.
I heard evidence, and was provided with an updated policy, addressing the issues concerning overwriting of supervision records. I was therefore satisfied that the issues concerning overwriting of records has been addressed.
I was not provided with sufficient evidence to allay my concern about the retention and the non-destruction of records and considered that the trust’s policy did not address the issue about destruction of records . I was therefore given insufficient reassurance that this specific concern is being addressed .
” 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 Strengthen the Clinical Supervision Policy to prohibit disposal or destruction of records before three years and link to the national Records Management Code of Practice.
Verbatim wording from the response “In addition, in response to HM Coroner's concern, the Trust has taken steps to further strengthen the relevant section of the Clinical Supervision Policy (enclosed). Section” Source location 2026-0150 - Response from Cumbria, Northumberland, Tyne & Wear 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 Issue a Trust-wide Policy Alert highlighting the coroner’s concern and the Clinical Supervision Policy amendment.
Verbatim wording from the response “To bring this update to the attention of all staff, the Trust have also issued a Trust-wide Policy Alert, via email on 27th April 26, also enclosed. This alert summarised HM Coroner's concern from this case and highlighted the policy amendment.” Source location 2026-0150 - Response from Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing policy already required clinical supervision records to be retained for at least three years; the destruction occurred outside expected policy guidance.
Verbatim wording from the response “HM Coroner remained concerned, following the inquest, about the retention and the non-destruction of records and considered that the Trust’s policy did not suitably address this.” Source location 2026-0150 - Response from Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust
Open published response
11 Mar 2026 CHARLOTTE LOUISE JONES · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 1 Inadequate information-sharing procedures for service users regardless of treatment-pathway acceptance 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
CHARLOTTE LOUISE JONES · 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
Charlotte Louise Jones was found deceased at her home on 10 February 2025, with her death attributed to fatal levels of alcohol and bromazolam. She had a history of self-harm and substance use, and had multiple attendances at A&E following overdose and self-harm before her death. The principal concern was that CNTW and Recovery Steps did not have an adequate procedure for exchanging information about service users, including those not accepted onto a particular treatment pathway.
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 Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate information-sharing procedures for service users regardless of treatment-pathway acceptance
Wider context from the report “Whilst CNTW and Recovery Steps have procedures by which information about service users is shared, those procedures are not yet appropriate to ensure adequate exchange of information about service users whether or not the service user has been accepted onto a particular treatment pathway .
” Open source report
17 Dec 2025 Valerie Jane Gibson · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 10 Inconsistent use of the Omnicell cabinet and electronic medication record View source Failure to supervise preceptee nurses during medication administration View source Failure to record the actual administering nurse on the electronic medication record View source Alternative access to controlled drugs without the required second fingerprint signature View source Recording medication administration before dispensing occurs View source Reliance on manual identification and entry of prescribed medication into the Omnicell View source Inaccurate recording of Omnicell medication quantities and stock movements View source Lack of a consistently understood procedure for disposing of incorrectly dispensed liquid medication View source Lack of a clear process for dispensing and administering medication View source Failure to check all patient possessions on arrival View source See 7 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. 13
Action
Update Omnicell guides and training checklists, publish them on the intranet, and circulate them through the Trust bulletin.
Stated completedThe respondent said that this action was complete when they made their response on 19 December 2025. View source
Action
Configure ARMS alerts so ward pharmacy teams can deliver face-to-face Omnicell training during newly employed nursing staff’s induction.
Stated completedThe respondent said that this action was complete when they made their response on 19 December 2025. View source
Action
Review and update property-search policy and associated training to require checking all clothing pockets.
Stated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025. View source
Action
Work with electronic-care-record suppliers to explore automated Omnicell stock-adjustment reporting and improve system connectivity and safety innovation.
Stated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025. View source
Action
Roll out the adopted six rights of medicines administration framework through approved posters and Trust-wide communications.
Stated plannedThe respondent said that this action was planned when they made their response on 19 December 2025. View source
Action
Add controlled-drug discrepancy-reporting guidance to the Medicines Optimisation Policy.
Stated completedThe respondent said that this action was complete when they made their response on 19 December 2025. View source
Action
Add medication-administration rights content to e-learning and produce a clinic and dispensing-area awareness poster.
Stated completedThe respondent said that this action was complete when they made their response on 19 December 2025. View source
Action
Develop a controlled-drug stock-adjustment report and implement the agreed escalation process for unusual Omnicell balance adjustments.
Stated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025. View source
Action
Develop educational and instructional videos supporting Omnicell use.
Stated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025. View source
Action
Update the Medicines Optimisation Policy and medicines-management e-learning package for Omnicell competencies and EPMA use, and circulate the policy updates.
Stated completedThe respondent said that this action was complete when they made their response on 19 December 2025. View source
Action
Update and deliver face-to-face Omnicell training for ward pharmacy teams, with training offered to bed-based nursing teams.
Stated completedThe respondent said that this action was complete when they made their response on 19 December 2025. View source
Action
Operate a Task and Finish group developing further safer-medicines-administration actions, including mandatory Omnicell assessment, competency support and possible medicines-management roles.
Stated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025. View source
Action
Revise nursing medicines competency assessment requirements covering EPMA, Omnicell, formulations, liquid disposal, supervision scenarios and medicines-administration sequencing.
Stated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025. View source See 10 more actions
×
AI-generated summary
Valerie Jane Gibson · 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 Jane Gibson died on 29 October 2023 at Monkwearmouth Hospital after being admitted under the Mental Health Act with psychotic symptoms and assessed as being at risk of self-harm and harm to others. The principal concerns were uncertainty and inconsistency in the checking of possessions, dispensing and administration of medication, supervision of nurses, and use of the Omnicell and electronic medication record systems, resulting in unclear records of what medication had been dispensed or administered.
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 Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent use of the Omnicell cabinet and electronic medication record
Wider context from the report “There was no consistency in the evidence from the nursing staff as to the correct use of the Omnicell medication cabinet and the electronic medication record (ePMA) . This resulted in different approaches being taken leading to differences between medication recorded as being dispensed from the Omnicell cabinet and that being recorded as administered to the patient on the electronic medication record (ePMA). Between 27th and 29th October 2023 Valerie’s Omnicell record showed that liquid medication had been dispensed for her. She was not prescribed this medication. Her electronic medication record (ePMA) showed that tablet medication was administered to her which was her prescribed medication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to supervise preceptee nurses during medication administration
Wider context from the report “The evidence highlighted a lack of understanding with regard to supervision requirements for preceptee nurses resulting in medication being administered without supervision and being recorded on a patient’s electronic medication record (ePMA) as being administered by a different registered nurse.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record the actual administering nurse on the electronic medication record
Wider context from the report “The evidence highlighted a lack of understanding with regard to supervision requirements for preceptee nurses resulting in medication being administered without supervision and being recorded on a patient’s electronic medication record (ePMA) as being administered by a different registered nurse .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Alternative access to controlled drugs without the required second fingerprint signature
Wider context from the report “The evidence suggested there were alternative ways to access controlled drugs within the Omnicell cabinet without the use of a 2nd fingerprint signature by using a stock code normally used by pharmacy when restocking the cabinet adding to the confusion over what was dispensed and what was administered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Recording medication administration before dispensing occurs
Wider context from the report “The evidence confirmed that on occasions the patient’s electronic medication record (ePMA) showed that medication had been administered to the patient before it had even been dispensed from the Omnicell cabinet with nurses admitting this was likely done to reduce workload during a busy medication round. This resulted in Valerie being recorded as receiving all of her medication on the morning of 29th October 2023 which was not the case as she was sadly found unresponsive before any medication was given to her and subsequently passed away.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Reliance on manual identification and entry of prescribed medication into the Omnicell
Wider context from the report “It was apparent that the Omnicell and electronic medication record (ePMA) are two distinct and separate systems that are supposed to be used alongside each other but the evidence highlighted the potential flaws in that approach due to the reliance on the person using the system adopting the correct approach. I was shocked that the Omnicell did not refer to a patient’s prescribed medication and relies on the nurse dispensing to have correctly identified from the patient’s electronic record (ePMA) the correct prescription and then inputting the correct medication and dose to the Omnicell . Differing amounts were inputted in and on 28th October 2023 and stock levels of the non-prescribed liquid medication showed a significantly large reduction which was over 3 times a normal dose with no evidence a spillage had occurred and no incident report completed. In addition, small doses were inputted to enable the medication to be returned to the cabinet if the door had shut before the nurse had replaced the bottle. This led to complete confusion over stock levels, what had been dispensed and whether it had been disposed of or administered to the patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate recording of Omnicell medication quantities and stock movements
Wider context from the report “It was apparent that the Omnicell and electronic medication record (ePMA) are two distinct and separate systems that are supposed to be used alongside each other but the evidence highlighted the potential flaws in that approach due to the reliance on the person using the system adopting the correct approach. I was shocked that the Omnicell did not refer to a patient’s prescribed medication and relies on the nurse dispensing to have correctly identified from the patient’s electronic record (ePMA) the correct prescription and then inputting the correct medication and dose to the Omnicell. Differing amounts were inputted in and on 28th October 2023 and stock levels of the non-prescribed liquid medication showed a significantly large reduction which was over 3 times a normal dose with no evidence a spillage had occurred and no incident report completed . In addition, small doses were inputted to enable the medication to be returned to the cabinet if the door had shut before the nurse had replaced the bottle. This led to complete confusion over stock levels, what had been dispensed and whether it had been disposed of or administered to the patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a consistently understood procedure for disposing of incorrectly dispensed liquid medication
Wider context from the report “Each nurse had a different understanding as to what the correct procedure was to dispose of liquid medication incorrectly dispensed . One thought it went straight into the blue disposal bin but the other did not think that was the case. The group medical director also had a slightly different view that a liquid could be disposed of in the blue disposal bin if it was in a sealed container. This added to the confusion over which medication had been administered to Valerie.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear process for dispensing and administering medication
Wider context from the report “I was concerned that the evidence highlighted significant staff uncertainty and confusion as to the correct process for dispensing and administering of medication resulting in complete lack of clarity as to what medication had been dispensed and what had been administered to patients which could easily lead to patients being over or under medicated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to check all patient possessions on arrival
Wider context from the report “It became clear in evidence that there was not a thorough check of Valerie’s possessions which arrived after she had been admitted . All possessions, no matter when they arrived, should have been checked . Additional tablets were found in a coat pocket and that coat was one of the possessions that arrived the day after her admission and was given to her without being checked. On balance of probabilities, toxicology suggested that Valerie had not consumed additional tablets over and above her prescribed dose, but there was clearly the opportunity for her to do so with staff admitting they would not have known if she had.
” 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 Update Omnicell guides and training checklists, publish them on the intranet, and circulate them through the Trust bulletin.
Verbatim wording from the response “- Omnicell guides and training checklists have been updated and are available to all staff on the Trust intranet and have been circulated via the Trust bulletin.” Source location Response from Cumbria, Northumberland, Tyne and Wear 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 Configure ARMS alerts so ward pharmacy teams can deliver face-to-face Omnicell training during newly employed nursing staff’s induction.
Verbatim wording from the response “- An alert on the Trusts Access Request Management System (ARMS) has been established to alert ward-based pharmacy teams whenever a new member of Trust nursing staff commences employment so that face to face Omnicell training can be delivered during their induction period.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update property-search policy and associated training to require checking all clothing pockets.
Verbatim wording from the response “Trust Response
The Trust has a policy CNTW(C)11, complimented by local operational procedures held at ward level, these are being reviewed and updated with the learning from this case. In relation to this concern, the current process around the checking of property is to be reinforced to ensure that all clothing pockets are checked as part of a property search. This will be made explicit in the search policy and associated training.” Source location Response from Cumbria, Northumberland, Tyne and Wear 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 Work with electronic-care-record suppliers to explore automated Omnicell stock-adjustment reporting and improve system connectivity and safety innovation.
Verbatim wording from the response “The Trust are also working with its electronic care records system supplier to explore the possibility of an automated reporting of stock balance adjustment report from the Omnicell system.” Source location Response from Cumbria, Northumberland, Tyne and Wear 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 Roll out the adopted six rights of medicines administration framework through approved posters and Trust-wide communications.
Verbatim wording from the response “- The Trust has adopted the ‘6 Rights of Medicines Administration’ (6R’s), a NICE-recommended safety framework designed to reduce the risk of medication errors during the administration process in health and care settings. The 6R’s are, Right Patient, Right Medicine, Right Dose, Right Route, Right Time, Right Documentation. The Framework is to be rolled out across CNTW, posters have been prepared for circulation and are awaiting approval of the Medicines Optimisation Committee (MOC) on 11/2/26. With Trust wide communications via the Bulletin and pharmacy Internet page to follow thereafter.” Source location Response from Cumbria, Northumberland, Tyne and Wear 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 Add controlled-drug discrepancy-reporting guidance to the Medicines Optimisation Policy.
Verbatim wording from the response “A) The pharmacy team has led a Trustwide switch from morphine sulphate oral solution 10mg/5ml (Oramorph) to morphine sulphate oro-dispersible tablets (Actimorph), as the preferred 1st line product. This will reduce the issues highlighted in this case regarding the use of liquid Controlled Drugs (CD’s).
B) Further guidance on the reporting of CD discrepancies has been added to the Trust Medicines optimisation policy. The Nurse Medicines competency assessment has had additional content added regarding medicines formulations (immediate release vs modified release).” Source location Response from Cumbria, Northumberland, Tyne and Wear 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 Add medication-administration rights content to e-learning and produce a clinic and dispensing-area awareness poster.
Verbatim wording from the response “In relation to this finding the Trust has added a segment to its medication administration e-learning package around the ‘Rights of Medication Administration’. A poster for display in clinics / dispensing areas has also been produced to raise awareness. In addition, the review of the medicine’s competency assessment will include a section on the correct sequencing involved in medicines administration. The Trust Pharmacy service is also in the process of developing educational / instructional videos to support the use of Omnicell.” Source location Response from Cumbria, Northumberland, Tyne and Wear 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 Develop a controlled-drug stock-adjustment report and implement the agreed escalation process for unusual Omnicell balance adjustments.
Verbatim wording from the response “A) A CD stock adjustment report to highlight unusual Omnicell stock balance adjustments is in development, and an escalation process has been agreed with bed-based services.
B) Operational Nurse Directors are responsible for ensuring ward based staff are aware of the need to report any CD discrepancies.
C) Aligned with this, the Controlled Drugs Accountable Officer delivered a controlled drugs briefing to operational nurse managers in January 2026.” Source location Response from Cumbria, Northumberland, Tyne and Wear 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 Develop educational and instructional videos supporting Omnicell use.
Verbatim wording from the response “In relation to this finding the Trust has added a segment to its medication administration e-learning package around the ‘Rights of Medication Administration’. A poster for display in clinics / dispensing areas has also been produced to raise awareness. In addition, the review of the medicine’s competency assessment will include a section on the correct sequencing involved in medicines administration. The Trust Pharmacy service is also in the process of developing educational / instructional videos to support the use of Omnicell.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Medicines Optimisation Policy and medicines-management e-learning package for Omnicell competencies and EPMA use, and circulate the policy updates.
Verbatim wording from the response “- The Trust Medicines Optimisation Policy and medicines management e-learning package have also received updates related to Omnicell task competencies and use of EPMA, policy updates have been circulated to staff via the Trust policy bulletin.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and deliver face-to-face Omnicell training for ward pharmacy teams, with training offered to bed-based nursing teams.
Verbatim wording from the response “- Ward based pharmacy teams have received updated face to face Omnicell training, this updated training has also been offered to nursing teams across bed based services.” Source location Response from Cumbria, Northumberland, Tyne and Wear 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 Operate a Task and Finish group developing further safer-medicines-administration actions, including mandatory Omnicell assessment, competency support and possible medicines-management roles.
Verbatim wording from the response “- In addition to the above, a Task and Finish group has been established to develop further actions and initiatives related to safer practice in medicines administration. The group met initially on 22/1/2026 and are scoping:” Source location Response from Cumbria, Northumberland, Tyne and Wear 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 Revise nursing medicines competency assessment requirements covering EPMA, Omnicell, formulations, liquid disposal, supervision scenarios and medicines-administration sequencing.
Verbatim wording from the response “- Nursing staff medicines competencies have been reviewed and updated to include use of EPMA and Omnicell.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Using the incorrect Omnicell restock code did not allow access to controlled drug compartments, which remained protected by two-fingerprint authentication.
Verbatim wording from the response “Further investigation of this concern has occurred since the inquest, and while an incorrect restock code (as opposed to a medicines issue code) was used to open the patient’s own medicines drawer, this did not allow access to the controlled drug compartments (bins) within the drawer. The controlled drug compartments (bins) require two fingerprints to open. Therefore, controlled drugs remained accessible only through the use of a ‘witness’ fingerprint from a 2nd nurse.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Integration of Omnicell and EPMA is currently not viable because evidence is limited, costs are significant, and integration may introduce patient safety risks.
Verbatim wording from the response “Potential integration of the two systems (a ‘closed loop system’) has been considered in conjunction with NHS England and Omnicell. At the present time integration of Omnicell and EPMA is not a viable option. There is limited published evidence from the acute sector of successful integration and no examples of integration within a Mental Health Trust. The process of integration would involve significant financial investment as well as the introduction of patient allocated barcodes / wristbands, which may bring unintended patient safety risks and would require careful consideration and consultation with stakeholders.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
23 Oct 2024 John Paul Hurst · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 2 Failure to record detailed information about detained persons’ mental health concerns View source Failure to provide detailed analysis and comprehensive reasoning for CJLD assessment conclusions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Paul Hurst · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Paul Hurst, who had a history of paranoid schizophrenia and previous suicide attempts, was released from custody on 13 September 2021 after concerns had been raised about his mental health and risk of suicide. He was found near train tracks on 15 September 2021 and died from haemorrhage associated with severe injury to his right leg, consistent with impact with a train. The principal concern was that the electronic custody record inadequately documented the mental-health and suicide-risk concerns, and lacked detailed analysis and reasoning for the CJLD assessment conclusion.
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 Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record detailed information about detained persons’ mental health concerns
Wider context from the report “At the Inquest I heard evidence that, following John’s arrest, concerns were expressed by police officers involved in the investigation as to his mental health, and by John’s sister as to his risk of ending his own life. These concerns were repeated by John’s sister to the Criminal Justice Liaison and Diversion Service (CJLD) prior to his assessment. The evidence was that when completing the release risk assessment, the custody sergeant had been greatly assisted by the information recorded on the electronic custody record regarding the concerns that led to the mental health assessment and the assessment itself, in addition to the custody sergeant’s own observations. The evidence highlighted that the electronic custody record contained limited information about the concerns of police officers and John’s sister , and there was a distinct lack of detail about the assessment itself and very little analysis of the concerns and reasoning for the CJLD conclusion.
I am concerned that the information on the electronic custody record was inadequate and lacked detail regarding the concerns for the detained person’s mental health, as identified by police officers and family, including the risk of suicide, the content of notes found and the detained persons history of suicidal ideation and previous engagement with mental health services . In addition, I am concerned that the record also lacked a detailed analysis of those concerns by CJLD and comprehensive reasoning for the assessment conclusion.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide detailed analysis and comprehensive reasoning for CJLD assessment conclusions
Wider context from the report “At the Inquest I heard evidence that, following John’s arrest, concerns were expressed by police officers involved in the investigation as to his mental health, and by John’s sister as to his risk of ending his own life. These concerns were repeated by John’s sister to the Criminal Justice Liaison and Diversion Service (CJLD) prior to his assessment. The evidence was that when completing the release risk assessment, the custody sergeant had been greatly assisted by the information recorded on the electronic custody record regarding the concerns that led to the mental health assessment and the assessment itself, in addition to the custody sergeant’s own observations. The evidence highlighted that the electronic custody record contained limited information about the concerns of police officers and John’s sister, and there was a distinct lack of detail about the assessment itself and very little analysis of the concerns and reasoning for the CJLD conclusion .
I am concerned that the information on the electronic custody record was inadequate and lacked detail regarding the concerns for the detained person’s mental health, as identified by police officers and family, including the risk of suicide, the content of notes found and the detained persons history of suicidal ideation and previous engagement with mental health services. In addition, I am concerned that the record also lacked a detailed analysis of those concerns by CJLD and comprehensive reasoning for the assessment conclusion .
” 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 Conduct monthly random audits of every CJLD staff member’s screening records and discuss audit outcomes in monthly clinical supervision to monitor implementation.
Verbatim wording from the response “In addition, CJLD Clinical Leads have been given express permission by the Northumbria Police (Superintendent responsible for Custody), to audit Trust staff entries into the electronic custody record provided the reason for accessing the record is documented. Clinical Audit of CJLD screening documentation and will be carried out by CJLD Clinical Leads monthly for every staff member. Three random samples are selected for each staff member each month. Audit includes records made on both ECR and RiO. Audit outcomes are and will be discussed in monthly Clinical Supervision.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update CJLD guidance for recording screening assessments, mental-health concerns, risks, clinical reasoning, referrals and handovers on electronic custody records.
Verbatim wording from the response “The Trust has carried out a thorough review of the guidance provided to staff in relation to entering information onto the electronic custody record and the following changes have been embedded:” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate the updated operating procedure and train CJLD staff on required electronic-record entries and verbal handover documentation.
Verbatim wording from the response “The updated Local Operating Procedure was circulated to staff on 12 November 2024 via email, please see "Exhibit A". Team training also took place on the 13 November 2024 to discuss the updated guidance. During” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS
Open published response
22 Aug 2024 Elise Walsh Deceased · Prevention of Future Deaths report Northumberland
View report summary
Concerns raised 2 Failure to read and consider patient complaint forms during handling and triage View source Failure to make significant patient information available promptly View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Elise Walsh Deceased · 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
Elise Walsh had a history of self-harm and suicidal ideation and suffered a severe hypoxic brain injury after an incident in hospital on 12 February 2022. She later developed aspiration pneumonia and died on 7 June 2023. Concerns included a significant note of intent not being made available earlier and complaint forms potentially being handled in a way that could cause important patient information to be missed or delay treatment or intervention.
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 Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to read and consider patient complaint forms during handling and triage
Wider context from the report “2. I am told the administrative staff do not read complaint forms and it is the process that complaint forms are placed in an envelope without being read or considered and are sent straight to another hospital . However it appears as part of the triage the envelope containing the complaint form is opened at that hospital by a mixture of administrative staff and clinical staff. I am concerned that important information from a patient could be missed and there could also be a significant delay in administering treatment or intervention.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make significant patient information available promptly
Wider context from the report “1. The deceased attended an appointment at St George’s Park Hospital on the 12 February 2022. After the appointment she was waiting for a taxi, walking up and down the corridor and appeared to be getting more agitated. She was not happy with how her appointment went and voiced those concerns verbally. When the taxi arrived, she refused to get in and the taxi left. She remained at reception where she voiced her anger at the Crisis Team and requested a Complaints Form. I describe it as a note of intent and do not repeat its content. It is not referred to in any witness statements, it is not referred to in the Serious Incident Investigation. I had it was discussed at the After Action Review but it has not made its way through to the Serious Incident Investigation. It was disclosed to my office on Friday 16 August 2024 and of greater concern the family were not aware of its existence. I am concerned this significant information was not made available much earlier.
” 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 Provide clinician support when reception staff raise patient concerns, including clinical review of written material where appropriate.
Verbatim wording from the response “explained at the Inquest, the Trust have however, implemented a system whereby if reception staff have concerns about a patient, they can call for support and a clinician will attend to support the reception staff until such concerns are resolved. If during this period of support the patient writes things down, then clinicians can make a decision as to whether or not it is appropriate to review what they have written, enabling them to act upon the contents if indicated.” Source location Response from Cumbria, Northumberland, Tyne and Wear 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 Redesign incident review templates to carry identified issues and key enquiry lines into full patient safety investigations.
Verbatim wording from the response “The Trust now carry out internal investigations in accordance with PSIRF (Patient Safety Incident Response Framework). In line with PSIRF CNTW's review templates have been redesigned to ensure that identified issues/key lines of enquiry are carried forward and are not lost when a review progresses to a full Patient Safety Incident Investigation. Following on from the Inquest the Head of Clinical Risk and Investigations has spoken with the Trust's dedicated Investigating Officers to remind them that whenever an issue is raised as part of discussion during an incident review process it is then explored further and addressed in the completed report.” Source location Response from Cumbria, Northumberland, Tyne and Wear 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 Remind dedicated investigating officers to investigate and address issues raised during incident reviews in completed reports.
Verbatim wording from the response “The Trust now carry out internal investigations in accordance with PSIRF (Patient Safety Incident Response Framework). In line with PSIRF CNTW's review templates have been redesigned to ensure that identified issues/key lines of enquiry are carried forward and are not lost when a review progresses to a full Patient Safety Incident Investigation. Following on from the Inquest the Head of Clinical Risk and Investigations has spoken with the Trust's dedicated Investigating Officers to remind them that whenever an issue is raised as part of discussion during an incident review process it is then explored further and addressed in the completed report.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Immediate opening and triage of complaint forms handed to receptionists cannot be implemented because of confidentiality issues.
Verbatim wording from the response “As you heard at the Inquest, owing to confidentiality issues it is unfortunately not possible to implement a process across the Trust, whereby any complaint forms which are handed to receptionists are opened and immediately triaged. Following the inquest this matter has been discussed at the Trust Wide Patient Safety Learning and Improvement Panel (PSLIP) and unfortunately it has not been possible to identify a different system which would allow for such urgent reviews, however the PSLIP panel did request the above addition to the complaints form. As” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
1 May 2024 Harry David HALL · Prevention of Future Deaths report Northumberland
View report summary
Concerns raised 1 Failure to record the reason for a missed appointment and whether an assessment was undertaken View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Harry David HALL · 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
Harry David Hall, who had a history of depression and recent suicidal ideation, was found dead in the rear garden of his home on 29 May 2023 after sustaining a self-inflicted traumatic head injury from a captive bolt gun. The principal concern was inadequate record keeping about the missed mental-health appointment and the lack of clarity about whether any assessment took place before his death; the report also noted delays in 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 Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record the reason for a missed appointment and whether an assessment was undertaken
Wider context from the report “The deceased was seen by his General Practitioner on 27 March 2023 when he described ongoing suicidal ideation. His General Practitioner referred him to the 24-hour crisis team at 17.56 hours on 27 March 2023. The Initial Response Team ("IRT") provides 24 hour access to urgent mental health care and treatment. The IRT called the deceased at 22.37hrs on 27 March 2023 and I am told during which no immediate risks of self-harm were identified and although frequent thoughts of suicide were being experienced they were felt to be chronic in nature. The clinical decision was to not to refer on the Crisis Team and instead refer to the West Northumberland Community Treatment Team. There were two letters the first dated 31 March 2023 offering an appointment on 17 May 2023 and the second dated 4 April offering an appointment on 26 June 2023. I heard there was a ten week delay in appointments although that delay has since been rectified. The appointment on 17 May 2023 did not go ahead. No evidence was given as to why the appointment on the 17 May 2023 did not go ahead. There is nothing in the records, it is unclear if any assessment was undertaken at that time and this is crucial information. It is speculation if the outcome would have been any different if the deceased had been seen prior to his death. I am concerned with regard to the record keeping at this time.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes that a cancelled appointment lacked rationale and says assessment remained within the applicable 18-week timeframe.
Verbatim wording from the response “There was therefore no cancelled appointment and therefore no omission of rationale for the perceived cancellation. Furthermore, as was explained in the hearing, Mr Hall would have been seen within the 18 week timeframe that was the appropriate benchmark at the time.” Source location Response from Cumbria, Northumberland, Tyne and Wear
Open published response
Concerns raised 2 Failure to co-ordinate care through multi-disciplinary and multi-agency meetings View source Failure to make safeguarding referrals for formal safeguarding supervision View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Christopher Paul Vickers · 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 Paul Vickers had worsening mental health and ADHD symptoms, with escalating risks of self-harm and harm to others. He was found with a ligature around his neck on 18 July 2021 and death was certified that day. The report identified repeated missed opportunities to coordinate his care through multi-disciplinary or multi-agency meetings and to make safeguarding referrals despite the escalating risks.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to co-ordinate care through multi-disciplinary and multi-agency meetings
Wider context from the report “1. There were multiple repeated missed opportunities to co-ordinate the Deceased’s care with the convention of multi-disciplinary and multi-agency meetings despite known escalating risk.
2. There were multiple repeated missed opportunities to make safeguarding referrals for formal safeguarding supervision from the safeguarding adult public protection team despite known escalating risk to self and to others.
There remains a risk that future deaths could occur as the missed opportunities were significant and multiple and relate to clear processes and policies that were not followed. Current action that has been undertaken does not address my concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make safeguarding referrals for formal safeguarding supervision
Wider context from the report “1. There were multiple repeated missed opportunities to co-ordinate the Deceased’s care with the convention of multi-disciplinary and multi-agency meetings despite known escalating risk.
2. There were multiple repeated missed opportunities to make safeguarding referrals for formal safeguarding supervision from the safeguarding adult public protection team despite known escalating risk to self and to others .
There remains a risk that future deaths could occur as the missed opportunities were significant and multiple and relate to clear processes and policies that were not followed. Current action that has been undertaken does not address my concerns.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the domestic violence policy to incorporate inquest and incident learning and clarify staff roles and responsibilities for safeguarding referrals.
Verbatim wording from the response “However, following the inquest, a decision was made to review the domestic violence policy, and this is due to be completed by July 2024, to ensure that the Trust incorporates all the learning from this inquest, and other incidents, and provides clarity on staff roles and responsibilities in relation to safeguarding referrals.” Source location Response from Cumbria, Northumberland, Tyne and Wear 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 Embed safeguarding and multi-agency meeting checks in four-weekly clinician supervision case reviews across all teams.
Verbatim wording from the response “Within all teams, clinician supervision takes place every 4 weeks, which includes a random sample of cases being checked, and safeguarding and the need for convening a multi-agency meeting is now embedded as part of this review process.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver bespoke training, email communications and team meetings to improve staff awareness and skills regarding safeguarding referrals and procedures.
Verbatim wording from the response “As explained at the inquest, since Mr Vickers' death, there has been a lot of work within the Trust to improve awareness and skills, through bespoke training, email communication and team meetings. This has emphasised the importance of when referrals to safeguarding should be made, and what process should be followed.” Source location Response from Cumbria, Northumberland, Tyne and Wear 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 Embed safeguarding and multi-agency meeting consideration in Crisis, ADHD and Community Treatment Team meetings, with MDT meetings following each assessment.
Verbatim wording from the response “Within the Crisis and ADHD team, MDT (Multi-Disciplinary Team) processes have changed, and safeguarding and consideration of a multi-agency meeting is now a standing agenda item. It serves to act as a reminder to clinicians to review and ensure all areas of identified risk have been addressed, and responded to where appropriate.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and circulate the domestic abuse policy, including guidance on identifying abuse risk and requesting MARAC referrals.
Verbatim wording from the response “In Mr Vickers' case, the concerns highlighted around referrals to safeguarding related to issues of domestic abuse to others. Since Mr Vickers' death the Trust's Multi-Agency Risk Assessment Conference (MARAC) policy (now the domestic abuse policy) has been updated and circulated to staff via the Trustwide policy bulletin. As part of this policy, there is guidance for staff around identifying if someone is at risk of abuse and when a referral for a MARAC should be requested (which is a police coordinated multi agency meeting including health representatives, police and children and adult social care).” Source location Response from Cumbria, Northumberland, Tyne and Wear 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 Conduct weekly telephone-triage reviews of selected crisis contacts to assess contact quality, safeguarding actions and whether multi-agency meetings were required.
Verbatim wording from the response “Within Crisis services a new process of a weekly telephone triage review has been implemented. This looks at all crisis team, which have not required a face-to-face assessment, as was sometimes the case in the past and in relation to Mr Vickers.” Source location Response from Cumbria, Northumberland, Tyne and Wear 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 Use a safeguarding incident-reporting template to support consistent practitioner advice on referrals and multi-agency communication, with recommended actions monitored by managers.
Verbatim wording from the response “Safeguarding issues are reported through an incident reporting system, which is reviewed by a dedicated Safeguarding Practitioner who will offer any relevant safeguarding advice to the reporting service and its manager. This advice will, where appropriate, advise on local authority referral and multiagency communication, with any recommended actions monitored by managers. A template has now been implemented for the Safeguarding Practitioner to assist with ensuring that the advice is provided in a consistent way.” Source location Response from Cumbria, Northumberland, Tyne and Wear 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 Conduct compliance audits against the domestic abuse policy to check that MARAC referrals are actioned in line with safeguarding advice.
Verbatim wording from the response “A compliance audit against the domestic abuse policy will look to ensure that MARAC referrals are being actioned in line with Safeguarding advice.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
7 Jun 2023 Brenda SHIELDS · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 6 Failure to involve family or carers in discharge processes View source Failure to involve family in discharge processes View source Failure to adequately incorporate alcohol problems, reported assurances and recent history into risk assessment View source Failure to plan follow-up after discharge View source Delays in sending discharge notifications to GPs View source Failure to make promised referrals to relevant specialist services View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Brenda SHIELDS · 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
Brenda Shields died at home in Carlisle on 8 December 2022 after taking her life by ligature suspension while under the influence of a very high blood alcohol level. The principal concerns were that she was discharged without planned follow-up, her family was not involved as expected, relevant notifications and referrals were delayed or not made, and insufficient weight was given to her alcohol problems and recent history when assessing risk.
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 Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve family or carers in discharge processes
Wider context from the report “(3) I refer you to the PFD report I issued referring to Charlotte Grace on 29/10/19. Assurances were given in response to that report which again focused on discharge without family/carer involvement which is surely paramount . I note actions mentioned in the incident report in this case but am still concerned that similar events may occur in future .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve family in discharge processes
Wider context from the report “(1) Brenda was discharged without any planned follow up. Her family were not involved in the discharge process despite assurances that they would be , her GP did not receive discharge notification from the Hadrian unit until 8 days after the event or from the Crisis team until 10 days after Brenda's death. Referrals promised from Hadrian unit to Drug/Alcohol services and Persistent Physical Symptoms Service were not made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately incorporate alcohol problems, reported assurances and recent history into risk assessment
Wider context from the report “(2) Inadequate weight seems to have been given to Brenda's alcohol problems and her assurances that all was, and would continue to be well were accepted at face value despite her recent history , her family find it hard to understand how she could be graded low risk on the day she died .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to plan follow-up after discharge
Wider context from the report “(1) Brenda was discharged without any planned follow up. Her family were not involved in the discharge process despite assurances that they would be, her GP did not receive discharge notification from the Hadrian unit until 8 days after the event or from the Crisis team until 10 days after Brenda's death. Referrals promised from Hadrian unit to Drug/Alcohol services and Persistent Physical Symptoms Service were not made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in sending discharge notifications to GPs
Wider context from the report “(1) Brenda was discharged without any planned follow up. Her family were not involved in the discharge process despite assurances that they would be, her GP did not receive discharge notification from the Hadrian unit until 8 days after the event or from the Crisis team until 10 days after Brenda's death . Referrals promised from Hadrian unit to Drug/Alcohol services and Persistent Physical Symptoms Service were not made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make promised referrals to relevant specialist services
Wider context from the report “(1) Brenda was discharged without any planned follow up. Her family were not involved in the discharge process despite assurances that they would be, her GP did not receive discharge notification from the Hadrian unit until 8 days after the event or from the Crisis team until 10 days after Brenda's death. Referrals promised from Hadrian unit to Drug/Alcohol services and Persistent Physical Symptoms Service were not made.
” 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 caregiver inclusion in safety and discharge planning through daily MDT review, audits and supervisory checks.
Verbatim wording from the response “Actions/Recommendations:” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the risk-assessment approach to move from quantified risk scoring towards a narrative approach aligned with NICE guidance.
Verbatim wording from the response “Consequently, the Trust is in the process of reviewing its approach to risk assessment with the intention of moving away from quantification of risk to that of a more narrative approach in line with recommendations made by NICE in their Self Harm: assessment, management and preventing recurrence [NG225] guidance of 2022.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record onward referrals and receiving-team acceptance on the electronic MDT proforma, with monthly compliance audits.
Verbatim wording from the response “"Discharge processes to be reviewed by Hadrian Ward to ensure onward referrals are communicated with receiving teams” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue rolling out carer-awareness and Getting To Know You training, including one-to-one training for new staff.
Verbatim wording from the response “Carer leads continue to roll out carer awareness training. This is at 80% across the service currently. A further 8 staff have had Carer Awareness and Getting To Know You training over the past 4 months. Carer leads also offer 1:1 Training for new staff working within CRHT.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and discuss Hadrian Unit discharge processes with staff to improve communication of onward referrals.
Verbatim wording from the response “Actions/Recommendations:” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The FACE risk assessment contained relevant risks, and its scoring was appropriate for the risks presented at discharge.
Verbatim wording from the response “In relation to the risk assessment conducted on the day Brenda was discharged, the Serious Incident Investigation Report found that the FACE risk assessment contained all of the relevant risks and scoring was appropriate for the presenting risks.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The discharge included planned follow-up, with ongoing support from the Cumbria East Crisis Team and planned referrals to other services.
Verbatim wording from the response “In addition to the above, this concern also suggests that Brenda was discharged from the Hadrian Unit and the Crisis Team without any planned follow up. Again, by way of clarification and in accordance with the written evidence provided, immediately following discharge from the Hadrian Unit, Brenda was supported in the community by the Cumbria East Crisis Team, and she continued to be supported by this service until the date of her sad death (on which date she was also discharged from the service). The role of crisis services is to provide people with safe, effective, compassionate, high-quality care whilst they remain in mental health crisis. Where appropriate and as in this case, the crisis service offers home treatment intervention to allow people to be discharged from hospital earlier whilst still experiencing an acute phase of illness.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The investigation concluded that identified family-involvement issues were not causative or contributory to the death.
Verbatim wording from the response “We note that the extent to which the issues with family involvement in this case were not explored in evidence due to the absence of any Trust witnesses however, the written evidence from the SI investigation concluded that the findings/learning identified in this investigation were not considered to be causative or contributory to Brenda's death, particularly as carers' views had been sought at a number of points during Brenda's care and treatment and the Getting To Know You documentation had been completed.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
Concerns raised 13 Failure to explore assault, violence and intimidation concerns with the service user, family and other agencies View source Failure to coordinate inpatient discharge with family and other agencies View source Failure of the care coordinator to establish direct contact and a relationship with the service user before discharge View source Failure to obtain care coordinator consent and agreement before role assignment View source Absence of an audit system for timely referrals View source Insufficient in-person engagement before discharge from the Community Treatment Team View source Inconsistent approaches to risk assessment View source Failure to refer service users with substance misuse needs to substance misuse services View source Failure to consider capacity concerns when appointing a care coordinator View source Failure to hold a multidisciplinary pre-discharge meeting for future planning View source Failure to make timely and complete clinical records documenting assessment, care planning and decision-making rationale View source Delays and failures in referral to the Community Treatment Team View source Failure to provide Consultant Psychiatrist review after 30 May 2018 View source See 10 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
Odessa Carey · 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
Odessa Carey was last seen alive at her home on 4 April 2019 and was found dead on 7 April 2019; the inquest recorded the conclusion “Unlawfully killed”. The report raised concerns about multi-agency risk assessment, substance-misuse referrals, discharge and care coordination, risk assessment, record keeping, and delays in referral to the Community Treatment Team.
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 Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to explore assault, violence and intimidation concerns with the service user, family and other agencies
Wider context from the report “1. Multi-agency Risk Assessment Conference (“MARAC”)
I heard evidence of issues of assault, violence and intimidation. Further that the consent of the individual reporting the concerns is not always required in order to complete a MARAC referral.
Whilst I recognise that the extent of the issues could have been diminished out of familial ties or for other reasons, I am concerned that staff did not explore the issues to a greater extent with the deceased, the wider family and other agencies.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate inpatient discharge with family and other agencies
Wider context from the report “3. Inpatient discharge 30 May 2018
The discharge was not a coordinated discharge in line with the trust CPA policy. There was no discharge meeting, no involvement with other agencies or family , the service user was still mentally unwell, having delusional beliefs, without supported accommodation, vulnerable, moving to a new locality and without familial support
I am concerned there was a lack of opportunity to involve the family or other agencies in the discharge.
I am concerned that there was no direct contact or introduction to the service user from the care coordinator whilst an inpatient or before discharge to establish a relationship and trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the care coordinator to establish direct contact and a relationship with the service user before discharge
Wider context from the report “3. Inpatient discharge 30 May 2018
The discharge was not a coordinated discharge in line with the trust CPA policy. There was no discharge meeting, no involvement with other agencies or family, the service user was still mentally unwell, having delusional beliefs, without supported accommodation, vulnerable, moving to a new locality and without familial support
I am concerned there was a lack of opportunity to involve the family or other agencies in the discharge.
I am concerned that there was no direct contact or introduction to the service user from the care coordinator whilst an inpatient or before discharge to establish a relationship and trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain care coordinator consent and agreement before role assignment
Wider context from the report “5. Appointment of a Care Coordinator
I heard that in line with the trust CPA policy paragraph 12.1 “Consent must always be sought from a professional prior to them being identified as a Care Coordinator. Under no circumstances must any professional be stated as Care Coordinator without negotiation and agreement. “
I am concerned that consent and agreement was not obtained from a care coordinator prior to being identified for the role of care coordinator and concerns regarding capacity were not considered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of an audit system for timely referrals
Wider context from the report “8. Contact with IRT and referral to Community Treatment Team
The service user contacted the service on a number of occasions and sought self-referral to the Crisis team on 19 September 2018 who assessed her as requiring a re-referral to the community team. No referral was made.
I am concerned that there was a delay in the referral to the Community Treatment Team and there is no audit system to ensure referrals are made and in a timely fashion.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient in-person engagement before discharge from the Community Treatment Team
Wider context from the report “4. Discharge from the Community Treatment Team on 6 August 2018
There was no pre-discharge meeting in line with trust CPA Policy involving the family, lead professionals, other agencies or a Consultant Psychiatrist for future planning.
A more assertive approach to engagement may have been appropriate.
I am concerned that following discharge from the Lowry ward to the community and prior to discharge from the community treatment team, the deceased was seen only four times in person by individuals from the mental health team and only once by the care coordinator.
I am concerned that more intense, in person engagement was warranted and discharge from the Community Treatment Team was premature.
I am concerned that the service user was not seen by a Consultant Psychiatrist at all after 30 May 2018 despite enquiring about a further appointment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent approaches to risk assessment
Wider context from the report “6. FACE Risk assessment tool
I am concerned that there continues to be an inconsistent approach to the assessment of risk. Various methods are still being deployed and there is a possibility of a disparity in the understanding of the risk to the service user and others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to refer service users with substance misuse needs to substance misuse services
Wider context from the report “2. Assessment of substance misuse
The service user had a history of substance misuse in particular cannabis and its impact on mental health was recognised.
Whilst I acknowledge issues regarding service user consent and compliance, I am concerned there was no referral to substance misuse services for advice or assessment and treatment whilst an inpatient or in the community.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider capacity concerns when appointing a care coordinator
Wider context from the report “5. Appointment of a Care Coordinator
I heard that in line with the trust CPA policy paragraph 12.1 “Consent must always be sought from a professional prior to them being identified as a Care Coordinator. Under no circumstances must any professional be stated as Care Coordinator without negotiation and agreement. “
I am concerned that consent and agreement was not obtained from a care coordinator prior to being identified for the role of care coordinator and concerns regarding capacity were not considered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to hold a multidisciplinary pre-discharge meeting for future planning
Wider context from the report “4. Discharge from the Community Treatment Team on 6 August 2018
There was no pre-discharge meeting in line with trust CPA Policy involving the family, lead professionals, other agencies or a Consultant Psychiatrist for future planning.
A more assertive approach to engagement may have been appropriate.
I am concerned that following discharge from the Lowry ward to the community and prior to discharge from the community treatment team, the deceased was seen only four times in person by individuals from the mental health team and only once by the care coordinator.
I am concerned that more intense, in person engagement was warranted and discharge from the Community Treatment Team was premature.
I am concerned that the service user was not seen by a Consultant Psychiatrist at all after 30 May 2018 despite enquiring about a further appointment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make timely and complete clinical records documenting assessment, care planning and decision-making rationale
Wider context from the report “7. Record Keeping Documentation
I am concerned that entries in the RiO medical records were not made in line with Trust guidance in a timely, complete manner or at all.
I am concerned that evidence of clinical assessment, care planning and the reasoning behind clinical decision making were not recorded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays and failures in referral to the Community Treatment Team
Wider context from the report “8. Contact with IRT and referral to Community Treatment Team
The service user contacted the service on a number of occasions and sought self-referral to the Crisis team on 19 September 2018 who assessed her as requiring a re-referral to the community team. No referral was made.
I am concerned that there was a delay in the referral to the Community Treatment Team and there is no audit system to ensure referrals are made and in a timely fashion.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Consultant Psychiatrist review after 30 May 2018
Wider context from the report “4. Discharge from the Community Treatment Team on 6 August 2018
There was no pre-discharge meeting in line with trust CPA Policy involving the family, lead professionals, other agencies or a Consultant Psychiatrist for future planning.
A more assertive approach to engagement may have been appropriate.
I am concerned that following discharge from the Lowry ward to the community and prior to discharge from the community treatment team, the deceased was seen only four times in person by individuals from the mental health team and only once by the care coordinator.
I am concerned that more intense, in person engagement was warranted and discharge from the Community Treatment Team was premature.
I am concerned that the service user was not seen by a Consultant Psychiatrist at all after 30 May 2018 despite enquiring about a further appointment.
” Open source report
2 Feb 2023 Daniel Graeme Futers · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 3 Lack of comprehensive planning for home leave and discharge from hospital View source Failure to maintain overall situational awareness about the patient View source Inadequate recording of information conveyed by telephone View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Daniel Graeme Futers · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daniel Graeme Futers died after falling from Wearmouth Bridge, Sunderland, on 5 April 2022. The report identified concerns about incomplete recording of information, inadequate planning for home leave and discharge, and insufficient situational awareness, including reconciliation of conflicting accounts about him.
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 Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of comprehensive planning for home leave and discharge from hospital
Wider context from the report “2. Comprehensive planning for home leave and discharge from hospital was not evident , including contingency planning and the involvement of the family .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain overall situational awareness about the patient
Wider context from the report “3. Overall situational awareness about Daniel was not evident , including the reconciliation of conflicting accounts about him .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate recording of information conveyed by telephone
Wider context from the report “1. The recording of information, particularly that conveyed by telephone, was not as comprehensive as it ought to have been . For example, a record of an alteration had not been made .
” 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 Include contingency planning to reduce repeat self-harm risk in updated Trust training materials.
Verbatim wording from the response “c. The risk assessment and associated plan is appropriate, the clinician and patient have a full and open discussion about risk and then between the point of the assessment and the incident, something changes to escalate risk that the clinician could not be aware of or have foreseen. Again, there are limits to the extent to which this can be mitigated against, however contingency planning to reduce the risk of a repeat self-harm attempt is specifically covered in the updated Trust training materials. Contingency and safety planning was evident in this case.” Source location Response from Cumbria, Northumberland, Tyne and Wear 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 Improve communication with carers and family members through disseminating lessons learned, training and continuous audit.
Verbatim wording from the response “In respect of communication with carers/family members, this is a matter which the Trust takes very seriously and acknowledges is an important part of patient care and treatment. The Trust is continuously driving improvement in this area by way of the dissemination of lessons learned, training and continuous audit.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes that information recording was inadequate, stating relevant information was documented or not reported to staff.
Verbatim wording from the response “It is therefore entirely unfair and disproportionate to criticise the Trust for its recording of information, or alleged lack thereof, when such information was not reported.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes that conflicting accounts of Daniel’s presentation existed during leave and therefore required reconciliation.
Verbatim wording from the response “HM Coroner is referred to the response provided above in respect of the reconciliation of alleged conflicting accounts about Daniel’s presentation. On the basis of the live evidence heard during the inquest hearing and the conversations/reviews by clinicians documented in Daniel’s medical records, there were no apparent conflicting accounts of Daniel’s mental health and presentation during his s.17 leave. As set out above, it is accepted that Daniel’s mum reported him as being bored and anxious during the leave. It was clear from the evidence of the Trust and the family that no additional concerns had been reported in respect of Daniel’s leave. We therefore cannot see that there were any” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust considers the risk assessment, safety plan and contingency planning appropriate to known circumstances and sufficient to mitigate risks.
Verbatim wording from the response “b. The risk assessment and associated plan is appropriate to the known circumstances however an individual has not disclosed their true thoughts and intentions in the course of the assessment. The Trust trains its clinicians to mitigate against this risk in so far as possible but there are limitations to what can practically be achieved and the subjective element of risk assessment cannot be eliminated completely. The risk assessments in this case take into account subjective and objective presentation, and collateral information from the family during the leave period. As set out above no issues were identified in the in depth review of the case that suggested a lack of clinical curiosity when considering Daniel’s presentation and treatment plan.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust considers multidisciplinary assessment, gradual leave progression, recall powers and monitoring sufficient for leave and discharge planning.
Verbatim wording from the response “In light of the above, the Trust considers that there had been comprehensive multi-disciplinary consideration of Daniel’s case prior to his s.17 leave being granted which was in line with the Trust policy/procedure in respect of s.17 leave. ████████ explained in his evidence that once Daniel had started to respond to treatment, his leave had been progressed gradually as part of his care and treatment plan alongside his depot medication. ████████ confirmed that there was no reason to suggest that the plan in place was not appropriate and that both Daniel’s subjective and objective presentation were considered in reaching this decision. To the extent that there had been any discrepancy between the objective and subjective presentation, ████████ confirmed that the decision to grant leave would have been reconsidered accordingly.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
12 May 2022 Joan Hoggett · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 4 Insufficient staffing capacity to cover required engagement work View source Failure to act upon information provided by the perpetrator’s family View source Failure to share relevant information with the perpetrator’s family View source Failure to take available opportunities for proactive engagement with the perpetrator 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
Joan Hoggett · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joan Hoggett died in Sunderland Royal Hospital on 5 September 2018 after being attacked and stabbed multiple times at her place of work. Concerns included insufficient engagement by the Mental Health Trust with the perpetrator’s family, missed opportunities for more proactive engagement, and challenges associated with staff capacity and absence.
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 Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing capacity to cover required engagement work
Wider context from the report “1. The family of the perpetrator were not as engaged by the Trust as much as they could have been in terms of:
- sharing information with them; and
- acting upon information provided by them.
I acknowledge that this must take into account the Service User’s capacity and consent and also respecting confidentiality, but in this case these matters did not seem to be an issue.
2. A more proactive approach may have been appropriate.
I am concerned that the opportunities to engage more were not taken.
Engagement with the perpetrator was influenced to some extent by the capacity of the Mental Health Trust and its personnel to meet the competing demands of the Service with the resources at their disposal . This was more challenging at times of staff absence and the ability of the Trust to sufficiently cover the work needed with the perpetrator and others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act upon information provided by the perpetrator’s family
Wider context from the report “1. The family of the perpetrator were not as engaged by the Trust as much as they could have been in terms of:
- sharing information with them; and
- acting upon information provided by them.
I acknowledge that this must take into account the Service User’s capacity and consent and also respecting confidentiality, but in this case these matters did not seem to be an issue.
2. A more proactive approach may have been appropriate.
I am concerned that the opportunities to engage more were not taken.
Engagement with the perpetrator was influenced to some extent by the capacity of the Mental Health Trust and its personnel to meet the competing demands of the Service with the resources at their disposal. This was more challenging at times of staff absence and the ability of the Trust to sufficiently cover the work needed with the perpetrator and others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant information with the perpetrator’s family
Wider context from the report “1. The family of the perpetrator were not as engaged by the Trust as much as they could have been in terms of:
- sharing information with them ; and
- acting upon information provided by them.
I acknowledge that this must take into account the Service User’s capacity and consent and also respecting confidentiality, but in this case these matters did not seem to be an issue.
2. A more proactive approach may have been appropriate.
I am concerned that the opportunities to engage more were not taken.
Engagement with the perpetrator was influenced to some extent by the capacity of the Mental Health Trust and its personnel to meet the competing demands of the Service with the resources at their disposal. This was more challenging at times of staff absence and the ability of the Trust to sufficiently cover the work needed with the perpetrator and others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to take available opportunities for proactive engagement with the perpetrator
Wider context from the report “1. The family of the perpetrator were not as engaged by the Trust as much as they could have been in terms of:
- sharing information with them; and
- acting upon information provided by them.
I acknowledge that this must take into account the Service User’s capacity and consent and also respecting confidentiality, but in this case these matters did not seem to be an issue.
2. A more proactive approach may have been appropriate.
I am concerned that the opportunities to engage more were not taken.
Engagement with the perpetrator was influenced to some extent by the capacity of the Mental Health Trust and its personnel to meet the competing demands of the Service with the resources at their disposal. This was more challenging at times of staff absence and the ability of the Trust to sufficiently cover the work needed with the perpetrator and others.
” 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 Discuss family-engagement compliance in monthly clinical supervision and monitor it through monthly random case-file audits.
Verbatim wording from the response “This issue is also now routinely discussed with staff as part of clinical supervision each month and compliance is monitored during the monthly random audit of caselfiles, the results of which are showing good compliance. The EIP service has also developed a documentation checklist for staff to refer to as a guide to ensure that the GTKY documentation is accurate and central to a service user’s care, within the parameters of consent and confidentiality.” Source location Response from CNTW NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete caseload reviews to assess embedding of the Getting to Know You process and appropriate signposting or referral for carers’ assessments.
Verbatim wording from the response “Since the above recommendation was made, the Trust has completed a number of caseload reviews to seek assurance that the GTKY process has been fully embedded into clinical practice and that carers are being signposted and referred for carers’ assessments as appropriate. This ensures that staff are proactively engaging with family members/carers in the provision of a service user’s care. The findings and actions following these caseload reviews have been shared across the EIP Team, Central Business Unit and locality meetings via the Trust-wide EIP steering group.” Source location Response from CNTW NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase staff time available for service users and carers through Quality Priority 3 patient-care improvement work.
Verbatim wording from the response “The Trust is planning further improvement work in 2022/23 through their delivery of Quality Priority 3: Patient Care, which will increase the time staff are able to spend with service users and carers. This will include engagement with stakeholders and reviews to measure the use of the Getting to Know You documentation. This work has been delayed due to the Covid19 pandemic however, as acknowledged in the final Niche investigation report (published on 29 June 2022), this issue as a whole has been significantly progressed.” Source location Response from CNTW NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review use of the Getting to Know You documentation to measure and further embed the process.
Verbatim wording from the response “The Trust is planning further improvement work in 2022/23 through their delivery of Quality Priority 3: Patient Care, which will increase the time staff are able to spend with service users and carers. This will include engagement with stakeholders and reviews to measure the use of the Getting to Know You documentation. This work has been delayed due to the Covid19 pandemic however, as acknowledged in the final Niche investigation report (published on 29 June 2022), this issue as a whole has been significantly progressed.” Source location Response from CNTW NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement improved carer information leaflets and a carer-specific electronic care-record folder capturing carers’ needs and support plans.
Verbatim wording from the response “By way of background, the ‘Getting to know you’ (GTKY) process is designed to support staff to get to know the whole family of the person being cared for. By applying a ‘Think Family’ approach our staff aim to gain a better understanding of the patient’s background and family circumstances as well as identifying more quickly the patient’s main carer(s). Within a few days of coming into contact with Trust services, a member of staff is expected to arrange to spend some time with the carer/family member, to get to know them. The GTKY process was reviewed in 2018 in collaboration with carers. The outcome of the review led to the design of improved information leaflets and a new carer specific folder within the Electronic Care Record which will capture the needs of carers and record a plan on who best to support their needs.” Source location Response from CNTW NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a documentation checklist to guide accurate, consent-compliant Getting to Know You records within service users’ care.
Verbatim wording from the response “This issue is also now routinely discussed with staff as part of clinical supervision each month and compliance is monitored during the monthly random audit of caselfiles, the results of which are showing good compliance. The EIP service has also developed a documentation checklist for staff to refer to as a guide to ensure that the GTKY documentation is accurate and central to a service user’s care, within the parameters of consent and confidentiality.” Source location Response from CNTW NHS
Open published response
17 Jun 2021 Daniel David Rennoldson · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 2 Failure to identify cases that have not been progressed View source Lack of contingency capacity for multiple simultaneous face-to-face responses View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Daniel David Rennoldson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daniel died at home on 11 November 2020 after expressing suicidal intentions and contacting mental health services and the police. Concerns included there being no contingency for more than one face-to-face response at a time and no mechanism to identify cases that had not progressed, with almost 12 hours elapsing before someone visited his home.
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 Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify cases that have not been progressed
Wider context from the report “2) almost 12 hours had elapsed from Daniel’s call to someone visiting his home address with no mechanism to identify cases, which had not been progressed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of contingency capacity for multiple simultaneous face-to-face responses
Wider context from the report “1) there appeared to be no contingency to deal with more than one face to face response at a time , leaving other callers potentially at risk;
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing Crisis Team staffing, cross-cover and flexible deployment provide sufficient contingency to respond to multiple face-to-face assessments.
Verbatim wording from the response “a. The Crisis service has the capacity to respond to more than one face to face assessment:” Source location 2021-0206-Response-from-Cumbria-Northumberland-Tyne-and-Wear-NHS-Foundation-Trust-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing referral tracking, handover, electronic board and multidisciplinary review mechanisms are sufficient to identify outstanding Crisis Team assessments.
Verbatim wording from the response “The Trust can confirm that there are already robust mechanisms in place to track referrals active to the Crisis Team, including those still awaiting an assessment.” Source location 2021-0206-Response-from-Cumbria-Northumberland-Tyne-and-Wear-NHS-Foundation-Trust-Redacted
Open published response
19 May 2021 Richard Burgess · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 7 Failure to evidence or apply comprehensive assessments of the impact of a person’s difficulties View source Failure to provide a social environment supporting psychological and physical needs View source Failure to use a proactive dementia care model based on detailed assessment, intervention and evaluation of changing needs and risks View source Failure to provide individualised person-centred care from the person’s perspective View source Failure to convert policy into practice View source Lack of a multidisciplinary dementia care team with suitable skills, qualifications and competencies View source Failure to maintain continuous family engagement in the “triangle of care” 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. 8
Action
Review patient-care information regularly and adapt care plans using environmental, medication, health, engagement, incident, observation and risk data.
Stated completedThe respondent said that this action was complete when they made their response on 24 May 2021. View source
Action
Train 10 staff members to provide dementia care mapping across relevant wards.
Stated completedThe respondent said that this action was complete when they made their response on 24 May 2021. View source
Action
Engage families and friends in care planning and incorporate life stories and ongoing assessment information into regularly reviewed care plans.
Stated completedThe respondent said that this action was complete when they made their response on 24 May 2021. View source
Action
Use policy and initiative champions to support implementation and embed new practices.
Stated completedThe respondent said that this action was complete when they made their response on 24 May 2021. View source
Action
Audit policy compliance and require annual competency-based training for observation and engagement practice.
Stated completedThe respondent said that this action was complete when they made their response on 24 May 2021. View source
Action
Apply a preventative, person-centred dementia-care model using assessment tools, tailored activities and proactive behavioural support plans.
Stated completedThe respondent said that this action was complete when they made their response on 24 May 2021. View source
Action
Provide dementia care, care-planning formulation, observation and engagement training to relevant staff.
Stated completedThe respondent said that this action was complete when they made their response on 24 May 2021. View source
Action
Conduct detailed multidisciplinary medication reviews with pharmacist input to assess use, effectiveness, prescriptions and changes.
Stated completedThe respondent said that this action was complete when they made their response on 24 May 2021. View source See 5 more actions Respondent positions A position is what this recipient says about the concern when it does not describe a specific action. 6
Position
Existing training, audits, communications, supervision and policy champions are considered sufficient to convert Trust policy into practice.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Regular review and analysis of relevant patient factors, with information translated into care plans, are considered sufficient assessment arrangements.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Existing family engagement, information gathering and regular care-plan reviews are considered sufficient for ongoing triangle-of-care communication.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Existing person-centred models, life stories and tailored activities are considered sufficient to address individuals’ psychological, physical and social needs.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Existing staffing, specialist expertise and dementia training are considered sufficient to provide staff with appropriate skills and competencies.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Existing preventative, person-centred care processes, reviews and medication safeguards are considered sufficient to manage dementia-related needs, risks and medication use.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source See 5 more positions
×
AI-generated summary
Richard Burgess · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Richard Burgess died at Holy Cross Nursing and Residential Care Home, Sunderland, on 30 November 2018 after being punched three times in the head by another patient on 31 August 2018. The principal concerns related to dementia care, including multidisciplinary staffing, proactive assessment and risk management, family engagement, person-centred care, and converting policy into practice.
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 Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to evidence or apply comprehensive assessments of the impact of a person’s difficulties
Wider context from the report “I did not have a sufficient level of confidence about:
• the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care;
• a prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need for medication;
• the evidence of assessments or the application of assessments of the impact of a person’s difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, belief and thoughts of the person ;
• a continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories;
• a focus on the person, asserting absolute value of the person, in an individualised approach, while understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs;
• converting policy into practice.
The Trust had done a lot of work since the death of Mr Burgess, and I should also be pleased to hear from the Secretary of State about wider learning for other Trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a social environment supporting psychological and physical needs
Wider context from the report “I did not have a sufficient level of confidence about:
• the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care;
• a prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need for medication;
• the evidence of assessments or the application of assessments of the impact of a person’s difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, belief and thoughts of the person;
• a continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories;
• a focus on the person, asserting absolute value of the person, in an individualised approach, while understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs ;
• converting policy into practice.
The Trust had done a lot of work since the death of Mr Burgess, and I should also be pleased to hear from the Secretary of State about wider learning for other Trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use a proactive dementia care model based on detailed assessment, intervention and evaluation of changing needs and risks
Wider context from the report “I did not have a sufficient level of confidence about:
• the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care;
• a prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need for medication ;
• the evidence of assessments or the application of assessments of the impact of a person’s difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, belief and thoughts of the person;
• a continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories;
• a focus on the person, asserting absolute value of the person, in an individualised approach, while understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs;
• converting policy into practice.
The Trust had done a lot of work since the death of Mr Burgess, and I should also be pleased to hear from the Secretary of State about wider learning for other Trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide individualised person-centred care from the person’s perspective
Wider context from the report “I did not have a sufficient level of confidence about:
• the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care;
• a prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need for medication;
• the evidence of assessments or the application of assessments of the impact of a person’s difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, belief and thoughts of the person;
• a continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories;
• a focus on the person, asserting absolute value of the person, in an individualised approach, while understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs;
• converting policy into practice.
The Trust had done a lot of work since the death of Mr Burgess, and I should also be pleased to hear from the Secretary of State about wider learning for other Trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to convert policy into practice
Wider context from the report “I did not have a sufficient level of confidence about:
• the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care;
• a prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need for medication;
• the evidence of assessments or the application of assessments of the impact of a person’s difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, belief and thoughts of the person;
• a continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories;
• a focus on the person, asserting absolute value of the person, in an individualised approach, while understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs;
• converting policy into practice .
The Trust had done a lot of work since the death of Mr Burgess, and I should also be pleased to hear from the Secretary of State about wider learning for other Trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a multidisciplinary dementia care team with suitable skills, qualifications and competencies
Wider context from the report “I did not have a sufficient level of confidence about:
• the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care ;
• a prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need for medication;
• the evidence of assessments or the application of assessments of the impact of a person’s difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, belief and thoughts of the person;
• a continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories;
• a focus on the person, asserting absolute value of the person, in an individualised approach, while understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs;
• converting policy into practice.
The Trust had done a lot of work since the death of Mr Burgess, and I should also be pleased to hear from the Secretary of State about wider learning for other Trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain continuous family engagement in the “triangle of care”
Wider context from the report “I did not have a sufficient level of confidence about:
• the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care;
• a prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need for medication;
• the evidence of assessments or the application of assessments of the impact of a person’s difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, belief and thoughts of the person;
• a continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories ;
• a focus on the person, asserting absolute value of the person, in an individualised approach, while understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs;
• converting policy into practice.
The Trust had done a lot of work since the death of Mr Burgess, and I should also be pleased to hear from the Secretary of State about wider learning for other Trusts.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review patient-care information regularly and adapt care plans using environmental, medication, health, engagement, incident, observation and risk data.
Verbatim wording from the response “2.2. As presented at the inquest, changes have been made to the way in which reviews of patient care takes place, with an emphasis now on regularly reviewing all of the information available, which includes, but is not limited to, the environment, medication, physical health, engagement by staff, incidents, observation levels, risks, patterns in challenging behaviour and analysing how these are all impacting the patient so care plans can be adapted accordingly.” Source location 2021-0163-Response-from-St-Nicholas-Hospital-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 Train 10 staff members to provide dementia care mapping across relevant wards.
Verbatim wording from the response “1.2. As part of the multi-disciplinary team (MDT), Mr Airey explained that the Trust employs specialist Psychiatrists who are trained to work with patients with dementia, in addition to Care of the Elderly nurses, who provide training and support to staff. The Trust also employs Activity Coordinators who are actively involved as part of the MDT process and has recently trained 10 members of staff to provide dementia care mapping training across the relevant wards.” Source location 2021-0163-Response-from-St-Nicholas-Hospital-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 Engage families and friends in care planning and incorporate life stories and ongoing assessment information into regularly reviewed care plans.
Verbatim wording from the response “4.1. As presented at the inquest, triangulation of care is an important aspect of care and the Trust regularly engages with families to help formulate care plans. As per ████████ evidence, care planning is an ongoing process, which evolves with the patient. Whilst the Trust uses life stories in the first instance to inform care plans, other information” Source location 2021-0163-Response-from-St-Nicholas-Hospital-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 Use policy and initiative champions to support implementation and embed new practices.
Verbatim wording from the response “6.4. The Trust also has champions for some of its policies/initiatives so that extra support is provided to assist in embedding practices, especially when they are new.” Source location 2021-0163-Response-from-St-Nicholas-Hospital-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 Audit policy compliance and require annual competency-based training for observation and engagement practice.
Verbatim wording from the response “6.1. All Policies and guidelines which are implemented by the Trust are put into practice, with staff receiving information and/or training on the implementation of them. As explained at the inquest, audits are put in place to monitor compliance, with some policies, such as the observation and engagement policy, requiring staff to complete yearly competency based training.” Source location 2021-0163-Response-from-St-Nicholas-Hospital-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 Apply a preventative, person-centred dementia-care model using assessment tools, tailored activities and proactive behavioural support plans.
Verbatim wording from the response “2.1. As presented at the inquest, the Trust does adopt a preventative approach to person centred care. Tools such as the Newcastle Model, life stories, dementia mapping etc., are used to help formulate care plans, which include activities linked to these assessments and ways to engage patients in therapeutic interventions that are tailored to their specific needs. Stage behaviour support plans also, by their very nature, set out proactive steps to try and prevent behaviour from escalating from one stage to another, with medication prescribed only if required.” Source location 2021-0163-Response-from-St-Nicholas-Hospital-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 Provide dementia care, care-planning formulation, observation and engagement training to relevant staff.
Verbatim wording from the response “1.1. As presented at the inquest, all staff employed by the Trust have the relevant skills, qualifications and competencies for their role. All staff working with dementia patients have received appropriate dementia care training, with relevant staff receiving care planning formulation training, in addition to observation and engagement training.” Source location 2021-0163-Response-from-St-Nicholas-Hospital-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 Conduct detailed multidisciplinary medication reviews with pharmacist input to assess use, effectiveness, prescriptions and changes.
Verbatim wording from the response “2.3. As explained by ████████, due to the nature and degree of presentations with dementia that require admission and detention in hospital, patients sometimes require regular medication to assist with their behaviour. With the new review process there is more detailed analysis at MDT meetings, with the input of a Pharmacist, as to how often medication is being used, its effectiveness and whether a regular prescription is required, in addition to any changes in such medication. There are also safeguards within the Mental Health Act that monitor and review these treatments.” Source location 2021-0163-Response-from-St-Nicholas-Hospital-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 Existing training, audits, communications, supervision and policy champions are considered sufficient to convert Trust policy into practice.
Verbatim wording from the response “6. Converting policy into practice.” Source location 2021-0163-Response-from-St-Nicholas-Hospital-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 Regular review and analysis of relevant patient factors, with information translated into care plans, are considered sufficient assessment arrangements.
Verbatim wording from the response “3. The evidence of assessments or the application of assessments of the impact of the persons’ difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, beliefs and thoughts of a person.” Source location 2021-0163-Response-from-St-Nicholas-Hospital-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 Existing family engagement, information gathering and regular care-plan reviews are considered sufficient for ongoing triangle-of-care communication.
Verbatim wording from the response “4. A continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories.” Source location 2021-0163-Response-from-St-Nicholas-Hospital-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 Existing person-centred models, life stories and tailored activities are considered sufficient to address individuals’ psychological, physical and social needs.
Verbatim wording from the response “5. A focus on the person, asserting absolute value of the person and individualised approach, whilst understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs.” Source location 2021-0163-Response-from-St-Nicholas-Hospital-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 Existing staffing, specialist expertise and dementia training are considered sufficient to provide staff with appropriate skills and competencies.
Verbatim wording from the response “1. The provision of a multi-disciplinary team and professionals with suitable skills, qualifications and competencies commensurate with their role and the speciality of dementia care.” Source location 2021-0163-Response-from-St-Nicholas-Hospital-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 Existing preventative, person-centred care processes, reviews and medication safeguards are considered sufficient to manage dementia-related needs, risks and medication use.
Verbatim wording from the response “2. A prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need of medication.” Source location 2021-0163-Response-from-St-Nicholas-Hospital-Published
Open published response
Concerns raised 6 Lack of a robust working arrangement between Emergency Services to obtain timely support from other agencies View source Failure to identify familial or social support for the patient View source Delays in reacting meaningfully and promptly to presenting danger View source Lack of a protocol enabling personnel to initiate responses beyond ambulance allocation View source Failure to accurately evaluate and grade the presenting danger View source Failure to enquire about the patient’s location and immediately available support View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
MAUREEN WHARTON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Maureen Wharton contacted ambulance services after stating that she had taken several medications and wanted to end her life. An ambulance arrived at her flat several hours after her first call, by which time she was deceased; a post-mortem attributed her death to the combined effects of Tramadol, Venlafaxine, Zopiclone and alcohol. Concerns focused on the delayed response, the assessment and grading of the calls, and missed opportunities to arrange timely support or assistance from family, other agencies, or emergency services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a robust working arrangement between Emergency Services to obtain timely support from other agencies
Wider context from the report “The Investigation of the circumstances of the death has focused amongst other aspects on the control communications between Maureen and Ambulance control personnel with particular reference to the detail of the actual conversations had between Maureen and the personnel, the method of evaluating and grading of information elicited from Maureen in that process.
It is correct to acknowledge the NEAS is still undertaking its own investigation and evaluation of these matters with a view to publishing a report before the end of the current year, concerns have been identified around apparent missed opportunities to react in a different or more timely manner to the facts and detail being presented in the course of these calls.
Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at Maureen’s flat. Whilst explanations around lack of resources and even possibly inadvertent allocation and/or interpretation of data may feature in the NEAS subsequent report by way of explanation of this delay, the real and imminent danger of Maureen’s admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way given the danger they clearly presented.
An apparent toxicological aide was either unappreciated or misinterpreted as an under assessed and graduated event - the need was obvious
a) No enquiry was made of Maureen as to the nature of her location and the potential support or assistance readily at hand or otherwise.
b) No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger
c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation
d) No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger.
There appears to be a need for a closer liaison and working relationship between Emergency Services which is sufficiently robust to react and present early support to the patient there having been such an accurate evaluation of an otherwise obvious developing critical situation and particularly if delays in reaction otherwise may also be apparent.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify familial or social support for the patient
Wider context from the report “The Investigation of the circumstances of the death has focused amongst other aspects on the control communications between Maureen and Ambulance control personnel with particular reference to the detail of the actual conversations had between Maureen and the personnel, the method of evaluating and grading of information elicited from Maureen in that process.
It is correct to acknowledge the NEAS is still undertaking its own investigation and evaluation of these matters with a view to publishing a report before the end of the current year, concerns have been identified around apparent missed opportunities to react in a different or more timely manner to the facts and detail being presented in the course of these calls.
Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at Maureen’s flat. Whilst explanations around lack of resources and even possibly inadvertent allocation and/or interpretation of data may feature in the NEAS subsequent report by way of explanation of this delay, the real and imminent danger of Maureen’s admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way given the danger they clearly presented.
An apparent toxicological aide was either unappreciated or misinterpreted as an under assessed and graduated event - the need was obvious
a) No enquiry was made of Maureen as to the nature of her location and the potential support or assistance readily at hand or otherwise.
b) No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger
c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation
d) No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger.
There appears to be a need for a closer liaison and working relationship between Emergency Services which is sufficiently robust to react and present early support to the patient there having been such an accurate evaluation of an otherwise obvious developing critical situation and particularly if delays in reaction otherwise may also be apparent.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in reacting meaningfully and promptly to presenting danger
Wider context from the report “The Investigation of the circumstances of the death has focused amongst other aspects on the control communications between Maureen and Ambulance control personnel with particular reference to the detail of the actual conversations had between Maureen and the personnel, the method of evaluating and grading of information elicited from Maureen in that process.
It is correct to acknowledge the NEAS is still undertaking its own investigation and evaluation of these matters with a view to publishing a report before the end of the current year, concerns have been identified around apparent missed opportunities to react in a different or more timely manner to the facts and detail being presented in the course of these calls.
Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at Maureen’s flat . Whilst explanations around lack of resources and even possibly inadvertent allocation and/or interpretation of data may feature in the NEAS subsequent report by way of explanation of this delay, the real and imminent danger of Maureen’s admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way given the danger they clearly presented.
An apparent toxicological aide was either unappreciated or misinterpreted as an under assessed and graduated event - the need was obvious
a) No enquiry was made of Maureen as to the nature of her location and the potential support or assistance readily at hand or otherwise.
b) No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger
c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation
d) No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger.
There appears to be a need for a closer liaison and working relationship between Emergency Services which is sufficiently robust to react and present early support to the patient there having been such an accurate evaluation of an otherwise obvious developing critical situation and particularly if delays in reaction otherwise may also be apparent.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol enabling personnel to initiate responses beyond ambulance allocation
Wider context from the report “The Investigation of the circumstances of the death has focused amongst other aspects on the control communications between Maureen and Ambulance control personnel with particular reference to the detail of the actual conversations had between Maureen and the personnel, the method of evaluating and grading of information elicited from Maureen in that process.
It is correct to acknowledge the NEAS is still undertaking its own investigation and evaluation of these matters with a view to publishing a report before the end of the current year, concerns have been identified around apparent missed opportunities to react in a different or more timely manner to the facts and detail being presented in the course of these calls.
Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at Maureen’s flat. Whilst explanations around lack of resources and even possibly inadvertent allocation and/or interpretation of data may feature in the NEAS subsequent report by way of explanation of this delay, the real and imminent danger of Maureen’s admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way given the danger they clearly presented.
An apparent toxicological aide was either unappreciated or misinterpreted as an under assessed and graduated event - the need was obvious
a) No enquiry was made of Maureen as to the nature of her location and the potential support or assistance readily at hand or otherwise.
b) No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger
c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation
d) No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger.
There appears to be a need for a closer liaison and working relationship between Emergency Services which is sufficiently robust to react and present early support to the patient there having been such an accurate evaluation of an otherwise obvious developing critical situation and particularly if delays in reaction otherwise may also be apparent.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately evaluate and grade the presenting danger
Wider context from the report “The Investigation of the circumstances of the death has focused amongst other aspects on the control communications between Maureen and Ambulance control personnel with particular reference to the detail of the actual conversations had between Maureen and the personnel, the method of evaluating and grading of information elicited from Maureen in that process.
It is correct to acknowledge the NEAS is still undertaking its own investigation and evaluation of these matters with a view to publishing a report before the end of the current year, concerns have been identified around apparent missed opportunities to react in a different or more timely manner to the facts and detail being presented in the course of these calls.
Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at Maureen’s flat. Whilst explanations around lack of resources and even possibly inadvertent allocation and/or interpretation of data may feature in the NEAS subsequent report by way of explanation of this delay, the real and imminent danger of Maureen’s admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way given the danger they clearly presented.
An apparent toxicological aide was either unappreciated or misinterpreted as an under assessed and graduated event - the need was obvious
a) No enquiry was made of Maureen as to the nature of her location and the potential support or assistance readily at hand or otherwise.
b) No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger
c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation
d) No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger.
There appears to be a need for a closer liaison and working relationship between Emergency Services which is sufficiently robust to react and present early support to the patient there having been such an accurate evaluation of an otherwise obvious developing critical situation and particularly if delays in reaction otherwise may also be apparent.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to enquire about the patient’s location and immediately available support
Wider context from the report “The Investigation of the circumstances of the death has focused amongst other aspects on the control communications between Maureen and Ambulance control personnel with particular reference to the detail of the actual conversations had between Maureen and the personnel, the method of evaluating and grading of information elicited from Maureen in that process.
It is correct to acknowledge the NEAS is still undertaking its own investigation and evaluation of these matters with a view to publishing a report before the end of the current year, concerns have been identified around apparent missed opportunities to react in a different or more timely manner to the facts and detail being presented in the course of these calls.
Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at Maureen’s flat. Whilst explanations around lack of resources and even possibly inadvertent allocation and/or interpretation of data may feature in the NEAS subsequent report by way of explanation of this delay, the real and imminent danger of Maureen’s admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way given the danger they clearly presented.
An apparent toxicological aide was either unappreciated or misinterpreted as an under assessed and graduated event - the need was obvious
a) No enquiry was made of Maureen as to the nature of her location and the potential support or assistance readily at hand or otherwise.
b) No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger
c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation
d) No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger.
There appears to be a need for a closer liaison and working relationship between Emergency Services which is sufficiently robust to react and present early support to the patient there having been such an accurate evaluation of an otherwise obvious developing critical situation and particularly if delays in reaction otherwise may also be apparent.
” Open source report
29 Oct 2019 Charlotte Grace · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 2 Failure to routinely involve agencies receiving discharged patients in the discharge process View source Failure to routinely involve supportive families or friends in the discharge process View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Charlotte Grace · 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
Charlotte Grace was discharged from hospital on 20 September 2018 and was found hanging the following evening; the inquest recorded that she took her life by hanging on 21 September 2018. The principal concern was that the Home Treatment Team and her nominated next of kin were not invited to the discharge meeting, despite her being at chronic high risk of suicide and being referred for follow-up care.
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 Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely involve agencies receiving discharged patients in the discharge process
Wider context from the report “(1) Lottie was discharged despite there being no input from those to whose care she was being entrusted . 2 years ago I sat on an inquest in Carlisle which found that a gentleman hanged himself 2 days after a discharge from the Carleton Clinic when again the Home Treatment Team were expected to take over but not invited to the discharge meeting . I understand this is now less likely to occur in Carlisle and would be generally desirable. I am concerned that agencies to whom a patient is discharged and families or friends [with consent] who will need to be supportive are not routinely involved in 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 Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely involve supportive families or friends in the discharge process
Wider context from the report “(1) Lottie was discharged despite there being no input from those to whose care she was being entrusted. 2 years ago I sat on an inquest in Carlisle which found that a gentleman hanged himself 2 days after a discharge from the Carleton Clinic when again the Home Treatment Team were expected to take over but not invited to the discharge meeting. I understand this is now less likely to occur in Carlisle and would be generally desirable. I am concerned that agencies to whom a patient is discharged and families or friends [with consent] who will need to be supportive are not routinely involved in the discharge process .
” 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 Carry out a learning review to identify best practice for involving significant clinicians and future-care providers in discharge meetings.
Verbatim wording from the response “1. A learning review was carried out following the investigation on 16th November 2018 in which it was discussed that attendance of significant clinicians involved with the patient’s care at the time and those responsible for providing future care would be best practice. The learning review suggested that where geographical barriers or workloads prevent face to face attendance at meetings, teleconferencing / videoconferencing could be used as an alternative.” Source location 2019-0402-Response-by-Cumbria-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 Move from telephone dial-in to Skype facilities for discharge meetings where geographical restrictions exist.
Verbatim wording from the response “2. Where geographical restrictions exist, teams utilise phone dial in and will move to Skype facilities within the next 3 months as part of the Trust’s IT mobilisation planning and roll out.” Source location 2019-0402-Response-by-Cumbria-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 Remind staff to use the discharge flow chart, including advance meeting arrangements and escalation where required attendance is unavailable.
Verbatim wording from the response “4. In order to ensure that the relevant teams/services are invited to discharge meetings, this is monitored as per the Trust’s discharge flow chart. This flow chart provides prompts for teams to be invited and indicates that meeting arrangements will be agreed at least 2 days ahead unless urgent. Where attendance is not possible the flow chart states that this should be escalated to team leaders. Although this flow chart was in existence at the time of the incident, it is apparent that it was not being used consistently however, following a safer discharge project staff have been reminded to utilise this. The project includes a commitment to ensure that an agreed follow up is in place within 48 hours of discharge.” Source location 2019-0402-Response-by-Cumbria-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold weekly interface meetings to discuss complex cases and escalate discharge-meeting non-attendance to clinical leads and, where persistent, the Associate Director.
Verbatim wording from the response “5. In addition to the above, weekly interface meetings take place which incorporate all community and inpatient services and ensure that complex cases are discussed alongside discharge meetings. If issues with attendance are identified, this is raised and actioned with clinical leads. Where regular non-attendance is identified, this is now being escalated to the Associate Director of the Clinical Business Unit.” Source location 2019-0402-Response-by-Cumbria-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 Amend and use the safer-discharge audit across wards to monitor family attendance and other discharge requirements, with weekly clinical review and monthly quality reporting.
Verbatim wording from the response “6. In order to monitor the discharge process the Trust use a safer discharge audit. This audit is used on each ward and monitors the following information:” Source location 2019-0402-Response-by-Cumbria-NHS-Trust
Open published response
3 Mar 2015 Paige Louise Bell · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 8 Failure to ensure medical personnel have immediate electronic access to complete patient notes View source Failure to include the RIO reference on observation record front sheets View source Insufficient time for staff to complete records promptly View source Insufficient space for commentary in observation records View source Unavailability of relevant, up-to-date and accurate information from notes View source Failure of observation forms to accommodate changes in observation rationale View source Failure of observation records to clearly require completion of all parts View source Difficulties navigating records to establish event chronology and decision rationale 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
Paige Louise Bell · 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
Paige Louise Bell, aged 20, died at Sunderland Royal Hospital on 14 August 2014 after applying a ligature to her neck following an episode of self-harm. The inquest identified contradictions in the observation policy as a contributing factor. Concerns included case notes not being held together or fully transferred with the patient, and the need for consistent observation policies and updated guidance on managing patients with Borderline Personality Disorder.
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 Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure medical personnel have immediate electronic access to complete patient notes
Wider context from the report “The case notes were not held in one place and not all transferred with the patient . I wondered if there were any ongoing plans to allow medical personnel to have immediate access to all notes electronically rather than notes following the patient as they will contain essential information for a patient’s healthcare and treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include the RIO reference on observation record front sheets
Wider context from the report “Although a new Engagement and Observation Policy is to be implemented in April 2015 it may be that you would wish to review matters arising from the Inquest to enhance this further (if appropriate) so that there are no contradictions that may create ambiguity in its application. I appreciate that a lot of work has gone into the new policy. However, I note the following (and this is not an exhaustive list): -
• The new Observation record does not allow sufficient space for commentary.
• The front sheet does not appear to have the RIO reference.
• On the face of the document it is not clear that staff must complete all parts of the record.
• If the rationale for observations were to change then the form needs to provide for that.
• It may be possible in the fullness of time for the record to be completed electronically (perhaps with a tablet) with a drop down box and a freehand note facility? This would also allow for mandatory completion of certain parts of a form.
• If electronic, the engagement/observation record could be readily accessible possibly via hyperlink. The same could be done for incident report forms rather than being manually filed.
No doubt there will be full training undertaken with regard to the new Policy.
I was concerned that not all relevant information was readily available and although I appreciate events can be fast moving it can then become even more important for staff to have access to up to date and accurate information from the notes.
All staff need time to be able to complete such records in a more timely way.
That takes me to my final concern and that relates to the difficulty with navigation around the records. Whilst this may be easier via a screen it was extremely difficult (even with time to do it) to be able to have a clear chronology of events and to understand the rationale for decisions. That has the potential to compromise patient management and safety.
I also enclose a copy of my report to the Secretary of State.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient time for staff to complete records promptly
Wider context from the report “Although a new Engagement and Observation Policy is to be implemented in April 2015 it may be that you would wish to review matters arising from the Inquest to enhance this further (if appropriate) so that there are no contradictions that may create ambiguity in its application. I appreciate that a lot of work has gone into the new policy. However, I note the following (and this is not an exhaustive list): -
• The new Observation record does not allow sufficient space for commentary.
• The front sheet does not appear to have the RIO reference.
• On the face of the document it is not clear that staff must complete all parts of the record.
• If the rationale for observations were to change then the form needs to provide for that.
• It may be possible in the fullness of time for the record to be completed electronically (perhaps with a tablet) with a drop down box and a freehand note facility? This would also allow for mandatory completion of certain parts of a form.
• If electronic, the engagement/observation record could be readily accessible possibly via hyperlink. The same could be done for incident report forms rather than being manually filed.
No doubt there will be full training undertaken with regard to the new Policy.
I was concerned that not all relevant information was readily available and although I appreciate events can be fast moving it can then become even more important for staff to have access to up to date and accurate information from the notes.
All staff need time to be able to complete such records in a more timely way.
That takes me to my final concern and that relates to the difficulty with navigation around the records. Whilst this may be easier via a screen it was extremely difficult (even with time to do it) to be able to have a clear chronology of events and to understand the rationale for decisions. That has the potential to compromise patient management and safety.
I also enclose a copy of my report to the Secretary of State.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient space for commentary in observation records
Wider context from the report “Although a new Engagement and Observation Policy is to be implemented in April 2015 it may be that you would wish to review matters arising from the Inquest to enhance this further (if appropriate) so that there are no contradictions that may create ambiguity in its application. I appreciate that a lot of work has gone into the new policy. However, I note the following (and this is not an exhaustive list): -
• The new Observation record does not allow sufficient space for commentary.
• The front sheet does not appear to have the RIO reference.
• On the face of the document it is not clear that staff must complete all parts of the record.
• If the rationale for observations were to change then the form needs to provide for that.
• It may be possible in the fullness of time for the record to be completed electronically (perhaps with a tablet) with a drop down box and a freehand note facility? This would also allow for mandatory completion of certain parts of a form.
• If electronic, the engagement/observation record could be readily accessible possibly via hyperlink. The same could be done for incident report forms rather than being manually filed.
No doubt there will be full training undertaken with regard to the new Policy.
I was concerned that not all relevant information was readily available and although I appreciate events can be fast moving it can then become even more important for staff to have access to up to date and accurate information from the notes.
All staff need time to be able to complete such records in a more timely way.
That takes me to my final concern and that relates to the difficulty with navigation around the records. Whilst this may be easier via a screen it was extremely difficult (even with time to do it) to be able to have a clear chronology of events and to understand the rationale for decisions. That has the potential to compromise patient management and safety.
I also enclose a copy of my report to the Secretary of State.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of relevant, up-to-date and accurate information from notes
Wider context from the report “Although a new Engagement and Observation Policy is to be implemented in April 2015 it may be that you would wish to review matters arising from the Inquest to enhance this further (if appropriate) so that there are no contradictions that may create ambiguity in its application. I appreciate that a lot of work has gone into the new policy. However, I note the following (and this is not an exhaustive list): -
• The new Observation record does not allow sufficient space for commentary.
• The front sheet does not appear to have the RIO reference.
• On the face of the document it is not clear that staff must complete all parts of the record.
• If the rationale for observations were to change then the form needs to provide for that.
• It may be possible in the fullness of time for the record to be completed electronically (perhaps with a tablet) with a drop down box and a freehand note facility? This would also allow for mandatory completion of certain parts of a form.
• If electronic, the engagement/observation record could be readily accessible possibly via hyperlink. The same could be done for incident report forms rather than being manually filed.
No doubt there will be full training undertaken with regard to the new Policy.
I was concerned that not all relevant information was readily available and although I appreciate events can be fast moving it can then become even more important for staff to have access to up to date and accurate information from the notes .
All staff need time to be able to complete such records in a more timely way.
That takes me to my final concern and that relates to the difficulty with navigation around the records. Whilst this may be easier via a screen it was extremely difficult (even with time to do it) to be able to have a clear chronology of events and to understand the rationale for decisions. That has the potential to compromise patient management and safety.
I also enclose a copy of my report to the Secretary of State.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of observation forms to accommodate changes in observation rationale
Wider context from the report “Although a new Engagement and Observation Policy is to be implemented in April 2015 it may be that you would wish to review matters arising from the Inquest to enhance this further (if appropriate) so that there are no contradictions that may create ambiguity in its application. I appreciate that a lot of work has gone into the new policy. However, I note the following (and this is not an exhaustive list): -
• The new Observation record does not allow sufficient space for commentary.
• The front sheet does not appear to have the RIO reference.
• On the face of the document it is not clear that staff must complete all parts of the record.
• If the rationale for observations were to change then the form needs to provide for that.
• It may be possible in the fullness of time for the record to be completed electronically (perhaps with a tablet) with a drop down box and a freehand note facility? This would also allow for mandatory completion of certain parts of a form.
• If electronic, the engagement/observation record could be readily accessible possibly via hyperlink. The same could be done for incident report forms rather than being manually filed.
No doubt there will be full training undertaken with regard to the new Policy.
I was concerned that not all relevant information was readily available and although I appreciate events can be fast moving it can then become even more important for staff to have access to up to date and accurate information from the notes.
All staff need time to be able to complete such records in a more timely way.
That takes me to my final concern and that relates to the difficulty with navigation around the records. Whilst this may be easier via a screen it was extremely difficult (even with time to do it) to be able to have a clear chronology of events and to understand the rationale for decisions. That has the potential to compromise patient management and safety.
I also enclose a copy of my report to the Secretary of State.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of observation records to clearly require completion of all parts
Wider context from the report “Although a new Engagement and Observation Policy is to be implemented in April 2015 it may be that you would wish to review matters arising from the Inquest to enhance this further (if appropriate) so that there are no contradictions that may create ambiguity in its application. I appreciate that a lot of work has gone into the new policy. However, I note the following (and this is not an exhaustive list): -
• The new Observation record does not allow sufficient space for commentary.
• The front sheet does not appear to have the RIO reference.
• On the face of the document it is not clear that staff must complete all parts of the record.
• If the rationale for observations were to change then the form needs to provide for that.
• It may be possible in the fullness of time for the record to be completed electronically (perhaps with a tablet) with a drop down box and a freehand note facility? This would also allow for mandatory completion of certain parts of a form.
• If electronic, the engagement/observation record could be readily accessible possibly via hyperlink. The same could be done for incident report forms rather than being manually filed.
No doubt there will be full training undertaken with regard to the new Policy.
I was concerned that not all relevant information was readily available and although I appreciate events can be fast moving it can then become even more important for staff to have access to up to date and accurate information from the notes.
All staff need time to be able to complete such records in a more timely way.
That takes me to my final concern and that relates to the difficulty with navigation around the records. Whilst this may be easier via a screen it was extremely difficult (even with time to do it) to be able to have a clear chronology of events and to understand the rationale for decisions. That has the potential to compromise patient management and safety.
I also enclose a copy of my report to the Secretary of State.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Difficulties navigating records to establish event chronology and decision rationale
Wider context from the report “Although a new Engagement and Observation Policy is to be implemented in April 2015 it may be that you would wish to review matters arising from the Inquest to enhance this further (if appropriate) so that there are no contradictions that may create ambiguity in its application. I appreciate that a lot of work has gone into the new policy. However, I note the following (and this is not an exhaustive list): -
• The new Observation record does not allow sufficient space for commentary.
• The front sheet does not appear to have the RIO reference.
• On the face of the document it is not clear that staff must complete all parts of the record.
• If the rationale for observations were to change then the form needs to provide for that.
• It may be possible in the fullness of time for the record to be completed electronically (perhaps with a tablet) with a drop down box and a freehand note facility? This would also allow for mandatory completion of certain parts of a form.
• If electronic, the engagement/observation record could be readily accessible possibly via hyperlink. The same could be done for incident report forms rather than being manually filed.
No doubt there will be full training undertaken with regard to the new Policy.
I was concerned that not all relevant information was readily available and although I appreciate events can be fast moving it can then become even more important for staff to have access to up to date and accurate information from the notes.
All staff need time to be able to complete such records in a more timely way.
That takes me to my final concern and that relates to the difficulty with navigation around the records . Whilst this may be easier via a screen it was extremely difficult (even with time to do it) to be able to have a clear chronology of events and to understand the rationale for decisions . That has the potential to compromise patient management and safety .
I also enclose a copy of my report to the Secretary of State.
” 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 Provide regular staff training reinforcing timely and detailed record keeping.
Verbatim wording from the response “With regard to the concerns about the lack of completion of the observation record, staff acknowledged at the inquest that this was not done on this occasion but they were aware that it should have been. Staff are aware that all parts of the document should be completed and this should include a rationale as to why a level of observation is changed. As discussed in ████████ evidence, the importance of record keeping has been reiterated to staff. Furthermore, ████████ confirmed that as the revised policy is rolled out across the Trust, staff will receive training on the policy which will include appropriate completion of the new observation record.” Source location 2015-0075-Response-by-Northumberland-Tyne-Wear-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide staff training on the revised Engagement and Observation Policy and completion of the new observation record as the policy is rolled out.
Verbatim wording from the response “With regard to the concerns about the lack of completion of the observation record, staff acknowledged at the inquest that this was not done on this occasion but they were aware that it should have been. Staff are aware that all parts of the document should be completed and this should include a rationale as to why a level of observation is changed. As discussed in ████████ evidence, the importance of record keeping has been reiterated to staff. Furthermore, ████████ confirmed that as the revised policy is rolled out across the Trust, staff will receive training on the policy which will include appropriate completion of the new observation record.” Source location 2015-0075-Response-by-Northumberland-Tyne-Wear-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 Immediate recording of every decision or action is impracticable in a busy mental health ward, so entries are made as soon as practically possible.
Verbatim wording from the response “In respect to the stated over the presentation of written copies of RiO records, ████████ explained that this is something which was identified in the Serious Incident Review. He explained that the RiO records are used by staff electronically, and a printed version does not properly reflect how they would be seen or used by staff. In particular the date and time of a meeting or incident is recorded in addition to when the record was made. This allows the entries to be recorded chronologically in relation to the date and time of the meeting or incident. As you heard in evidence, in a very busy and demanding mental health ward” Source location 2015-0075-Response-by-Northumberland-Tyne-Wear-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 Electronic RiO records and information-sharing through team meetings and handovers provide a more appropriate account than printed records alone.
Verbatim wording from the response “In respect to the stated over the presentation of written copies of RiO records, ████████ explained that this is something which was identified in the Serious Incident Review. He explained that the RiO records are used by staff electronically, and a printed version does not properly reflect how they would be seen or used by staff. In particular the date and time of a meeting or incident is recorded in addition to when the record was made. This allows the entries to be recorded chronologically in relation to the date and time of the meeting or incident. As you heard in evidence, in a very busy and demanding mental health ward” Source location 2015-0075-Response-by-Northumberland-Tyne-Wear-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The observation record’s front sheet need not include the RiO number because the patient’s name and hospital number enable electronic record retrieval.
Verbatim wording from the response “In relation to the concerns about space on the new observation record, staff are aware that they can write in the box below if necessary. The RiO number (on our electronic patient record system) is not required on the front sheet, as unlike the continuation sheets, the front sheet has the patient's name and hospital number written on it which will enable the patient to be found on RiO.” Source location 2015-0075-Response-by-Northumberland-Tyne-Wear-NHS-Trust
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations