Concerns raised 10 Delays in calling an ambulance View source Failure to ensure adequate staff training for emergency response View source Failure to ensure agency nurses read patients' care plans before starting duties View source Failure to attach the defibrillator appropriately View source Delays in starting resuscitation View source Failure to ensure agency nurses are familiar with the ward before starting duties View source Failure to raise the emergency alarm View source Failure to provide adequate staff induction View source Inadequate information given to the ambulance service View source Delays in bringing the defibrillator View source See 7 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.
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AI-generated summary
James O’Brien · 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
James O’Brien collapsed in his room at Churchill Hospital on the night of 8/9 December 2015 and died at St Thomas’ Hospital on 9 December 2015. Concerns included delays in starting resuscitation, calling an ambulance and bringing the defibrillator, inappropriate defibrillator attachment, inadequate information provided to ambulance services, and failures in staff training, induction and ward familiarity. The inquest concluded that the emergency response by hospital staff was inadequate and that earlier intervention might have made a difference.
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 Cygnet Behavioural Health Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in calling an ambulance
Wider context from the report “(3) There was a delay of about 6 minutes in calling the ambulance .
” 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 Cygnet Behavioural Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure adequate staff training for emergency response
Wider context from the report “(7) There was a failure to ensure that staff were adequately trained to respond to an emergency situation .
” 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 Cygnet Behavioural Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure agency nurses read patients' care plans before starting duties
Wider context from the report “(9) The agency nurse in charge of the ward was called shortly before the shift started, was not familiar with the ward, and did not have time to read the care plans of the patients before starting his duties .
” 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 Cygnet Behavioural Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to attach the defibrillator appropriately
Wider context from the report “(5) The defibrillator was not attached appropriately .
” 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 Cygnet Behavioural Health Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in starting resuscitation
Wider context from the report “(2) There was a delay of about 4 minutes in starting resuscitation .
” 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 Cygnet Behavioural Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure agency nurses are familiar with the ward before starting duties
Wider context from the report “(9) The agency nurse in charge of the ward was called shortly before the shift started , was not familiar with the ward , and did not have time to read the care plans of the patients before starting his duties.
” 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 Cygnet Behavioural Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to raise the emergency alarm
Wider context from the report “(1) There was a failure to press the alarm .
” 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 Cygnet Behavioural Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate staff induction
Wider context from the report “(8) There was a failure to provide adequate induction to staff .
” 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 Cygnet Behavioural Health Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequate information given to the ambulance service
Wider context from the report “(6) Inadequate information was given to the London Ambulance Service .
” 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 Cygnet Behavioural Health Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in bringing the defibrillator
Wider context from the report “(4) There was a delay of about 8 minutes in bringing the defibrillator .
” Open source report
Concerns raised 1 Failure to maintain restrictions on plastic bags 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.
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AI-generated summary
Ms Natasha Ford · 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
Ms Natasha Ford was found at Raglan House with a plastic bag over her head secured by shoelaces and died after being taken to hospital. The inquest heard that she had previously placed a plastic bag over her head, after which restrictions on plastic bags were introduced briefly and then removed following a policy change.
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 Cygnet Behavioural Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain restrictions on plastic bags
Wider context from the report “1. Evidence emerged during the inquest that there was a previous incident on the 27 July 2017 where she had placed a plastic bag over her head. Plastic bags were then restricted for a short time and then blanket restrictions were removed. This was due to a change in policy in procedure and in line with reducing restrictive practice policy and procedure.
” Open source report
Concerns raised 3 Lack of guidance for psychiatric staff on CPAP, sedative medication risks and oximetry in OSA View source Failure to establish monitoring arrangements for high-risk sedated patients with OSA View source Failure to establish dialogue between specialist physicians and psychiatrists about managing OSA risks View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Lee Mark Anthony Bates · 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
Lee Mark Anthony Bates died at 01.18 on 24 February 2014 in Cambian Churchill London Clinic after ingesting a potentially fatal overdose of Zopiclone in conjunction with benzodiazepines while under one-to-one eyesight observation. The principal concerns were inadequate staff training in one-to-one observation and insufficient coordination between psychiatric and sleep-apnoea specialists about CPAP use, sedative medication risks, and monitoring of patients with severe obstructive sleep apnoea.
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 Cygnet Behavioural Health Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for psychiatric staff on CPAP, sedative medication risks and oximetry in OSA
Wider context from the report “The court heard that neither the psychiatrists sought advice from the sleep apnoea clinic nor did the clinic inform the psychiatrists of the importance of using CPAP, the risks of not doing so and the risks of sedative medication especially if not using it and the desirability of oximetry . ████████ director of the hospital, said that there was no guidance from GSTT about the use of the CPAP machine , of which psychiatric staff would not be familiar. He presumed that none of the psychiatrists sought guidance about medication, observation or use of the machine in a patient with severe sleep apnoea, as they did not see the need. He expected that the sleep clinic would provide any advice that psychiatrists needed in managing the OSA in a psychiatric unit.
████████ consultant psychiatrist at Cambian, acknowledged that there were risks of death to people with severe OSA given drugs and then not taking CPAP. Physical health care needs were advised by GPs. He said that psychiatric staff did not know about the importance of CPAP, nor whether introduction of a drug required monitoring . There is the facility to use pulse oximetry in the hospital, but the implications, if it were to be used in all OSA patients, would need to be considered. There are many OSA patients in Cambian.
It is clear that there is an on going risk of avoidable death in patients with OSA in Cambian Churchill hospital (especially if severe and associated with morbid obesity), Although this risk is reduced by use of CPAP machine and increased by use of sedative drugs, and may be mitigated by use of oximetry, such measures require dialogue between specialist physicians and psychiatrists and might require special provision for monitoring of patients that are high risk and require sedation. Neither hospital has addressed how this dialogue is to be instigated when required, nor how these risks should be addressed; reliance on GP advice seeming to be insufficient.
” 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 Cygnet Behavioural Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to establish monitoring arrangements for high-risk sedated patients with OSA
Wider context from the report “The court heard that neither the psychiatrists sought advice from the sleep apnoea clinic nor did the clinic inform the psychiatrists of the importance of using CPAP, the risks of not doing so and the risks of sedative medication especially if not using it and the desirability of oximetry. ████████ director of the hospital, said that there was no guidance from GSTT about the use of the CPAP machine, of which psychiatric staff would not be familiar. He presumed that none of the psychiatrists sought guidance about medication, observation or use of the machine in a patient with severe sleep apnoea, as they did not see the need. He expected that the sleep clinic would provide any advice that psychiatrists needed in managing the OSA in a psychiatric unit.
████████ consultant psychiatrist at Cambian, acknowledged that there were risks of death to people with severe OSA given drugs and then not taking CPAP. Physical health care needs were advised by GPs. He said that psychiatric staff did not know about the importance of CPAP, nor whether introduction of a drug required monitoring . There is the facility to use pulse oximetry in the hospital, but the implications, if it were to be used in all OSA patients, would need to be considered. There are many OSA patients in Cambian.
It is clear that there is an on going risk of avoidable death in patients with OSA in Cambian Churchill hospital (especially if severe and associated with morbid obesity), Although this risk is reduced by use of CPAP machine and increased by use of sedative drugs, and may be mitigated by use of oximetry, such measures require dialogue between specialist physicians and psychiatrists and might require special provision for monitoring of patients that are high risk and require sedation . Neither hospital has addressed how this dialogue is to be instigated when required, nor how these risks should be addressed ; reliance on GP advice seeming to be insufficient.
” 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 Cygnet Behavioural Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to establish dialogue between specialist physicians and psychiatrists about managing OSA risks
Wider context from the report “The court heard that neither the psychiatrists sought advice from the sleep apnoea clinic nor did the clinic inform the psychiatrists of the importance of using CPAP, the risks of not doing so and the risks of sedative medication especially if not using it and the desirability of oximetry. ████████ director of the hospital, said that there was no guidance from GSTT about the use of the CPAP machine, of which psychiatric staff would not be familiar. He presumed that none of the psychiatrists sought guidance about medication, observation or use of the machine in a patient with severe sleep apnoea, as they did not see the need. He expected that the sleep clinic would provide any advice that psychiatrists needed in managing the OSA in a psychiatric unit.
████████ consultant psychiatrist at Cambian, acknowledged that there were risks of death to people with severe OSA given drugs and then not taking CPAP. Physical health care needs were advised by GPs. He said that psychiatric staff did not know about the importance of CPAP, nor whether introduction of a drug required monitoring. There is the facility to use pulse oximetry in the hospital, but the implications, if it were to be used in all OSA patients, would need to be considered. There are many OSA patients in Cambian.
It is clear that there is an on going risk of avoidable death in patients with OSA in Cambian Churchill hospital (especially if severe and associated with morbid obesity), Although this risk is reduced by use of CPAP machine and increased by use of sedative drugs, and may be mitigated by use of oximetry, such measures require dialogue between specialist physicians and psychiatrists and might require special provision for monitoring of patients that are high risk and require sedation. Neither hospital has addressed how this dialogue is to be instigated when required , nor how these risks should be addressed; reliance on GP advice seeming to be insufficient.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Agree a protocol with St Thomas’ to improve communication and care coordination for patients referred to physical health clinics.
Verbatim wording from the response “With that in mind, and following the inquest into the death of Mr Bates when you indicated your proposal to make this report, my hospital manager at Cambian Churchill Hospital has met with ████████ at St Thomas’ and agreed a protocol going forward to cover the matter set out in the attached document, in order to reduce the possibility of inadequate communication or care in the future.” Source location 2015-0381-Response-by-Cambian-Group
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for physical-health care after referral is transferred to St Thomas’ specialists, over whom the hospital has no control.
Verbatim wording from the response “Your Report raises an issue in relation to communication between our hospital and the sleep apnoea clinic at St Thomas’. As you will appreciate, the clinic is operated by Guys and St Thomas’ NHS Foundation Trust which is separate from our hospital. We therefore clearly have no control over them, and vice versa.” Source location 2015-0381-Response-by-Cambian-Group
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations