Concerns raised 3 Geographic concentration of tertiary specialist services for treatment-resistant OCD View source Insufficient capacity of tertiary specialist services for treatment-resistant OCD View source Restrictive criteria for access to tertiary specialist services for treatment-resistant OCD 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
Scott Alan Taylor · 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
Scott Alan Taylor, who had treatment-resistant obsessive compulsive disorder and was receiving community treatment, died by suicide on 12 May 2023. The report raises concerns about the limited number, geographical concentration, access criteria and capacity of tertiary services for patients with treatment-resistant OCD, including a reported waiting list of over 12–15 months.
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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Geographic concentration of tertiary specialist services for treatment-resistant OCD
Wider context from the report “At the time of writing this report it appears that only a small number of tertiary centres able to care for patients with treatment resistant OCD exist in the United Kingdom. They appear to be located in London and the South East.
The criteria to access these services and the limited capacity they have, it seems prevents clinicians treating patients being able to call upon specialist services that a tertiary centre/s can provide to they patients. Particularly, where a patient’s case is complex and resistant to all that primary and secondary care services can offer in terms of treatment.
These centres are also not located across the whole of the United Kingdom for ease of access for those patients not residing in the immediate locality of the current centres .
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient capacity of tertiary specialist services for treatment-resistant OCD
Wider context from the report “At the time of writing this report it appears that only a small number of tertiary centres able to care for patients with treatment resistant OCD exist in the United Kingdom . They appear to be located in London and the South East.
The criteria to access these services and the limited capacity they have , it seems prevents clinicians treating patients being able to call upon specialist services that a tertiary centre/s can provide to they patients. Particularly, where a patient’s case is complex and resistant to all that primary and secondary care services can offer in terms of treatment.
These centres are also not located across the whole of the United Kingdom for ease of access for those patients not residing in the immediate locality of the current centres.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Restrictive criteria for access to tertiary specialist services for treatment-resistant OCD
Wider context from the report “At the time of writing this report it appears that only a small number of tertiary centres able to care for patients with treatment resistant OCD exist in the United Kingdom. They appear to be located in London and the South East.
The criteria to access these services and the limited capacity they have, it seems prevents clinicians treating patients being able to call upon specialist services that a tertiary centre/s can provide to they patients. Particularly, where a patient’s case is complex and resistant to all that primary and secondary care services can offer in terms of treatment.
These centres are also not located across the whole of the United Kingdom for ease of access for those patients not residing in the immediate locality of the current centres.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commissioning specialist tertiary OCD care is assigned to ICBs, overseen by NHS England, which will provide the response.
Verbatim wording from the response “Responsibility for the commissioning of specialist tertiary care for the treatment of OCD sits with Integrated Care Boards (ICBs) which are overseen by NHS England.” Source location Response from Department of Health and Social Care
Open published response
24 Jun 2026 Naeem Ahmed · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 2 Failure of trust systems to provide an integrated view of doctors’ timing, sequencing, and cumulative workload across employers View source Failure to safely dispose of small volumes of medicines in sharps bins 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
Naeem Ahmed · 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
Naeem Ahmed, a Consultant Anaesthetist, was found dead in a hospital rest room on 21 June 2025 after using alcohol and a substance that is redacted in the report. The concerns included access to potentially fatal medicines from sharps bins and fragmented systems for managing doctors’ working patterns, secondary employment and cumulative workload across providers.
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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of trust systems to provide an integrated view of doctors’ timing, sequencing, and cumulative workload across employers
Wider context from the report “The review and the coronial investigation also revealed that Naeem died whilst working the 9th shift in a run of 11 night shifts for UHD which began on 12th June 2025 and that in June 2025 he undertook clinical work for more than one provider on the same calendar day on different occasions, and on one occasion he undertook daytime work for an external provider before commencing a resident overnight shift for the Trust later the same day. The review also identified that trust systems for job planning, rostering, appraisal, and secondary employment operated independently and were not designed to provide an integrated view of timing, sequencing, or cumulative workload across employers, whether over short periods or across an annual cycle . Whilst UHD have undertaken work to resolve this issue, I am concerned that this practice exists at other Trusts in England and Wales and could lead to fatigue and fatal outcomes to patients and doctors.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to safely dispose of small volumes of medicines in sharps bins
Wider context from the report “Evidence at the Inquest revealed that at the time of Naeem’s death a process in place at Poole Hospital that if there were small volumes of medicines to be disposed of by representatives of the Trust which were less than 50ml in volume, such as after surgery had taken place, these would be squirted into the sharps bins and then the needles would also be disposed of in the sharps bin too. This was identified in the independent review which concluded that this practice posed a risk that fatal medicines could be accessed from the sharps bin . As a result, UHD now use gels in the sharps bins which immediately denature and destroy the liquids squirted into the sharps bins. I am concerned that what was happening at the time of Naeem’s death continues to happen at other Trusts across England and Wales and could lead to future deaths.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Medicine disposal matters are operational issues outside the Department’s remit.
Verbatim wording from the response “In considering your report, officials within the Department of Health and Social Care made enquiries with NHS England and concluded that the concerns you have raised are more appropriately addressed by NHS England directly. The matters relating to the disposal of medicines are operational issues that fall within NHS England's remit. This includes responsibility for coordinating the regional response. Accordingly, NHS England is best placed to respond to these aspects of your correspondence. I am advised that NHS England will therefore provide you with a full and comprehensive response to the operational concerns you have raised.” Source location Response from Department of Health and Social Care
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 NHS England is responsible for addressing the operational concerns, including coordinating the regional response.
Verbatim wording from the response “In considering your report, officials within the Department of Health and Social Care made enquiries with NHS England and concluded that the concerns you have raised are more appropriately addressed by NHS England directly. The matters relating to the disposal of medicines are operational issues that fall within NHS England's remit. This includes responsibility for coordinating the regional response. Accordingly, NHS England is best placed to respond to these aspects of your correspondence. I am advised that NHS England will therefore provide you with a full and comprehensive response to the operational concerns you have raised.” Source location Response from Department of Health and Social Care
Open published response
24 Jun 2026 Nola-Reign Morgan · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 6 Delays in transferring patients between antenatal and HDU wards View source Failure to identify causes of transfer delays and take steps to avoid unnecessary delay recurring View source Insufficient training to enable obstetric and midwifery teams to identify the risk of chorioamnionitis and ensure adequate monitoring View source Lack of specific guidance for identifying and treating chorioamnionitis in pre-term mothers View source Lack of national antenatal guidance establishing when and in what circumstances fetal monitoring should be used, especially when chorioamnionitis is suspected View source Failure of local antenatal monitoring guidance to address chorioamnionitis, transfer times and consideration of continuous fetal monitoring 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.
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AI-generated summary
Nola-Reign Morgan · 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
Nola-Reign Morgan was born prematurely on 5 February 2024 after her mother developed suspected chorioamnionitis, and died three days later despite resuscitation and neonatal care. The report identified delays in transferring her mother to the labour ward and high dependency unit, a period without fetal monitoring, and gaps in national and local guidance and staff training on monitoring and managing suspected chorioamnionitis in pre-term pregnancies.
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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring patients between antenatal and HDU wards
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to identify causes of transfer delays and take steps to avoid unnecessary delay recurring
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient training to enable obstetric and midwifery teams to identify the risk of chorioamnionitis and ensure adequate monitoring
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of specific guidance for identifying and treating chorioamnionitis in pre-term mothers
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national antenatal guidance establishing when and in what circumstances fetal monitoring should be used, especially when chorioamnionitis is suspected
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of local antenatal monitoring guidance to address chorioamnionitis, transfer times and consideration of continuous fetal monitoring
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the future.
” Open source report
Concerns raised 4 Failure to maintain emergency department capacity and timely patient flow View source Insufficient social care provision for onward discharge support View source Failure to complete ambulance handovers within the 15-minute target View source Failure to prevent emergency department crowding from patients left awaiting handover View source See 1 more concern
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
Geoffrey Gordon Fuller · 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
Geoffrey Gordon Fuller, aged 91, called an ambulance for a dislocated hip and experienced a 13-hour delay, including prolonged periods waiting for an ambulance response and hospital handover, during which he suffered pain and was unable to move. He later died at Royal Cornwall Hospital from a ruptured abdominal aortic aneurysm, which the report states was unrelated to the dislocated hip and to which the delay contributed no more than minimally. The principal concerns were persistent ambulance handover delays, emergency department overcrowding, and insufficient social care provision, with associated risks to patient care and ambulance availability.
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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain emergency department capacity and timely patient flow
Wider context from the report “1. On the day of Mr Fuller’s ambulance delay, RCHT ED was accommodating 105 patients. ED has a capacity of 42 patients . ED accommodated the surplus patients on trolleys in corridors, seated within the waiting room or remaining inside ambulances in the parking area outside ED.
2. The situation had not improved as at the date of this Inquest.
3. EDs have a national target for 95% of patients to be admitted, transferred or discharged within 4 hours. It was noted that there is a recent major study which shows that the standardised mortality rate starts to rise from 5 hours after the patient’s time of arrival at the ED and they concluded that after 6–8 hours, there is one extra death for every 82 patients delayed. This increased mortality is partly attributed to the fact that patients in ED are not receiving the surgery or specialist care that is available on the wards.
4. Data indicates that RCHT have been failing to meet the 4-hour target for a significant number of patients. For the opening months of 2026 approximately 50% of patients have still been in ED after 4 hours .
5. RCHT witnesses reported that over the last few weeks the ED has been regularly required to accommodate over 100 patients (in a unit with a capacity for 42 patients) . This has involved significant numbers of patients still in ED after 12 hours, some still in ED after 24 hours .
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient social care provision for onward discharge support
Wider context from the report “1. The court found there was insufficient bed availability on acute wards which was attributable to significant numbers of patients in hospital with no reason to reside (NCTR) , these being patients who are medically optimised but cannot be discharged due to lack of onward care support .
2. On the day of the ambulance delay, 7 July 2025, almost 20% of patients in RCHT were recorded as NCTR.
3. The court noted the main cause for the numbers of NCTR patients was insufficient social care provision , whether commissioned by social services or NHS.
4. Investigations in 2022 and 2023 by SWAST and the Healthcare Safety Investigation Branch (HSIB) found a direct link between ambulance delays and inadequate social care provision. The court noted the SWAST systems report which found…
“…..there is a direct link between patients waiting in the hospital for discharge to social care and patients being cared for inside ambulances and Emergency Departments.”
5. This court has previously noted data indicating significant vacancies in social care posts in Cornwall are vacant reflecting the national picture of nationwide vacant direct social care posts. [see previous PFD reports on this subject]
6. The court noted that the NHS does not carry responsibility for the recruitment and retention of social care staff or any broad obligation to promote the social care market.
7. The HSSIB report referred to the fact that the organisations immediately required to deal with ambulance delays are ambulance trusts and acute hospitals, In Cornwall that is SWAST and RCHT. These organisations do not have control over the services primarily responsible for ambulance delays, namely social care provision and support. They are unable to influence the whole-system and therefore carry risks that they cannot wholly mitigate or manage.
8. The court noted the HSSIB report which states that delayed discharges (and consequent ambulance delays) are a national issue which is attributed to a whole system failure of health and social care. The court noted the HSSIB investigation’s first safety recommendation is an urgent ‘whole system’ response to reduce patient harm.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to complete ambulance handovers within the 15-minute target
Wider context from the report “1. The court noted that the NHS national target is for ambulances to handover patients to hospital is within 15 minutes of arrival.
2. The total ambulance delay on 7 July 2025 for Mr Fuller was approximately 13 hours, involving delays in both response and handover.
3. The delay in ambulance response was 10 hours and 12 minutes, during which time Mr Fuller was in pain and unable to move due to a dislocated hip.
4. On arrival at Royal Cornwall Hospital (RCHT), Mr Fuller spent a further 2 hours and 52 minutes before being handed over to the emergency department.
5. On 7 July 2025, at RCHT, the average handover time was two hours, 24 minutes with over 211 hours of ambulance availability lost to these handover delays. This is the equivalent of approximately 19 double crewed ambulance (DCA) shifts lost to delays (based on a standard 11-hour shift).
6. Data for the two months before Mr Fuller’s death reveals average handover delays at RCHT of 1 hour and 26 minutes for May 2025, and 1 hour and 27 minutes for June 2025 (beyond the 15 minute target) .
7. Recent data indicates the picture has not improved. Significant average handover delays at RCHT were recorded for every month of 2026 to date (beyond the target 15 minutes) . The data for May 2026 indicates an average handover delay of 1 hour and 22 minutes beyond the 15-minute target.
8. The day before this Inquest, 7 June 2026, SWAST recorded average handover delays at RCHT of 1 hour and 10 minutes .
9. These handover delays lead to the unavailability of ambulances to respond to emergency calls. Furthermore, the average handover delays conceal spikes such as that which led to the long delay in this case. Such long delays increase the risk of mortality.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent emergency department crowding from patients left awaiting handover
Wider context from the report “10. The court heard evidence of a new policy being implemented by SWAST to try and reduce ambulance resources being tied down in lengthy waits at hospital. After a 90-minute handover delay the ambulance paramedics will provide notice to ED that a patient is being left on a trolley in a corridor with fluids and medications if required so long as that patient is stable. This has led to significant crowding in RCHT emergency department (ED) .
” 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 Publish national clinical standards for emergency departments, acute pathways and discharge to improve flow and safer emergency care.
Verbatim wording from the response “This includes, through delivering the Urgent and Emergency Care Delivery Plan 2025/26, having invested over £450 million to expand urgent and emergency care capacity. We have also published national clinical standards through the Model Emergency Department, Model Acute Pathway and Model Discharge programmes, which are designed to improve flow through hospitals, reduce prolonged waits and support safer emergency care.” Source location Response from Department of Health and Social Care
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 Invest over £450 million to expand urgent and emergency care capacity through the 2025/26 delivery plan.
Verbatim wording from the response “This includes, through delivering the Urgent and Emergency Care Delivery Plan 2025/26, having invested over £450 million to expand urgent and emergency care capacity. We have also published national clinical standards through the Model Emergency Department, Model Acute Pathway and Model Discharge programmes, which are designed to improve flow through hospitals, reduce prolonged waits and support safer emergency care.” Source location Response from Department of Health and Social Care
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 health and care partners to improve discharge arrangements, strengthen service integration and ensure safe, timely and appropriate care.
Verbatim wording from the response “We note your findings regarding the whole-system nature of these issues and will carefully consider this report alongside wider evidence on discharge delays, patient flow and urgent and emergency care pressures. The Government remains committed to working with partners across the health and care system to improve discharge arrangements, strengthen integration between services and ensure patients receive safe, timely and appropriate care.” Source location Response from Department of Health and Social Care
Open published response
17 Jun 2026 Jake Harvey READ · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 2 Lack of national guidance and timelines for administering medication in Mental Health agitation or Mental Health crisis View source Lack of direct access to required Mental Health medication for Mental Health Liaison Team Non-Medical Prescribers in Emergency Departments 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
Jake Harvey READ · 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
Jake Harvey READ was declared deceased at home on 5 May 2025 after sustaining self-inflicted knife injuries. He had attended an emergency department two days earlier seeking mental health support but left before planned Diazepam was prescribed. The principal concerns were the absence of national guidance or timelines for administering medication during mental health agitation or crisis, and the lack of direct access to the medication for a qualified non-medical prescriber, which contributed to a delay in prescribing.
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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance and timelines for administering medication in Mental Health agitation or Mental Health crisis
Wider context from the report “My primary concern in Jake's case is that evidence heard that there is no national guidance or timelines in place for the administration of medication required in cases where an individual has been identified as being in a state of Mental Health agitation or Mental Health crisis .
On the 3rd May 2025 Jake arrived at the Emergency Department of the Ipswich Hospital at 16:36.
Jake was identified as requiring a consultation with the Mental Health Liaison Team at 17:05.
Two staff from the Mental Health Liaison Team first met Jake at 17:30.
At approximately 18:20-1830 it was identified that Jake required a dose of Diazepam to calm his agitation, to allow for a more effective Mental Health Assessment.
Prior to administration of the Diazepam clinical observations were required and these were being completed at 18:35. The observations showed no contraindications for the administration of Diazepam.
However, the Diazepam was not prescribed to Jake until 21:19, some 2 hours and 44 minutes after the clinical observations had shown no contraindications for the administration of Diazepam.
It is believed that Jake had left the Emergency Department at some time between 19:00 and 19:30.
It was not possible to identify on the available evidence whether the administration of Diazepam to Jake on the 3rd May would have prevented his death. However, it was acknowledged that there was a chance that had the Diazepam been administered, it might have changed the tragic sequence of events leading to Jake's death.
Evidence heard that in some medical cases clinical staff are given a clear timeline in guidance as to when it is expected a required medication is to be administered (sepsis being cited as an example). The court was told that no such guidance exists for the administration of drugs in Mental Health cases .
In Jake's case clinical staff stated that had such a timeline been in place, this would have prompted staff to prescribe and administer the necessary drug earlier than it was.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of direct access to required Mental Health medication for Mental Health Liaison Team Non-Medical Prescribers in Emergency Departments
Wider context from the report “My second concern is that at the time of Jake's attendance on 3rd May 2025, one of the Mental Health Liaison Team staff who spoke to Jake at 17:30 was a qualified Non-Medical Prescriber, who could have prescribed the Diazepam to Jake herself.
However, at that time, even though a Mental Health Liaison Team Non-Medical Prescriber had assessed Jake required an immediate dose of Diazepam, this clinician had no direct access to the required drug .
Therefore, at that time, the Non-Medical Prescriber had to request an Emergency Department clinician to prescribe it for them . In Jake's case this caused the 2 hours and 44-minute delay between clinical observations being completed and drug prescription being made.
Evidence was heard that the East Suffolk and North Essex NHS Trust and the Norfolk and Suffolk Foundation Trust have changed the system at the Ipswich Hospital, and now the Mental Health Liaison Team Non-Medical Prescribers are able to both prescribe and access prescription medications within the Emergency Department, without the need to request an Emergency Department clinician to prescribe it for them.
When asked, the witness providing this evidence could not say whether the same provision was available in hospitals other than those covered by the relevant trusts.
As such, it is not known if direct access to Mental Health medication by Mental Health clinicians working in an Emergency Department is just a local arrangement, or if it is replicated in other jurisdictions?
” 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 Responsibility for relevant clinical guidance, NHS service delivery and oversight sits with NHS England.
Verbatim wording from the response “The report raises concerns about the availability of guidance on the administration of medication to patients in a state of agitation or crisis, particularly in relation to timelines; and the ability of non-medical prescribers to both prescribe and access prescription medicines in emergency departments for patients presenting in such circumstances. Responsibility for these matters, including relevant clinical guidance, service delivery and oversight of NHS services, sits with NHS England. NHS England is also responsible for coordinating the regional response where appropriate and is therefore best placed to provide a detailed response to the concerns identified in your report.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 4 Lack of a designated lead with oversight and authority over coordinated care View source Failure to coordinate alerts and subsequent treatment or long-term intervention View source Fragmented information sharing and updating across healthcare providers View source Lack of an easily recognised national risk designator across patient records View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Alex Ganski · 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
Alex Ganski, aged 19, died from fatal injuries after jumping from a bridge while under the influence of ketamine and diazepam, following a relapse in drug misuse and longstanding mental health difficulties. The principal concerns were the absence of a designated lead with oversight and authority across services, fragmented information sharing, and no clear national mechanism to identify and communicate his wider mental health and drug-misuse 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a designated lead with oversight and authority over coordinated care
Wider context from the report “The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs:
a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age.
b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence. And then – critically - directing and assuring the right treatment or long-term intervention to follow.
c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented, in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction.
d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information. Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse. As such the situation is ameliorated by local changes but appears to be a wider and national issue.
I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs.
My further concern is that there was no simple mechanism or designation across those patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues, in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken.
This lack of an easily recognised national designator, shown across systems and records,such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved, and creates a risk of further similar deaths.
I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resources grounds, that this report will be acted upon.
I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate alerts and subsequent treatment or long-term intervention
Wider context from the report “The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs:
a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age.
b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence . And then – critically - directing and assuring the right treatment or long-term intervention to follow .
c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented, in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction.
d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information. Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse. As such the situation is ameliorated by local changes but appears to be a wider and national issue.
I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs.
My further concern is that there was no simple mechanism or designation across those patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues, in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken.
This lack of an easily recognised national designator, shown across systems and records,such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved, and creates a risk of further similar deaths.
I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resources grounds, that this report will be acted upon.
I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Fragmented information sharing and updating across healthcare providers
Wider context from the report “The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs:
a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age.
b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence. And then – critically - directing and assuring the right treatment or long-term intervention to follow.
c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented , in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction .
d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information . Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse. As such the situation is ameliorated by local changes but appears to be a wider and national issue.
I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs.
My further concern is that there was no simple mechanism or designation across those patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues, in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken.
This lack of an easily recognised national designator, shown across systems and records,such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved, and creates a risk of further similar deaths.
I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resources grounds, that this report will be acted upon.
I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of an easily recognised national risk designator across patient records
Wider context from the report “The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs:
a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age.
b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence. And then – critically - directing and assuring the right treatment or long-term intervention to follow.
c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented, in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction.
d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information. Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse. As such the situation is ameliorated by local changes but appears to be a wider and national issue.
I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs.
My further concern is that there was no simple mechanism or designation across those patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues , in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken.
This lack of an easily recognised national designator, shown across systems and records,such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved , and creates a risk of further similar deaths.
I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resources grounds, that this report will be acted upon.
I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives.
” Open source report
5 Jun 2026 Neeshat Dalal · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 1 Lack of appropriately qualified dietitian provision for inpatients undergoing psychiatric care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Neeshat Dalal · 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
Neeshat Dalal was admitted for severe depression after experiencing difficulty eating and drinking and undergoing three attempts to end her life with an insulin overdose. She collapsed during her third ECT treatment on 13 December 2022, was transferred to the emergency department, and died in the Acute Medicine Unit in the early hours of 14 December 2022. The concerns included inadequate consideration of her nutritional needs and vomiting, insufficient medical information before ECT, and delays or omissions in aspects of her acute hospital 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriately qualified dietitian provision for inpatients undergoing psychiatric care
Wider context from the report “Funding is required for the specific provision of appropriately qualified dieticians who can meet the nutritional needs of inpatients undergoing psychiatric care in SPFT and in other Trusts where such support does not already exist .
” 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 Individual NHS Trusts and employers determine staffing levels and workforce composition to meet patients’ needs safely.
Verbatim wording from the response “Individual NHS Trusts and other employers are responsible for determining staffing levels and workforce composition. They are best placed to understand their services and the” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 1 Failure to provide a designated clinical area for emergency department patients when capacity is reached View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David John Smart · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David John Smart developed a life-threatening rectal bleed after a polypectomy and required surgery after conservative management continued to be unsuccessful. He died from known complications of Andexanet Alfa, used to reverse Rivaroxaban so that surgery could be performed. The inquest raised concerns about patients being cared for in corridors when the Emergency Department reached capacity, including the continued use of corridors despite actions intended to improve patient flow.
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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a designated clinical area for emergency department patients when capacity is reached
Wider context from the report “During the inquest I heard evidence that at the of Mr Smart's attendance to the Emergency Department of the Royal Sussex County Hospital, Brighton that there were around 20 patients in the corridor as the Department had reached capacity and there was no clinical area available to do so . I understand from previous inquests that the area is not designated as a clinical area .
I have heard in other inquests relating to deaths prior to June 2025 that is being taken by University Hospitals Sussex NHS Foundation Trust currently to (1) reduce the number of patients who present to the Emergency Department who could be seen by other services in the community and (2) to create an improved patient flow through the Royal Sussex County Hospital.
The evidence in this inquest was that, despite these actions, the corridor continues to be used when the Emergency Department reaches capacity .
I was also advised that the use of corridors to care for patients is not only an issue at the Royal Sussex County Hospital, Brighton but is used throughout the country .
Prevention of Future Death reports in relation to the use of the corridor for patient care was made during investigations into deaths which occurred in December 2022 and February 2025 and the use of the corridor remains ongoing .
” 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 Continue action to improve patient flow across the urgent and emergency care pathway.
Verbatim wording from the response “The Government and NHS England will continue to take action across the full urgent and emergency care pathway to improve patient flow, expand available capacity, and reduce avoidable demand on accident and emergency departments. This includes focused support for the most challenged trusts, alongside strengthened reporting arrangements and the introduction of a consistent national definition of corridor care to support greater transparency. We will also begin publishing data on corridor care for the first time, subject to assurance of data quality.” Source location Response from Department of Health and Social Care
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 focused support to the most challenged trusts.
Verbatim wording from the response “The Government and NHS England will continue to take action across the full urgent and emergency care pathway to improve patient flow, expand available capacity, and reduce avoidable demand on accident and emergency departments. This includes focused support for the most challenged trusts, alongside strengthened reporting arrangements and the introduction of a consistent national definition of corridor care to support greater transparency. We will also begin publishing data on corridor care for the first time, subject to assurance of data quality.” Source location Response from Department of Health and Social Care
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 action to expand available urgent and emergency care capacity.
Verbatim wording from the response “The Government and NHS England will continue to take action across the full urgent and emergency care pathway to improve patient flow, expand available capacity, and reduce avoidable demand on accident and emergency departments. This includes focused support for the most challenged trusts, alongside strengthened reporting arrangements and the introduction of a consistent national definition of corridor care to support greater transparency. We will also begin publishing data on corridor care for the first time, subject to assurance of data quality.” Source location Response from Department of Health and Social Care
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 NHS England is responsible for directly addressing the concerns about corridor care and providing the full response.
Verbatim wording from the response “In considering your report, officials within the Department of Health and Social Care have made enquiries with NHS England and concluded that these concerns are more appropriately addressed by NHS England directly. I am advised that NHS England will therefore provide you with a full and comprehensive response on the concerns you have raised.” Source location Response from Department of Health and Social Care
Open published response
21 May 2026 George Edward James Haldenby · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Delays in processing hospital-issued FP10 prescriptions in prisons without 24-hour healthcare provision View source Incomplete availability of critical medications held in prison View source Lack of local policy or process for managing out-of-hours FP10 prescriptions View source Lack of mandatory refresher training in first aid and CPR for prison staff 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
George Edward James Haldenby · 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
George Edward James Haldenby was a serving prisoner with severe heart failure who collapsed at HMP The Verne on 29 January 2022 and died that day at Dorset County Hospital. The report identifies delays in receiving an increased dose of Furosemide, and a delay in recognising the collapse and starting CPR, as substantive concerns. It also raises concerns about the absence of regular refresher training in first aid and CPR and the lack of a clear process for handling hospital prescriptions issued outside prison healthcare hours.
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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in processing hospital-issued FP10 prescriptions in prisons without 24-hour healthcare provision
Wider context from the report “In prisons without 24 hour healthcare provision, if a prisoner receives treatment at a hospital and is issued with a medication prescription on a FP10 form, this cannot be processed at the prison in the absence of a doctor or prescribing nurse , and pharmacies in hospitals are not always open 24 hours a day for it to be dispensed as TTO medication. This means there will be a delay in prisoners receiving necessary and lifesaving medication over a weekend or bank holiday period until staff are in the prison who can action the prescription.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Incomplete availability of critical medications held in prison
Wider context from the report “Whilst at HMP The Verne there is now a duty Doctor who can be called upon out of hours to progress such prescriptions, there is a lack of local policy or process to ensure the prison and healthcare staff have an understanding of how to deal with the situation should a FP10 be issued outside of hours when a prescribing health professional is not available in the prison to ensure a prisoner receives necessary medications without delay. Although critical medications are held at the prison in a locked cabinet, not all medication are included and Furosemide, which was critical in George’s care, is one of those that is not held by the prison as a critical medicine .
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of local policy or process for managing out-of-hours FP10 prescriptions
Wider context from the report “Whilst at HMP The Verne there is now a duty Doctor who can be called upon out of hours to progress such prescriptions, there is a lack of local policy or process to ensure the prison and healthcare staff have an understanding of how to deal with the situation should a FP10 be issued outside of hours when a prescribing health professional is not available in the prison to ensure a prisoner receives necessary medications without delay. Although critical medications are held at the prison in a locked cabinet, not all medication are included and Furosemide, which was critical in George’s care, is one of those that is not held by the prison as a critical medicine.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory refresher training in first aid and CPR for prison staff
Wider context from the report “After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR . During the evidence, a Custodial Manager at HMP the Verne stated that the last time he had first aid or CPR training was in 1991, 35 years ago, when he started as a prison officer. Whilst there is a requirement to have a duty first aider on site 24 hours a day, without all staff being suitably and regularly trained in signs of collapse and administering CPR , there could be a delay in delivering effective CPR as it may take time for the duty first aider to get to the prisoner, and a future death could occur.
” 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 NHS England is responsible for addressing concerns about obtaining hospital-prescribed medication out of hours in prisons without 24-hour healthcare.
Verbatim wording from the response “The report raises concerns about the lack of process in place in prisons without 24-hour healthcare provision, to ensure that hospital prescribed medication is available when prescribed out of hours, and over weekends and bank holiday periods.” Source location 2026-0312 - Response from Department of Health and Social Care
Open published response
7 May 2026 Elsie Margaret Jones · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Inadequate supervision of patients with severe dementia on acute hospital wards View source Delays in finding suitable specialist placements for patients with severe dementia View source Delays in securing funding for specialist placements for patients with severe dementia View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Elsie Margaret 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
Elsie Margaret Jones, who had advanced dementia and was at high risk of falling, spent several months in hospital while awaiting discharge to a specialist service. She experienced several falls, including a fall on 1 November 2025 that caused a hip fracture, and died on 16 November 2025 after receiving palliative care. The concern was that lengthy delays in securing funding and suitable specialist placements for patients with severe dementia can leave them inadequately supervised on acute hospital wards, creating a risk of future deaths.
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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate supervision of patients with severe dementia on acute hospital wards
Wider context from the report “The inquest heard evidence that patients who suffer from severe dementia who need specialist placements often spend many months in hospital whilst funding and suitable placements are being found. Given the resources available on acute hospital wards this puts these patients at risk as they cannot always be adequately supervised . I am concerned that the lengthy delays in securing funding and finding suitable placements for these most vulnerable patients creates a risk of future deaths and I consider action should be taken.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in finding suitable specialist placements for patients with severe dementia
Wider context from the report “The inquest heard evidence that patients who suffer from severe dementia who need specialist placements often spend many months in hospital whilst funding and suitable placements are being found. Given the resources available on acute hospital wards this puts these patients at risk as they cannot always be adequately supervised. I am concerned that the lengthy delays in securing funding and finding suitable placements for these most vulnerable patients creates a risk of future deaths and I consider action should be taken.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in securing funding for specialist placements for patients with severe dementia
Wider context from the report “The inquest heard evidence that patients who suffer from severe dementia who need specialist placements often spend many months in hospital whilst funding and suitable placements are being found. Given the resources available on acute hospital wards this puts these patients at risk as they cannot always be adequately supervised. I am concerned that the lengthy delays in securing funding and finding suitable placements for these most vulnerable patients creates a risk of future deaths and I consider action should be taken.
” 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 Continue working with NHS England, CQC and local partners to improve discharge timeliness and ensure safe, appropriate care and supervision for people with severe dementia.
Verbatim wording from the response “We will continue to work closely with NHS England, CQC and local partners to address the risks identified in your report, including improving the timeliness of discharge and ensuring that people with severe dementia receive safe, appropriate care and supervision.” Source location Response from Department of Health and Social Care
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 Regulation 18 duties and CQC risk-management expectations address staffing, supervision and safe care without mandating fixed staffing levels or one-to-one supervision.
Verbatim wording from the response “Providers are required under Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 to ensure sufficient numbers of suitably qualified, competent and” Source location Response from Department of Health and Social Care
Open published response
30 Apr 2026 Joseph William Cooper · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to provide drug and alcohol service professionals with access to relevant mental health records View source Lack of a complete and unified digital NHS health records system View source Lack of commissioned services and treatment pathways for co-occurring mental health and substance misuse conditions View source Failure of online alcohol retailers to prevent rapid delivery of large quantities of alcohol with only basic age-verification checks View source See 1 more concern
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AI-generated summary
Joseph William Cooper · 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
Joseph William Cooper died outside his home on 19 June 2025 after sustaining multiple traumatic injuries in a fall while profoundly intoxicated. His death was contributed to by depression and alcohol dependence syndrome. Concerns included unmet mental health needs for people with co-occurring mental health and substance misuse conditions, the ready online availability of large quantities of alcohol, and professionals’ lack of access to his mental health records.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide drug and alcohol service professionals with access to relevant mental health records
Wider context from the report “3) The court heard evidence that professionals from the drug and alcohol service treating Mr Cooper had no access to his mental health records despite both mental health and drug and alcohol services being provided under the auspices of the same NHS Foundation Trust .
Whilst the court heard that Pennine Care NHS Foundation Trust is urgently seeking to grant viewer access to relevant patients’ mental health records to the drug and alcohol team, it is a matter of concern that no complete and unified digital NHS health records system currently exists within England and Wales.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a complete and unified digital NHS health records system
Wider context from the report “3) The court heard evidence that professionals from the drug and alcohol service treating Mr Cooper had no access to his mental health records despite both mental health and drug and alcohol services being provided under the auspices of the same NHS Foundation Trust.
Whilst the court heard that Pennine Care NHS Foundation Trust is urgently seeking to grant viewer access to relevant patients’ mental health records to the drug and alcohol team, it is a matter of concern that no complete and unified digital NHS health records system currently exists within England and Wales .
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of commissioned services and treatment pathways for co-occurring mental health and substance misuse conditions
Wider context from the report “1) The court heard evidence that at the time of his death, Mr Cooper had unmet mental health needs principally as a consequence of no specific service or treatment pathway existing locally which would provide wholistic and co-ordinated care for co-occurring mental health and substance misuse conditions (also known as ‘dual diagnosis’). I am concerned as to the lack of availability of commissioned services to provide care for patients with co-occurring mental health and substance misuse conditions both in this and other areas .
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of online alcohol retailers to prevent rapid delivery of large quantities of alcohol with only basic age-verification checks
Wider context from the report “2) Mr Cooper was able to order large quantities of alcohol via online delivery services and have them delivered to his door quickly, including on occasions when he was already obviously intoxicated. I am concerned that large quantities of alcohol are so quickly and readily available from a range of retailers via online delivery services with only basic age-verification checks being undertaken .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop statutory guidance on the duty to co-operate under the Health and Care Act 2012.
Verbatim wording from the response “The national actions in the delivery framework include the commitment to publish guidance on the statutory duty to co-operate issued under the Health and Care Act 2012. This statutory guidance, which is currently in development, will define how commissioners and services should work together to achieve positive health outcomes for people with co-occurring needs and enable better joint working between mental health services and drug and alcohol services.” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with NHS England and sector partners to overcome barriers to data sharing between services.
Verbatim wording from the response “Secondly, regarding your concerns raised regarding sharing information and data between services and clinicians, the delivery framework also states that all service providers need to work together with all relevant local services to agree data sharing arrangements that reflect the needs of people with a co-occurring mental health and substance use need. This is also in line with the NICE guidance recommendations on information sharing, 1.4.6 and 1.4.7. Work is ongoing alongside NHSE and sector partners to overcome the challenges and barriers to data sharing between services.” Source location Response from Department of Health and Social Care
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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 Introduce the Single Patient Record to enable sharing of patient information across relevant health and social care providers.
Verbatim wording from the response “Furthermore, the upcoming introduction of the Single Patient Record will allow patient information to be more easily shared with patients and their relevant health and social care providers (such as GPs, hospital doctors, social care workers and others involved in their direct care). The Single Patient Record will provide a single record of patient needs and history, consistently across the NHS and social care in England.” Source location Response from Department of Health and Social Care
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the Co-occurring Mental Health and Substance Use Delivery framework.
Verbatim wording from the response “Firstly, your report raises concerns over the current provision of treatment and support for those with co-occurring mental health and substance use conditions. We know that people with co-occurring substance use and mental health needs too often do not receive the integrated, person-centred care they require and deserve. I want to assure you that the Department of Health and Social Care (DHSC) is taking action on this issue to improve the standards of care and integration of services for those with co-occurring substance use and mental health needs. In December 2025, DHSC and NHS England (NHSE) jointly published the Co-occurring Mental Health and Substance Use Delivery framework: https://www.gov.uk/government/publications/co-occurring-mental-health-and-substance-use-delivery-framework.” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working across the department to improve integrated care for people with substance use issues.
Verbatim wording from the response “Thank you for bringing these concerns to my attention. I want to assure you my department recognise these issues and are continuing to work closely together to improve integrated care for those with substance use issues. I hope this response is helpful.
Yours sincerely,” Source location Response from Department of Health and Social Care
Open published response
30 Apr 2026 Poppy Hope LOMAS · Prevention of Future Deaths report North London
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Concerns raised 4 Use of terminology failing to convey the gravity and unsafe nature of delivery against medical advice View source Unavailability of a pulse oximeter for maternal heart rate in the home delivery kit View source Failure to hold a multidisciplinary risk discussion for an unsafe home birth View source Failure to obtain consent documenting the risks of an unsafe home birth View source See 1 more concern
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AI-generated summary
Poppy Hope LOMAS · 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
Poppy Hope LOMAS died in hospital on 26 October 2022, aged 7 days, after being born in poor condition following a home delivery. The report describes multiple unrecognised risk factors during the delivery and identifies concerns about consent and risk communication, multidisciplinary review, terminology used for unsafe deliveries, and the absence of a maternal pulse oximeter from the home delivery kit.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Use of terminology failing to convey the gravity and unsafe nature of delivery against medical advice
Wider context from the report “It is a matter of concern that the nationally used expression “Out of Guidance” is used in these circumstances, which may fail to convey the gravity of the decisions being taken , rather than an expression that captures all elements:- in particular that the delivery is against medical advice, the Royal College of Obstetricians and Gynaecologists guidance and that as a consequence it is an unsafe delivery.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a pulse oximeter for maternal heart rate in the home delivery kit
Wider context from the report “It is a matter of concern that the Home Delivery kit does not include a pulse oximeter for maternal heart rate .
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to hold a multidisciplinary risk discussion for an unsafe home birth
Wider context from the report “It is a matter of concern that where the patient has chosen to have an unsafe birth at home consideration is not given to holding a Multi-Disciplinary Team Meeting with the consultant obstetrician, hospital midwives & community midwives and the patient , to ensure that the patient receives an understanding of the risks to the baby and to themselves..
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain consent documenting the risks of an unsafe home birth
Wider context from the report “It is a matter of concern that where the patient has chosen to have an unsafe birth at home and has decided to refuse to consent to the care the hospital recommend for the management of the unsafe birth, that consideration is not given to the patient signing a consent form that clearly sets out the risks .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for the specific homebirth concerns sits with NHS England, which will issue the substantive response.
Verbatim wording from the response “In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns, and I understand there is work underway to develop national standards and a clear framework for homebirth services. As responsibility for the specific matters of concern you have raised sits with NHS England, they will be issuing a substantive response addressing each of these concerns.” Source location Response from Department of Health and Social Care
Open published response
24 Apr 2026 Kenneth John Morris · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 2 Failure to provide required one-to-one nursing care View source Critically stretched healthcare resources View source
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AI-generated summary
Kenneth John Morris · 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
Kenneth John Morris, aged 78, died at Hull Royal Infirmary on 10 December 2025 after a second unwitnessed ward fall caused intracranial haemorrhage, brain damage and early post-traumatic epilepsy. The principal concern was that he did not receive required one-to-one nursing care because of understaffing and more pressing cases, and evidence indicated that similar deaths may occur while resources remain critically stretched.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide required one-to-one nursing care
Wider context from the report “This gentleman should have received one to one nursing care but due to a combination of understaffing and more pressing cases on the ward, he did not receive such care . Evidence was heard that had he received such care he would not have fallen and died. Evidence was also heard that within the Hull Trust and probably throughout the NHS, resources are critically stretched and whilst improvements are being proposed, I believe that the current situation makes it probable that similar deaths will occur.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Critically stretched healthcare resources
Wider context from the report “This gentleman should have received one to one nursing care but due to a combination of understaffing and more pressing cases on the ward, he did not receive such care. Evidence was heard that had he received such care he would not have fallen and died. Evidence was also heard that within the Hull Trust and probably throughout the NHS, resources are critically stretched and whilst improvements are being proposed, I believe that the current situation makes it probable that similar deaths will occur .
” 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 Publish a new 10 Year Workforce Plan to support appropriate NHS staffing and workforce distribution.
Verbatim wording from the response “In our 10 Year Health Plan we committed to publishing a new 10 Year Workforce Plan. The plan, which will be published this year, will help ensure the NHS has the right people in the right places to deliver the best care for patients.” Source location Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual NHS trusts and employers are responsible for determining staffing levels and workforce composition.
Verbatim wording from the response “I have carefully considered the situation. Individual NHS Trusts and other employers are responsible for determining staffing levels and workforce composition. They are best placed to understand their services and the needs of their patients in order to deliver safe and effective care. I would expect Hull University Teaching Hospitals NHS Trust and all other NHS Trusts to ensure that their staffing arrangements, are appropriate following the tragic death of Mr Morris.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 3 Failure to clearly communicate treatment plans and required actions in consultant correspondence View source Failure of secondary-care specialists to issue required prescriptions at diagnosis View source Failure to provide prompt access to patient medical records across NHS Trusts View source
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Theresa Lydon · 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
Theresa Lydon had severe ulcerative colitis and was admitted to hospital on four occasions before her death following complications of surgery, including an intra-abdominal haemorrhage. The report identifies concerns about delayed prescribing, unclear communication of treatment plans, inadequate access to medical records between NHS Trusts, and the absence of repeated blood tests that contributed to her death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly communicate treatment plans and required actions in consultant correspondence
Wider context from the report “(1) During the course of the inquest it was established Mrs Lydon was diagnosed with a condition and treatment was prescribed in the form of a repeat prescription drug in May 2021. The diagnosing consultant set out the treatment plan in a letter to her GP and the format of the letter was such it was difficult for the receiving GP to see what actions were required by him .
This is compounded when paper correspondence is routinely scanned and emailed by administrators and the GP is 'drawn' to certain sections of the document by the administrators. It was remarked in evidence by the GP that all consultants seem to format their correspondence differently and there is no uniform format so a GP can see clearly at the outset what the treatment plan is and what action needs to be taken .
Evidence from the Hospital Trust in question stated they had changed the format of this type of correspondence to make it easier to identify the actions to be taken. In Mrs Lydon's case, the drug she was prescribed in May 2021 was not identified from the correspondence and was supplied to her in June 2022 when the situation was discovered. Whilst a remedy has been implemented locally I have a concern that nationally there is a risk of future deaths if important correspondence contained treatment plans is not clearly communicated to those responsible for implementing them .
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of secondary-care specialists to issue required prescriptions at diagnosis
Wider context from the report “(2) Evidence was given at inquest that when a diagnosis is made by a specialist in a secondary care setting, if drugs are to be prescribed that must be undertaken by the patient's GP . It was confirmed that the current practice does not allow for a specialist to issue a prescription for the required drugs at the point of diagnosis and then instruct the patient's GP to continue the process . In Mrs Lydon's case this would have ensured she received the clinically indicated drugs immediately.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prompt access to patient medical records across NHS Trusts
Wider context from the report “(3) On Mrs Lydon's admission to hospital in Gateshead in July 2022 certain investigations, treatment and diagnosis were made. She was then discharged and returned to hospital in South Tyneside, a neighbouring NHS Trust in August for what amounted to a further 3 hospital admissions there before her death. Evidence was heard that the doctors in South Tyneside whilst aware of her recent admission in Gateshead could not access her medical records for that admission . They requested them in August, but they were not supplied until November, after she had died .
I understand much work regionally has been undertaken since 2022 with North East England based NHS Trusts to make 'real time' access to patient records possible, but whilst improved it is not complete and this is also a national issue I understand.
Given the two hospitals Mrs Lydon was a patient in are only 6 miles apart it raises a concern that doctors attending Mrs Lydon in one location are denied access to another hospital records so close at hand and I understand this is not a position unique to these hospitals. To me, the inability of doctors to promptly access a patient's medical records from other NHS Trusts to provide the best possible care creates a risk of future deaths.
” 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 Introduce a Single Patient Record across England to enable consistent sharing of patient information among relevant health and social care providers from 2028.
Verbatim wording from the response “I would like to highlight action we are taking at a national level which will radically improve data sharing between NHS service providers, whether they are neighbouring hospitals as was in Mrs Lydon’s case, or at opposite ends of the country.” Source location Response from Department of Health and Social Care
Open published response
16 Apr 2026 Adam Ankers · Prevention of Future Deaths report West London
View report summary
Concerns raised 5 Insufficient understanding of defibrillator use among lay persons and trained first aid persons View source Insufficient dissemination and mandatory coverage of Sudden Cardiac Arrest training across football leagues, clubs, coaches and referees View source Difficulty among lay people and ambulance call handlers in recognising signs of agonal breathing or cardiac arrest View source Unavailability of cardiac screening for all young people and football players aged 14 and upwards View source Failure of cascade communication of genetic or hereditary diseases to reach family members who need to know View source See 2 more concerns
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AI-generated summary
Adam Ankers · 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
Adam Ankers suffered a cardiac arrest while playing grassroots football on 31 January 2024 due to a previously unidentified inherited cardiac condition, and died in hospital on 4 February 2024 following brain stem death. Agonal breathing and cardiac arrest were not recognised at the pitch or by the 999 call handler, and an AED was brought to the pitch but not used. The report identified concerns about recognition of agonal breathing and cardiac arrest, access to and use of defibrillators, dissemination of sudden cardiac arrest training, cardiac screening, and cascade communication of inherited disease information.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of defibrillator use among lay persons and trained first aid persons
Wider context from the report “POINT C: That there is a need for better understanding of the use of defibrillators particularly by lay persons and trained first aid persons
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient dissemination and mandatory coverage of Sudden Cardiac Arrest training across football leagues, clubs, coaches and referees
Wider context from the report “POINT B: That the Football Association’s Sudden Cardiac Arrest training is not more widely disseminated or mandatory for all FA Accredited and Affiliated leagues and clubs and all grassroots football coaches and referees .
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Difficulty among lay people and ambulance call handlers in recognising signs of agonal breathing or cardiac arrest
Wider context from the report “POINT A: That there is difficulty in lay people (trained or not) including ambulance call handlers in understanding the signs of agonal breathing or cardiac arrest
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of cardiac screening for all young people and football players aged 14 and upwards
Wider context from the report “POINT D: That cardiac screening in those aged 14 and upwards reduces the risk of sudden cardiac death and this is not available to all young people or your football players
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of cascade communication of genetic or hereditary diseases to reach family members who need to know
Wider context from the report “POINT E: That cascade communication of genetic or hereditary diseases is imperfect and does not reach more than half of those in families that need to know about it .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Population screening for sudden cardiac death should not currently be offered because tests are insufficiently accurate and may cause harm.
Verbatim wording from the response “The UK NSC last reviewed screening for the conditions associated with sudden cardiac death in people under the age of 39 years old in 2019. The conclusion of that review was that population screening should not be offered, as research showed that current tests are not accurate enough to use on young people with no symptoms.” Source location Response from Department of Health and Social Care
Open published response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England will respond on concerns about recognising agonal breathing or cardiac arrest, defibrillator use, and cascade communication of hereditary conditions.
Verbatim wording from the response “In preparing this response, my officials have made enquiries with NHS England officials. They have confirmed that NHS England will respond to you directly on POINT A, POINT C and POINT E.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 4 Failure to alert relevant providers and assure appropriate follow-up treatment after significant incidents View source Lack of an easily recognised national designator for significant wider and historical health and drug-misuse risks View source Fragmented sharing and updating of health and drug-misuse information across providers View source Lack of a designated lead with full oversight and authority over coordinated care View source See 1 more concern
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AI-generated summary
Alex Ganski · 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
Alex Ganski died from fatal injuries after jumping from a bridge while under the influence of ketamine and diazepam, following a relapse in drug misuse and longstanding mental health difficulties. The report identified concerns about fragmented information sharing between services and the absence of a clear lead with overall oversight and authority for his care, creating missed opportunities to address the combined risks of poor mental health, drug misuse and self-harm.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to alert relevant providers and assure appropriate follow-up treatment after significant incidents
Wider context from the report “The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs:
a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age.
b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence . And then – critically – directing and assuring the right treatment or long-term intervention to follow .
c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented, in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction.
d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information. Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse. As such the situation is ameliorated by local changes but appears to be a wider and national issue.
I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs.
My further concern is that there was no simple mechanism or designation across the various patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues, in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken.
This lack of an easily recognised national designator, shown across systems and records, such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved, and creates a risk of further similar deaths.
I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resource grounds, that this report will be acted upon.
I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of an easily recognised national designator for significant wider and historical health and drug-misuse risks
Wider context from the report “The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs:
a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age.
b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence. And then – critically – directing and assuring the right treatment or long-term intervention to follow.
c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented, in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction.
d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information. Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse. As such the situation is ameliorated by local changes but appears to be a wider and national issue.
I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs.
My further concern is that there was no simple mechanism or designation across the various patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues , in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken.
This lack of an easily recognised national designator, shown across systems and records, such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved , and creates a risk of further similar deaths.
I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resource grounds, that this report will be acted upon.
I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Fragmented sharing and updating of health and drug-misuse information across providers
Wider context from the report “The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs:
a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age.
b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence. And then – critically – directing and assuring the right treatment or long-term intervention to follow.
c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented, in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction .
d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information . Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse . As such the situation is ameliorated by local changes but appears to be a wider and national issue.
I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs.
My further concern is that there was no simple mechanism or designation across the various patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues, in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken.
This lack of an easily recognised national designator, shown across systems and records, such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved, and creates a risk of further similar deaths.
I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resource grounds, that this report will be acted upon.
I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a designated lead with full oversight and authority over coordinated care
Wider context from the report “The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs:
a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age.
b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence. And then – critically – directing and assuring the right treatment or long-term intervention to follow.
c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented, in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction.
d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information. Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse. As such the situation is ameliorated by local changes but appears to be a wider and national issue.
I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs.
My further concern is that there was no simple mechanism or designation across the various patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues, in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken.
This lack of an easily recognised national designator, shown across systems and records, such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved, and creates a risk of further similar deaths.
I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resource grounds, that this report will be acted upon.
I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives.
” 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 Develop and publish guidance on the statutory duty to cooperate between local authorities and NHS bodies.
Verbatim wording from the response “These actions include the commitment to publish guidance on the statutory duty to co-operate issued under the Health and Care Act 2012. This guidance, which is currently in development, will define how local authorities and NHS bodies should work together to achieve positive health outcomes for people with co-occurring needs. The duty to co-operate guidance will be supported by an accompanying national standard checklist for joint care planning. DHSC will develop the checklist to support implementation of the duty to co-operate guidance when agreeing care plans. This will enable more consistency between mental health services and drug and alcohol services.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reduce the longest waits for specialist mental health services.
Verbatim wording from the response “Alongside this we are reducing the longest waits for specialist services, embedding mental health support for young people within new Young Futures Hubs, and accelerating the rollout of Mental Health Support Teams across England to reach full national coverage by 2029. These teams are designed to support earlier identification of risk, rapid information-sharing between services and clearer pathways into longer-term support where required.” Source location Response from Department of Health and Social Care
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 Strengthen clinical leadership, multiagency working and information sharing through children and young people’s mental health reforms.
Verbatim wording from the response “Through our wider children and young people’s mental health reforms, we are working to strengthen clear clinical leadership and oversight, multiagency working, and information sharing, so that no child falls through gaps between services.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the draft Personalised Care Framework with NHS organisations ahead of publication.
Verbatim wording from the response “The Personalised Care Framework also looks to improve continuity, clarity and safety by ensuring people experiencing serious mental illness have a named professional coordinating their care, a care plan that reflects their needs now, quicker re-access to support when things deteriorate, and more consistent standards of good care wherever they live. The Personalised Care Framework has been shared in draft with NHS organisations ahead of its expected publication.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Accelerate rollout of Mental Health Support Teams across England toward full national coverage.
Verbatim wording from the response “Alongside this we are reducing the longest waits for specialist services, embedding mental health support for young people within new Young Futures Hubs, and accelerating the rollout of Mental Health Support Teams across England to reach full national coverage by 2029. These teams are designed to support earlier identification of risk, rapid information-sharing between services and clearer pathways into longer-term support where required.” Source location Response from Department of Health and Social Care
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 NHS England and sector partners to overcome barriers to data sharing between services.
Verbatim wording from the response “Regarding your concerns raised in relation to sharing information and data between services and clinicians, the delivery framework also states that all service providers need to work together with all relevant local services to agree data sharing arrangements that reflect the needs of people with a co-occurring mental health and substance use need. This is also in line with the NICE guidance recommendations on information sharing, 1.4.6 and 1.4.7. Work is ongoing alongside NHSE and sector partners to overcome barriers to data sharing between services.” Source location Response from Department of Health and Social Care
Open published response
26 Mar 2026 Madison James Bruce SMITH · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Increased risk of sudden unexpected death from prone sleeping in young babies View source Failure to restrict use of the term nurse to registered nurses View source Lack of required formal training or medical qualifications for maternity service providers View source Lack of statutory regulation of maternity service agencies and individuals View source Promotion of prone sleeping by unqualified maternity and sleep providers View source Failure of maternity service courses to undergo quality assurance or meet minimum standards View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Madison James Bruce SMITH · 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
Madison James Bruce Smith was found unresponsive in his cot on 18 October 2024 after being placed prone to sleep by a person describing themselves as a maternity nurse. He died in hospital, and the cause of death was unascertained, although prone sleeping was identified as increasing the risk of sudden unexpected death. The report raised concerns about the lack of statutory regulation, training and qualification requirements for maternity nurses and agencies, and the misleading use of the term “nurse”.
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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Increased risk of sudden unexpected death from prone sleeping in young babies
Wider context from the report “3.The inquest was told that the promotion of prone sleeping by unqualified individuals describing themselves as maternity nurses and experts in sleep poses a very significant risk to a young baby. A baby will sleep more deeply in a prone position which is why superficially it can seem to be a solution where a baby sleeps poorly. However, whenever a young baby is placed in such a position it will increase the risk that they will die suddenly and unexpectedly . All health professionals need to be vigilant in continuing to emphasise the national guidance on safe sleeping and be vigilant in flagging up to a family that prone sleeping in a child that cannot independently turn over is not a solution to a poor sleep routine but rather is a factor that increases the risk of a sudden and unexpected death.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict use of the term nurse to registered nurses
Wider context from the report “2. Anyone the inquest was told, can attach the term nurse to a word such as night/maternity/ post-natal. The inquest was told that only the term registered nurse is protected and restricted in its use . An individual who has no medical training or formal early years training can offer their services to a family with young children describing themselves as for example a maternity nurse. This can the inquest was told give a misleading impression of their expertise and skill set to a family employing them. A statutory bar on the word nurse being used by anyone other than a registered nurse on the NMC register would avoid this situation from arising.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of required formal training or medical qualifications for maternity service providers
Wider context from the report “1.The inquest heard evidence that there is a significant demand from families with very young children who would like to get their children into a sleep routine at an early stage. To meet that demand there are now agencies and individuals who seek to meet that demand. However, the inquest was told that there is no statutory regulation of these individuals or of the agencies. Consequently, anyone can set up an agency that purports to offer training and expertise in maternity services. They need not have any formal training or any medical qualification . The courses they offer do not need to be quality assured or meet any minimum standards.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of statutory regulation of maternity service agencies and individuals
Wider context from the report “1.The inquest heard evidence that there is a significant demand from families with very young children who would like to get their children into a sleep routine at an early stage. To meet that demand there are now agencies and individuals who seek to meet that demand. However, the inquest was told that there is no statutory regulation of these individuals or of the agencies . Consequently, anyone can set up an agency that purports to offer training and expertise in maternity services. They need not have any formal training or any medical qualification. The courses they offer do not need to be quality assured or meet any minimum standards.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Promotion of prone sleeping by unqualified maternity and sleep providers
Wider context from the report “3.The inquest was told that the promotion of prone sleeping by unqualified individuals describing themselves as maternity nurses and experts in sleep poses a very significant risk to a young baby . A baby will sleep more deeply in a prone position which is why superficially it can seem to be a solution where a baby sleeps poorly. However, whenever a young baby is placed in such a position it will increase the risk that they will die suddenly and unexpectedly. All health professionals need to be vigilant in continuing to emphasise the national guidance on safe sleeping and be vigilant in flagging up to a family that prone sleeping in a child that cannot independently turn over is not a solution to a poor sleep routine but rather is a factor that increases the risk of a sudden and unexpected death.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of maternity service courses to undergo quality assurance or meet minimum standards
Wider context from the report “1.The inquest heard evidence that there is a significant demand from families with very young children who would like to get their children into a sleep routine at an early stage. To meet that demand there are now agencies and individuals who seek to meet that demand. However, the inquest was told that there is no statutory regulation of these individuals or of the agencies. Consequently, anyone can set up an agency that purports to offer training and expertise in maternity services. They need not have any formal training or any medical qualification. The courses they offer do not need to be quality assured or meet any minimum standards .
” 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 Create a protection-of-title offence criminalising unregistered use of the title “nurse”, subject to specified exemptions.
Verbatim wording from the response “As you point out, currently, the title ‘registered nurse’ is protected in law. This is obviously not enough to safeguard the public, and we are taking action to address the misuse of the trusted title ‘nurse’ by unregulated professionals.” Source location 2026-0179 - Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with professional, governmental, trade union and social care stakeholders to develop the protection-of-title offence.
Verbatim wording from the response “The term ‘nurse’ is used across multiple professions – for example, ‘dental nurse’ and ‘veterinary nurse’ – and it is not our intention to prevent the legitimate use of the title ‘nurse’ in these instances. The legislation will therefore include exemptions to allow other professionals to use the title legitimately, and later this year we will be seeking views on which roles should be exempted. The Government will continue to work with key stakeholders, including the NMC, the devolved governments, the Royal College of Nursing, trade unions, other professional representatives and the social care sector, on developing the protection of title offence.” Source location 2026-0179 - Response from Department of Health and Social Care
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 Seek views on which roles should be exempted from the new protection-of-title offence.
Verbatim wording from the response “The term ‘nurse’ is used across multiple professions – for example, ‘dental nurse’ and ‘veterinary nurse’ – and it is not our intention to prevent the legitimate use of the title ‘nurse’ in these instances. The legislation will therefore include exemptions to allow other professionals to use the title legitimately, and later this year we will be seeking views on which roles should be exempted. The Government will continue to work with key stakeholders, including the NMC, the devolved governments, the Royal College of Nursing, trade unions, other professional representatives and the social care sector, on developing the protection of title offence.” Source location 2026-0179 - Response from Department of Health and Social Care
Open published response
24 Mar 2026 Robert Joseph DAY · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 1 Absence of national guidance for frontline emergency crews dealing with time-critical mental health situations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Robert Joseph DAY · 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
Robert Day died on 15 January 2025 after taking a significant overdose of prescription medication and refusing treatment after an ambulance and police response. The principal concern was the absence of national guidance for frontline emergency services dealing with complex, time-critical situations involving mental health concerns, which the report said risks the lives of others.
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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Absence of national guidance for frontline emergency crews dealing with time-critical mental health situations
Wider context from the report “The fundamental issue was considered to be 'what can the frontline crew actually do' in such complex situations. I heard evidence that, sadly, Robert's situation is unlikely to have been novel but that there is an absence of national guidance to frontline emergency services in dealing with the complexities of cases such as Robert's .
I acknowledge the complex interplay between the various agencies and services involved, but highlight to you my concern that the absence of any national guidance / advice to frontline emergency crews risks the lives of others who are found to be at time critical risk as a result of underlying mental health concerns .
” 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 NHS England is responsible for addressing concerns about national guidance for frontline emergency crews and will respond directly.
Verbatim wording from the response “In preparing this response, my officials have made enquiries with NHS England and the Care Quality Commission to ensure we adequately address your concerns. Upon reviewing your report, our NHSE colleagues felt it was more appropriate to reply directly to you given concerns around the absence of any national guidance/advice to frontline emergency crews. You may want to address your report to NHSE, so that they can also address your concerns. For CQC, you will see that their response to your concerns is highlighted in this letter below.” Source location Response from DHSC & Department for Women's Health and Mental Health
Open published response
19 Mar 2026 Paul Robert Joseph NASH · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 3 Failure to convey information about critically depleted seizure medication to the GP View source Failure to prioritise prescriptions for same-day supply of critically depleted seizure medication View source Difficulties obtaining sufficient quantities of epilepsy medication for continuous access 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
Paul Robert Joseph NASH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul Robert Joseph NASH, who had epilepsy secondary to HSV encephalitis, was found deceased at home on 23 October 2025 after apparently suffering a seizure during the night. He had run out of Carbamazepine and missed three doses. The concerns included that the GP surgery did not appear to be told that he had completely run out of medication and did not prioritise the prescription for same-day collection, as well as wider difficulties for epilepsy patients in obtaining sufficient medication supplies.
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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to convey information about critically depleted seizure medication to the GP
Wider context from the report “1. During the phone call with the Surgery on 21 October 2025, HEADWAY made it clear to the Surgery that the Deceased had run out of his Carbamazepine (seizure medication) completely and, although he had taken that morning's dose, if he did not receive more medication that day he would not have his evening dose or any other doses. Although HEADWAY was reassured that the GP would be notified that the Deceased had run out of his seizure medication, this fact did not appear to have been conveyed to the GP and the prescription was not prioritised to ensure he received it the same day.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise prescriptions for same-day supply of critically depleted seizure medication
Wider context from the report “1. During the phone call with the Surgery on 21 October 2025, HEADWAY made it clear to the Surgery that the Deceased had run out of his Carbamazepine (seizure medication) completely and, although he had taken that morning's dose, if he did not receive more medication that day he would not have his evening dose or any other doses. Although HEADWAY was reassured that the GP would be notified that the Deceased had run out of his seizure medication, this fact did not appear to have been conveyed to the GP and the prescription was not prioritised to ensure he received it the same day .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Difficulties obtaining sufficient quantities of epilepsy medication for continuous access
Wider context from the report “2. The Deceased's Consultant Neurologist indicated that many epilepsy patients across the country currently experience difficulties in obtaining sufficient quantities of medication to ensure optimum seizure control i.e. it is difficult for them to obtain batch quantities to ensure they always have access to some in the event that they find they are running low or there are delays in the pharmacy processing a repeat prescription (apparently in some areas processing can take up to 10 days) .
” 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 Work with the pharmacy sector to improve awareness of emergency supply provisions and patients’ access to emergency medicines.
Verbatim wording from the response “The Department recognises that awareness of emergency supply provisions amongst both patients and pharmacy staff can be improved. The Department is committed to working with the pharmacy sector to improve awareness and ensure patients can access emergency supplies when necessary to prevent harm or death. We are currently in consultation with the sector representative body, Community Pharmacy England, on the 2026/27 Community Pharmacy Contractual Framework. As part of this consultation we will take into account learnings from Paul Nash’s death.” Source location 2026-0161 - Response from Department of Health and Social Care
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 NHS England and delegated Integrated Care Boards commission and performance-manage general practice, including addressing persistent performance concerns.
Verbatim wording from the response “General practice is commissioned and performance-managed by NHS England, with responsibility delegated to Integrated Care Boards, who are expected to work with practices to provide support and agree improvement plans where performance concerns arise. Where issues persist, commissioners can intervene and use contractual levers, including remedial action, to ensure safe and appropriate patient care.” Source location 2026-0161 - Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing regulations and NHS pharmacy terms require community pharmacies to dispense NHS medicines with reasonable promptness and notify patients of delays.
Verbatim wording from the response “The Department recognises that delays in pharmacies processing repeat prescriptions can result in patients unexpectedly running out of vital medicines. That is why all community pharmacies providing dispensing services for NHS patients in England are required to dispense medicines for patients on demand with reasonable promptness. This is set out in regulations and within the terms of service for all pharmacies on the NHS Pharmaceutical list.” Source location 2026-0161 - Response from Department of Health and Social Care
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 urgent-supply arrangements, including pharmacist emergency supplies and NHS 111 referrals, provide routes to obtain urgently needed medicines.
Verbatim wording from the response “The Department recognises that delays in prescriptions being sent by GPs, such as in Paul Nash’s tragic case, can result in patients being left without vital medication. Provisions are in place to prevent patients being left in this situation. If a patient needs to access an urgent supply of their medicines, then there are a range of options available, which can be found at Emergency prescriptions - NHS.” Source location 2026-0161 - Response from Department of Health and Social Care
Open published response
19 Mar 2026 JOHN DAVID BEAGLEY · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 2 National shortage of maxillofacial surgeons and consultants View source Lack of NHS funding for a substantial element of maxillofacial surgeon training 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
JOHN DAVID BEAGLEY · 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 DAVID BEAGLEY died of squamous cell carcinoma after treatment for carcinoma of the scalp. Following surgery in November and December 2023, his wound did not heal, a radiotherapy referral was not submitted, and opportunities for referral were missed; the cancer later progressed and radiotherapy was administered between September and October 2024. The inquest heard concerns about a national shortage of maxillofacial surgeons and the potential impact on patient care, including the effects of lengthy and insufficiently funded training.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation National shortage of maxillofacial surgeons and consultants
Wider context from the report “During the course of the inquest, the Court heard evidence that:
1. There was a national shortage of maxillofacial surgeons/consultants .
2. The said shortage could impact upon the care of patients.
3. It was perceived that the long medical training for such surgeons (including dentistry training) was unattractive for prospective surgeons due to the fact that a large element of the training was not funded by the NHS and would have to be funded from the clinician’s own finances.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of NHS funding for a substantial element of maxillofacial surgeon training
Wider context from the report “During the course of the inquest, the Court heard evidence that:
1. There was a national shortage of maxillofacial surgeons/consultants.
2. The said shortage could impact upon the care of patients.
3. It was perceived that the long medical training for such surgeons (including dentistry training) was unattractive for prospective surgeons due to the fact that a large element of the training was not funded by the NHS and would have to be funded from the clinician’s own finances .
” 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 Keep healthcare-student funding arrangements under close review, balancing student support with value for taxpayers’ money.
Verbatim wording from the response “The Government keeps the funding arrangements for all healthcare students under close review. At all times we must balance the level of support students receive with the need to deliver as much value as possible for taxpayers’ money.” Source location 2026-0158 - Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Move all OMF surgeon recruitment to ST1 entry-level training from 2027.
Verbatim wording from the response “Up until 2026, there has been another application point for the specialty at ST3, which is a part of higher specialty training and requires applicants to have completed core training and relevant exams. Due to reducing fill levels at ST3, all recruitment for OMF Surgeons will be at ST1 from 2027 onwards.” Source location 2026-0158 - Response from Department of Health and Social Care
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 Individual NHS trusts and employers are responsible for ensuring sufficient specialist staffing and access to provide safe care.
Verbatim wording from the response “Individual NHS Trusts and other employers are responsible for ensuring that there are sufficient and appropriate staff to provide safe care. I would expect NHS Trusts to review their staffing levels, and access to specialists where needed, to ensure that they are appropriate to treat patients who come forward seeking care.” Source location 2026-0158 - Response from Department of Health and Social Care
Open published response
12 Mar 2026 Albert Thomas Bellingham · Prevention of Future Deaths report North London
View report summary
Concerns raised 2 Lack of appropriate training for doctors working in care homes when dealing with pressure sores View source Lack of guidance supporting an interventionalist supervisory role when dealing with pressure sores 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
Albert Thomas Bellingham · 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
Albert Thomas Bellingham died in hospital on 10 November 2024 from bacteraemia associated with an infected sacral pressure sore that developed after his admission following a fall. The principal concern was inadequate preventative nursing care, with the inquest concluding that neglect in treating the sacral sore contributed to his death; the report also raises consideration of guidance and training for doctors working in care homes.
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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate training for doctors working in care homes when dealing with pressure sores
Wider context from the report “Consideration of guidance to support interventionalist, supervisory role with appropriate training for doctors working in care homes when dealing with pressure sore .
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance supporting an interventionalist supervisory role when dealing with pressure sores
Wider context from the report “Consideration of guidance to support interventionalist, supervisory role with appropriate training for doctors working in care homes when dealing with pressure sore.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responsible for addressing concerns about pressure sore guidance and training for doctors working in care homes.
Verbatim wording from the response “In considering your report, officials within the Department of Health and Social Care have made enquiries with NHS England and concluded that these concerns are more appropriately addressed by NHS England directly. I am advised that NHS England will therefore provide you with a full and comprehensive response on the concerns you have raised.” Source location Response from DHSC
Open published response
12 Mar 2026 Tania Louise JARMAN · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 2 Use of artificially elevated thresholds for mental health bed referrals View source Fewer mental health beds than patients assessed as needing them 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
Tania Louise JARMAN · 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
Tania Louise JARMAN died aged 54 on 27 February 2024 at Park House, a non-clinical crisis placement, after tying a ligature with the probable intention of ending her life. Her mental health had worsened before her death, and her admission removed her from protective factors including her mother and home. The principal concerns were the longstanding shortage of mental health beds and the risk that this could lead to an artificially elevated threshold for referrals, potentially denying beds to patients with a clinical need.
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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Use of artificially elevated thresholds for mental health bed referrals
Wider context from the report “2. In addition, the fact that this situation is longstanding now raises the risk that clinical decisions as to bed referrals may use an artificially elevated threshold for referral because decision makers are “hardened”. This potentially denies beds to patients who do in fact have a clinical need for them .
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Fewer mental health beds than patients assessed as needing them
Wider context from the report “1. There is a long standing and well publicised concern that there are fewer mental health beds than patients who are assessed as needing these . I draw your attention to the fact that this situation is ongoing and continues to pose a risk to life .
” Open source report
11 Mar 2026 Janette Margaret PALMER · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1 Lack of knowledge among care home and sheltered housing providers of the UK Power Networks Priority Services Register and enhanced response View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Janette Margaret PALMER · 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
Janette Palmer died at St Nicholas Hospice on 24 February 2025 after an unwitnessed fall causing a left hip fracture, a heart attack, and subsequent bronchopneumonia. A power cut had occurred at her supported living accommodation, but it could not be established whether the lights were out when she fell or whether this contributed to the fall. The report raises concern that providers of care homes and sheltered housing may lack knowledge of the UK Power Networks Priority Services Register and therefore may not access enhanced support during power outages.
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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge among care home and sheltered housing providers of the UK Power Networks Priority Services Register and enhanced response
Wider context from the report “In their evidence Havebury Housing Partnership (the Housing Association which runs Chestnut Court) stated that it had no knowledge that a Priority Services Register existed, or knowledge of the enhanced response available if their properties were on that register .
Given the circumstances of Janette’s case, it is not suggested that had Chestnut Court been on the Priority Service Register her tragic death would not have occurred.
However, I am concerned that the lack of knowledge that the UK Power Networks Priority Services Register actually exists , may just not relate to the Havebury Housing Partnership but also to the many other providers of care home and sheltered housing facilities.
I am concerned that in different circumstances, such as an extreme weather event, residents of other care homes and sheltered housing will not benefit from the enhanced response available and deaths may occur, due to a lack of knowledge of the UK Power Networks Priority Services Register by the individuals or businesses running those facilities .
” 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 Publish guidance for identifying and supporting vulnerable people during emergencies, including reminders about Priority Services Registers.
Verbatim wording from the response “Furthermore, published guidance on identifying and supporting persons who are vulnerable in an emergency is aimed at Local Resilience Forums and recommends that local partners and emergency services should remind individuals who think they might need additional support during an emergency of the existence of Priority Service Registers.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate clear Priority Services Register guidance to care providers through the Adult Social Care Operational Resilience Forum and Care Quality Commission monthly bulletin.
Verbatim wording from the response “We are determined to ensure that all those receiving and providing care are aware of the PSR and the benefits it can provide, especially to vulnerable people and people with medical devices. In addition to the existing communications activities outlined above, we will be circulating clear guidance on the PSR to all care providers via the Adult Social Care Operational Resilience Forum and the Care Quality Commission monthly bulletin, who will cascade this to all of their care providers and networks. This will ensure that all individuals and carers have the necessary information they need to ensure vulnerable people are safe and supported. The guidance will outline how individuals and carers can sign up for the PSR, how to sign up for each of the utilities, as well as highlight both the benefits and the limitations of the PSR.” Source location Response from Department of Health and Social Care
Open published response
11 Mar 2026 Mark Simpson · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 2 Failure to add NHS 111 consultation reports to patients’ medical records View source Failure to ensure medically informed review and escalation of potentially significant NHS 111 information View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mark Simpson · 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
Mark Simpson died on 22 October 2025 after being found unresponsive and not breathing at home; the medical cause of death was acute heart failure due to ischaemic heart disease and coronary artery atheroma, with renal cell carcinoma also recorded. The report raises concerns that information about his NHS 111 consultation for prolonged chest pain was assessed by non-medically qualified staff, was not relayed to a clinician, and was not added to his medical record.
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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to add NHS 111 consultation reports to patients’ medical records
Wider context from the report “Concern 2
If reports of this nature, forwarded to a GP Practice after a consultation with the NHS 111 Service, are not added to a patient’s medical record at the Practice , should a subsequent consultation become necessary, the medical professional conducting that consultation in the absence of potentially very relevant information may go on to make inappropriate decisions and place their patient at risk .
I believe it is necessary for to raise this concern, but it is not for me to be prescriptive about what should / can be done.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure medically informed review and escalation of potentially significant NHS 111 information
Wider context from the report “If a patient contacts the NHS 11 service it is necessary and appropriate for that patient’s GP Practice to be informed. Mark Simpson contacted the NHS 111 service reporting chest pain for approximately seven hours before being advised to call 999 should the pain become dramatically worse or he feel breathless. His GP Practice was provided with a record of that consultation, but this information was not relayed to a clinician nor was it added to Mark's medical record at the surgery.
Concern 1
The information forwarded to the GP Practice was considered by a member of staff who was not medically qualified , and yet in deciding the consultation did not need to be brought to the attention of a medical professional was making an important decision with potentially significant ramifications for that patient.
Notwithstanding that a GP Practice may receive numerous reports about patients of this type, if such potentially significant information is not considered by a member of staff with medical knowledge, important information may be missed and to the later detriment of the patient.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation ICBs, as GP contract commissioners, are responsible for monitoring compliance and taking action when practices breach contractual requirements.
Verbatim wording from the response “In summary: (1) GMC Good Medical Practice requires clear, accurate and contemporaneous records and emphasises continuity of care and information sharing before referral; (2) regulation 67 specifically requires GP contractors to keep adequate records and include clinical reports from other services/professionals; (3) the GP contract makes referral part of essential services and includes explicit requirements to review NHS 111 “Post Event Messages” and out-of-hours clinical details within specified timescales. These standards and contractual requirements are directly relevant to the handling and incorporation of NHS 111/out-of-hours information into the patient record and to the responsibilities that continue while a patient is awaiting specialist care. We expect ICBs, as commissioners of GP contracts, to monitor GP practice compliance with, and performance against, the contract.” Source location 2026-0139 - Response from DHSC
Open published response
10 Mar 2026 John Ioannou · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Failure to learn from communication failures in the care of patients with profound learning disabilities View source Failure to investigate the case under the Patient Safety Framework View source Failure to establish the aetiology and timing of a fatal infection 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
John Ioannou · 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 Ioannou, a 61-year-old non-verbal man receiving 24-hour residential care, died after a cardiac arrest on 24 June 2025 following treatment for a problem with his PEG apparatus. An autopsy identified an infection at the PEG site that spread to his small intestine and caused peritonitis. The principal concerns were that the death was not investigated under NHS England’s Patient Safety Framework, and that the cause and timing of the infection and possible communication failures were not fully explored.
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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to learn from communication failures in the care of patients with profound learning disabilities
Wider context from the report “1. The Barts Health Trust chose not to investigate this case as part of NHS England’s Patient Safety Framework. Mr Ioannou’s death ought to have been subject to such an investigation.
Firstly, despite an autopsy, the aetiology and precise timing of Mr Ioannou’s fatal infection was not fully understood. In a functioning clinical governance setting, both the possibility of the trust having missed a pre-existing infection at the time of the treatment on 23rd June 2025 or the prospect that the treatment itself caused the infection should have been explored.
Secondly, in the context of the treatment of a patient with a profound learning disability where communication failures may have contributed to poor care, a valuable learning opportunity was missed .
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate the case under the Patient Safety Framework
Wider context from the report “1. The Barts Health Trust chose not to investigate this case as part of NHS England’s Patient Safety Framework. Mr Ioannou’s death ought to have been subject to such an investigation.
Firstly, despite an autopsy, the aetiology and precise timing of Mr Ioannou’s fatal infection was not fully understood. In a functioning clinical governance setting, both the possibility of the trust having missed a pre-existing infection at the time of the treatment on 23rd June 2025 or the prospect that the treatment itself caused the infection should have been explored.
Secondly, in the context of the treatment of a patient with a profound learning disability where communication failures may have contributed to poor care, a valuable learning opportunity was missed.
” 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 Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to establish the aetiology and timing of a fatal infection
Wider context from the report “1. The Barts Health Trust chose not to investigate this case as part of NHS England’s Patient Safety Framework. Mr Ioannou’s death ought to have been subject to such an investigation.
Firstly, despite an autopsy, the aetiology and precise timing of Mr Ioannou’s fatal infection was not fully understood . In a functioning clinical governance setting, both the possibility of the trust having missed a pre-existing infection at the time of the treatment on 23rd June 2025 or the prospect that the treatment itself caused the infection should have been explored .
Secondly, in the context of the treatment of a patient with a profound learning disability where communication failures may have contributed to poor care, a valuable learning opportunity was missed.
” Open source report
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