15 Nov 2023 Madeleine Eve SAVORY · Prevention of Future Deaths report Suffolk
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Concerns raised 1 Insufficient national availability of Tier 4 paediatric mental health beds for timely allocation View source
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AI-generated summary
Madeleine Eve SAVORY · 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
Madeleine Savory, aged 15, died on 26 February 2022 after being found ligatured in a bathroom on Bergholt Ward at Ipswich Hospital, following a period during which their whereabouts were unknown. The substantive concerns included the availability of Tier 4 paediatric mental health beds, failures in risk assessment and communication, ward staff understanding of risk, and the implementation of a school safety plan.
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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 national availability of Tier 4 paediatric mental health beds for timely allocation
Wider context from the report “I also received helpful evidence from the East of England Provider Collaborative concerning the measures which that organisation had undertaken in their area of responsibility to address my concern in relation to the availability and allocation of Tier 4 beds in a paediatric mental health facilities to children such as Madeleine .
The availability, nationally, of Tier 4 beds in paediatric mental health facilities to allow for the timely allocation to children in need of care in such facilities such as Madeleine Savory.
” 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 considering concerns about Tier 4 bed availability and setting out responsive actions.
Verbatim wording from the response “Your report raises concerns over the availability of Tier 4 beds in paediatric mental health facilities. I understand that NHS England has carefully considered the matters of concern in your report and has provided you with a comprehensive response setting out the actions being taken to improve care quality and patient safety and improve availability of Tier 4 beds where these are needed.” Source location Response from Department of Health and Social Care
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15 Nov 2023 Calogero Di Blasi · Prevention of Future Deaths report Avon
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Concerns raised 3 Failure of specialty teams to communicate investigation information and share results in a timely manner View source Failure of 2-week urgent cancer pathway timeframes to include investigation reporting and referring-clinician review View source Insufficient breadth of endoscopist training for recognition of less frequently occurring lesions View source
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Calogero Di Blasi · 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
Calogero Di Blasi was referred for possible stomach and bowel cancer and underwent investigations including endoscopies and a CT scan. During a further endoscopy, a gastric varix was mistaken for an abnormal area and biopsied, causing a massive bleed; he died on 1 December 2022. The concerns included communication failures between specialist teams, insufficient timeframes for reviewing investigations on the urgent cancer pathway, and limitations in endoscopist training for recognising less common lesions.
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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 of specialty teams to communicate investigation information and share results in a timely manner
Wider context from the report “(1) That one of the teams caring for Mr Di Blasi was completely unaware of the input from another specialty team , despite both referrals being made under the 2-week urgent referral pathway. The lack of communication between these teams meant that timely sharing of results did not occur . Even the very knowledge of the fact that a CT scan had taken place would have alerted the endoscopist to check those results, and it is likely that the second endoscopy would not have gone ahead. I understand this to be a national issue and is likely to apply to other investigations being carried out.
” 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 2-week urgent cancer pathway timeframes to include investigation reporting and referring-clinician review
Wider context from the report “(2) That the reporting timeframes on the 2-week urgent cancer pathway referral does not take into account timeframes for reporting investigative procedures or subsequent review by the referring clinicians .
” 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 breadth of endoscopist training for recognition of less frequently occurring lesions
Wider context from the report “(3) The current training for Endoscopists for JAG certification requires the performance of 200 endoscopies. However, these tend to focus on the clinician’s area of specialty and therefore there is a danger that lesion recognition will be limited and insufficient to ensure that endoscopists are able to recognise less frequently occurring lesions . With the need for an increasing number of endoscopists, action should be taken.
” 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 Reformed cancer waiting-time standards by introducing the 28-day Faster Diagnosis Standard and consolidating nine reporting standards into three.
Verbatim wording from the response “Since the death of Mr Di Blasi, NHS England and the Department have reformed cancer waiting time standards, following a clinically led review. This has replaced the two-week wait standard with the Faster Diagnosis Standard (FDS) for patients to get a cancer diagnosis or all-clear within 28 days of an urgent referral. The FDS moves focus away from process to deliver a clear clinical outcome – either diagnosing or ruling out cancer. This represents an improvement on the preceding 2-week wait standard, which was simply to “see a specialist” and addresses the coroners concerns, as the new standard takes into account times for reporting and reviewing diagnostic procedures. The reform also consolidated cancer standards from nine to three to reduce bureaucracy of reporting against a large number of standards.” 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 Local management and implementation of national policies and procedures is assigned to NHS England and the responsible Integrated Care Board.
Verbatim wording from the response “In preparing this response, Departmental officials have made enquiries with NHS England. The matters of concern you raise relate to the local management and implementation of national policies and procedures. As such, I requested NHS England liaise with the North Somerset and South Gloucestershire Integrated Care Board (ICB) responsible for University Hospitals Bristol and Weston NHS Foundation Trust.” 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 The Faster Diagnosis Standard is considered to address concerns by including diagnostic reporting and review times within the cancer waiting-time standard.
Verbatim wording from the response “Since the death of Mr Di Blasi, NHS England and the Department have reformed cancer waiting time standards, following a clinically led review. This has replaced the two-week wait standard with the Faster Diagnosis Standard (FDS) for patients to get a cancer diagnosis or all-clear within 28 days of an urgent referral. The FDS moves focus away from process to deliver a clear clinical outcome – either diagnosing or ruling out cancer. This represents an improvement on the preceding 2-week wait standard, which was simply to “see a specialist” and addresses the coroners concerns, as the new standard takes into account times for reporting and reviewing diagnostic procedures. The reform also consolidated cancer standards from nine to three to reduce bureaucracy of reporting against a large number of standards.” Source location Response from Department of Health and Social Care
Open published response
15 Nov 2023 Lynda BLACKMORE · Prevention of Future Deaths report South Wales Central
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Concerns raised 1 Handover delays impacting ambulance response times for patients requiring emergency treatment or conveyance to hospital 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
Lynda BLACKMORE · 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
Lynda Blackmore had established heart failure and diabetes and developed a painful, bruised and swollen left leg. After becoming acutely unwell, she experienced a delay of about 13 hours before an ambulance took her to hospital, where she was diagnosed with sepsis and died later that day. The principal concern was that ambulance response times were affected by mis-categorisation, resource availability and hospital handover delays, posing a risk to people requiring emergency treatment or hospital conveyance.
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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 Handover delays impacting ambulance response times for patients requiring emergency treatment or conveyance to hospital
Wider context from the report “My concern here is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital . As Mr Garner stated in his evidence at para 45, the handover delays experienced at/around the time that the deceased was awaiting assistance were well in excess of the targets enshrined in the Welsh Health Circular of May 2016 .
Such delays pose a risk to the lives of those requiring emergency treatment/conveyance to hospital.
” Open source report
14 Nov 2023 Maxwell Frame · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 1 Absence of a national policy on the placement of central venous catheters View source
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Maxwell Frame · 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
Maxwell Frame presented with sepsis caused by a pelvic abscess and bowel obstruction and underwent emergency surgery. A central venous catheter was incorrectly inserted into an artery and was later removed; clot dislodged during removal, causing strokes, after which he received palliative care and died. The report identified concern about the absence of a single national policy for central venous catheter placement.
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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 Absence of a national policy on the placement of central venous catheters
Wider context from the report “Absence of a national policy on the placement of CVC’s
Over the course of the inquest hearing, oral evidence was provided by several anaesthetic/ ICU doctors ranging from experienced consultants, specialty Dr’s and a Core Trainee 2 all of whom had experience to varying degrees of placing CVC’s. These Dr’s had worked in several hospitals predominantly across the Midlands and North of England. The Trust had a policy entitled Central Venous Access Device which identified the steps that I have identified earlier should have taken place but were not. I was advised by the Dr’s who gave evidence that there was no single standard policy that they had encountered nationally for the placement of CVC’s . The Trust in this case following their internal investigation of Mr Frame’s case had felt it necessary to revise their policy. Further, I was advised by some of the Dr’s who gave evidence that they felt a national policy regarding the placement of CVC’s would be beneficial.
” 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 No further departmental action is considered necessary because the treating clinician departed from existing national recommendations, guidelines and Trust policy.
Verbatim wording from the response “I was deeply saddened to read the circumstances of Mr Frame’s death. The report has prompted careful reflection within my department, and from NICE and other stakeholders involved in the issuing of national clinical guidance as detailed in their responses. However, as you note in your report, the actions taken by the treating clinician departed from already existing national recommendations, NICE guidelines for administering this procedure and the Trusts own policy. I therefore do not consider there is any further action for the Department of Health and Social Care to take at this time.” 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 Existing national standards and guidance are sufficient to inform local standards for central venous catheter placement.
Verbatim wording from the response “In preparing this response, Departmental officials have made enquiries with the Care Quality Commission (CQC) and the National Institute for Clinical Excellence (NICE). In their published response to your report, NICE cite existing guidance and national safety standards, including: national safety standards for invasive procedures, national CVC Insertion Safety Checklist, as well as guidance on safe vascular access (2016) which recommends the use of ultrasound locating devices for placing CVC’s. The Department understands the guidance on safe vascular access is currently being updated and is due to be published in 2024. These existing standards and guidance should be used to inform local standards developed at the Trust.” Source location Response from Department of Health and Social Care
Open published response
13 Nov 2023 Roger Adrian Stevenson · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 8 Failure to provide continuing care addressing cyclical chronic mental ill health outside periods of crisis View source Lack of steps to address isolation among service users suffering ill health View source Potentially inappropriate housing of vulnerable adults needing care and support View source Failure to clearly record service users' consent to disclosure to family members View source Failure to provide 72-hour follow-up after Emergency Department presentation View source Delays in accessing mental health services and treatment View source Lack of means for mental health practitioners to engage service users' families in treatment support View source Insufficient staffing capacity for mental health treatment View source See 5 more concerns
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AI-generated summary
Roger Adrian Stevenson · 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
Roger Adrian Stevenson was found deceased in supported accommodation on 2 May 2022, having last been known to be alive on 30 April 2022; the medical cause of death was fatal toxic morphine intoxication. The report identified concerns that Roger had become lost to mental health services, including a lack of follow-up, delays in care-coordinator allocation, insufficient continuity between services, and limited long-term support for cyclical mental ill health.
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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 continuing care addressing cyclical chronic mental ill health outside periods of crisis
Wider context from the report “1. That Roger, as a vulnerable adult who had been recognised to be in need of care and support, had been lost in the system (e.g. with a lack of 72 hour follow up in 2021) and may have been inappropriately housed.
2. There was a need for recognition of service users with cyclical chronic mental ill health issues – in this case being that help Roger received tended to be only at the time of crisis thus doing nothing to address long-term underlying chronic conditions .
3. That there was a lack steps taken to address isolation felt by service users suffering ill health where there were likely to be substantial delays in accessing services (such as being allocated a care co-ordinator) and receiving treatment which could lead to further feelings of desperation leading to thoughts of suicide and self-harm.
4. KMPT needed to ensure service users do receive a 72 hour follow up after presenting to an Emergency Department,
” 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 steps to address isolation among service users suffering ill health
Wider context from the report “1. That Roger, as a vulnerable adult who had been recognised to be in need of care and support, had been lost in the system (e.g. with a lack of 72 hour follow up in 2021) and may have been inappropriately housed.
2. There was a need for recognition of service users with cyclical chronic mental ill health issues – in this case being that help Roger received tended to be only at the time of crisis thus doing nothing to address long-term underlying chronic conditions.
3. That there was a lack steps taken to address isolation felt by service users suffering ill health where there were likely to be substantial delays in accessing services (such as being allocated a care co-ordinator) and receiving treatment which could lead to further feelings of desperation leading to thoughts of suicide and self-harm.
4. KMPT needed to ensure service users do receive a 72 hour follow up after presenting to an Emergency Department,
” 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 Potentially inappropriate housing of vulnerable adults needing care and support
Wider context from the report “1. That Roger, as a vulnerable adult who had been recognised to be in need of care and support, had been lost in the system (e.g. with a lack of 72 hour follow up in 2021) and may have been inappropriately housed .
2. There was a need for recognition of service users with cyclical chronic mental ill health issues – in this case being that help Roger received tended to be only at the time of crisis thus doing nothing to address long-term underlying chronic conditions.
3. That there was a lack steps taken to address isolation felt by service users suffering ill health where there were likely to be substantial delays in accessing services (such as being allocated a care co-ordinator) and receiving treatment which could lead to further feelings of desperation leading to thoughts of suicide and self-harm.
4. KMPT needed to ensure service users do receive a 72 hour follow up after presenting to an Emergency Department,
” 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 clearly record service users' consent to disclosure to family members
Wider context from the report “6. That mental health practitioners did not have means by which to engage with the families of service users, effectively recognising such families as an additional resource able to support mental health treatment by monitoring service users and encouraging them to engage with such treatment (and as an adjunct to that a way of noting that where consent has been given by a service user to disclose matters to family members this is clearly noted so that mental health staff are aware of it and can act promptly in so doing ).
” 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 72-hour follow-up after Emergency Department presentation
Wider context from the report “1. That Roger, as a vulnerable adult who had been recognised to be in need of care and support, had been lost in the system (e.g. with a lack of 72 hour follow up in 2021 ) and may have been inappropriately housed.
2. There was a need for recognition of service users with cyclical chronic mental ill health issues – in this case being that help Roger received tended to be only at the time of crisis thus doing nothing to address long-term underlying chronic conditions.
3. That there was a lack steps taken to address isolation felt by service users suffering ill health where there were likely to be substantial delays in accessing services (such as being allocated a care co-ordinator) and receiving treatment which could lead to further feelings of desperation leading to thoughts of suicide and self-harm.
4. KMPT needed to ensure service users do receive a 72 hour follow up after presenting to an Emergency Department ,
” 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 accessing mental health services and treatment
Wider context from the report “1. That Roger, as a vulnerable adult who had been recognised to be in need of care and support, had been lost in the system (e.g. with a lack of 72 hour follow up in 2021) and may have been inappropriately housed.
2. There was a need for recognition of service users with cyclical chronic mental ill health issues – in this case being that help Roger received tended to be only at the time of crisis thus doing nothing to address long-term underlying chronic conditions.
3. That there was a lack steps taken to address isolation felt by service users suffering ill health where there were likely to be substantial delays in accessing services (such as being allocated a care co-ordinator ) and receiving treatment which could lead to further feelings of desperation leading to thoughts of suicide and self-harm.
4. KMPT needed to ensure service users do receive a 72 hour follow up after presenting to an Emergency Department,
” 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 means for mental health practitioners to engage service users' families in treatment support
Wider context from the report “6. That mental health practitioners did not have means by which to engage with the families of service users , effectively recognising such families as an additional resource able to support mental health treatment by monitoring service users and encouraging them to engage with such treatment (and as an adjunct to that a way of noting that where consent has been given by a service user to disclose matters to family members this is clearly noted so that mental health staff are aware of it and can act promptly in so doing).
” 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 staffing capacity for mental health treatment
Wider context from the report “7. That staffing shortages continue to be a major issue in mental health treatment and that although efforts towards recruitment may alleviate this to some extent KMPT adding text to template letters giving a little more information to service users as to when they may expect to be seen is unlikely to be sufficient. Where such text is used though there would be an opportunity of referring to 3rd party agencies from whom additional support can be sought including charities like the Samaritans or emergency numbers (999 and 111).
” 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 Make emergency mental health support available through NHS111 across England.
Verbatim wording from the response “The Government is committed to improving urgent mental health services. We have now made emergency mental health support through NHS111 available everywhere in England. For those with severe needs or in crisis, 24/7 urgent mental health helplines are already available in all areas of the country. These crisis lines currently take around 200,000 calls a month. Linking these through to NHS111 will provide a consistent route for people to access support across the country. Delivering this commitment will enable anyone experiencing a mental health crisis to access assessment and, if appropriate, onward referral and treatment at any time of the day by calling NHS111.” 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 Grow the NHS mental health workforce by an additional 27,000 staff between 2019/20 and 2023/24.
Verbatim wording from the response “With regard to your concerns around staffing shortages, the government is not able to comment on staffing levels locally, as responsibility for the staffing and operations of mental health services lies with the relevant trust. However, we do recognise the wider need to increase capacity in NHS mental health services. Nationally, we are making positive progress on our ambition to grow the mental health workforce by an extra 27,000 staff between 2019/20 and 2023/24. We delivered three quarters of this (around 20,800) by December 2023 with further growth expected to have been achieved once the full year figures for 2023/24 are available.” 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 Expand and transform community mental health services for adults with severe mental illness through the NHS Long Term Plan.
Verbatim wording from the response “We recognise that the demand on NHS mental health services has risen significantly, and this means that some people may face waiting times that are much longer than we would like. Through the NHS Long Term Plan, we are committed to expanding and transforming mental health services in England so that more people can get the help and support that they need. As part of this, we are set to reach nearly £1 billion additional funding invested by 2023/24 (compared to 2018/19) to transform community mental health services for adults with severe mental illness.” Source location 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 is responsible for addressing the report’s concerns about local mental health service issues.
Verbatim wording from the response “I note that you have also addressed matters of concern to the Chief Executive of NHS England, and I would expect her response to address the concerns raised around local issues.” 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 The relevant trust is responsible for local mental health service staffing levels and operations.
Verbatim wording from the response “With regard to your concerns around staffing shortages, the government is not able to comment on staffing levels locally, as responsibility for the staffing and operations of mental health services lies with the relevant trust. However, we do recognise the wider need to increase capacity in NHS mental health services. Nationally, we are making positive progress on our ambition to grow the mental health workforce by an extra 27,000 staff between 2019/20 and 2023/24. We delivered three quarters of this (around 20,800) by December 2023 with further growth expected to have been achieved once the full year figures for 2023/24 are available.” Source location Response from Department of Health and Social Care
Open published response
9 Nov 2023 Christopher Ivan HART · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1 Lack of sufficient ambulance resource in Suffolk 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
Christopher Ivan HART · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher Hart became unwell at home and an ambulance was requested, but no ambulance was immediately available because of high service demand and hospital off-loading delays. He was later found unresponsive and could not be resuscitated; the report states that his cardiac condition caused his death and that the ambulance delay directly contributed to it. The principal concern was continuing and regular ambulance non-availability in Suffolk and the wider East of England region, with insufficient ambulance resources potentially leading to future loss of life.
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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 Lack of sufficient ambulance resource in Suffolk
Wider context from the report “Evidence heard from a Patient Safety Officer from the East of England Ambulance Service identified that, despite previous measures put in place, there are continuing and regular instances of non-availability of ambulances occurring in Suffolk and the wider East of England region.
These periods of non-availability (in this case of over 8 ½ hours) fall far short of the target attendance times set by the East of England Ambulance Trust itself.
Expert evidence from a Consultant Interventional Cardiologist, whose unit treats up to three thousand patients with serious cardiac issues such as Christopher’s each year, identified that had an ambulance for Christopher arrived within the target time, the drugs he could have been given by ambulance personnel, and his early transport to hospital, would on a balance of probabilities have saved his life.
I am therefore concerned that the continuing lack of sufficient ambulance resource in Suffolk will lead to future loss of life.
” Open source report
7 Nov 2023 Gina Marie BYWATER · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1 Lack of sufficient ambulance resource in Suffolk View source
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AI-generated summary
Gina Marie BYWATER · 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
Gina Marie Bywater became unwell with vomiting, shortness of breath and later chest pains, but an ambulance was not available for nearly 10 hours despite repeated 999 calls. She was found in cardiac arrest and subsequently died from a heart attack. The principal concern was the continuing lack of sufficient ambulance resources in Suffolk and the wider East of England, resulting in delays that the report states contributed to her death.
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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 Lack of sufficient ambulance resource in Suffolk
Wider context from the report “Evidence heard from a Patient Safety Officer from the East of England Ambulance Service identified that, despite previous measures put in place, there are continuing and regular instances of non-availability of ambulances occurring in Suffolk and the wider East of England region .
These periods of non-availability (in this case nearly 10 hours) fall far short of the target attendance times set by the East of England Ambulance Trust itself.
Expert evidence from a Consultant Interventional Cardiologist, whose unit treats up to three thousand patients with serious cardiac issues such as Gina’s each year, identified that had an ambulance for Gina arrived within the target time, the drugs she could have been given by ambulance personnel, and her early transport to hospital, would on a balance of probabilities have saved her life.
I am therefore concerned that the continuing lack of sufficient ambulance resource in Suffolk will lead to future loss of life.
” 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 Provide £200 million in additional funding to ambulance trusts to expand capacity and improve response times.
Verbatim wording from the response “Your report highlights that EEAST and local hospitals were experiencing high demand and long handover delays. To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans.” Source location Response from Department of Health and Social Care
Open published response
31 Oct 2023 Evelyn Ann Burcham · Prevention of Future Deaths report Somerset
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Concerns raised 4 Unavailability of riser-recliner chairs with controls that limit unauthorised use View source Failure to assess and mitigate the risk of cognitively impaired residents accessing riser-recliner chair controls View source Health and safety risk from disabling riser-recliner chair controls at the mains View source Risk of death to other residents from cognitively impaired residents operating riser-recliner chair controls View source See 1 more concern
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Evelyn Ann Burcham · 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
Evelyn Ann Burcham, who had dementia and required full care, was tipped from a riser-recliner chair after another resident accessed and operated its remote control while it was unattended. She sustained a severe brain bleed and died ten days later. The principal concern was that the risk of cognitively impaired residents accessing and operating chair controls had not been foreseen, and that the chairs lacked a suitable safety feature to restrict access to the controls.
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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 Unavailability of riser-recliner chairs with controls that limit unauthorised use
Wider context from the report “I am concerned that these chairs are common place in care home settings where residents suffer from cognitive impairment. The risks of another resident with dementia accessing the controls of the riser-recliner chair(s) was not foreseen by the Home and so was not factored into any operative risk assessment at the time; hence no measures were in place to minimise the risk. There remains a real and immediate risk that those with a cognitive impairment that manifests itself in a compulsion to fiddle and/or press buttons, can create a risk of death to other residents in the same care facility or setting. If this particular care home group did not foresee the risk then it is likely that others have not foreseen it either.
I was told at the Home had made enquiries with manufacturers of these standard riser-recliner chairs about the ability to ‘lock’ the remote control and/or find a safe was of storing it so that it is not accessible to anyone who does not have the authority, training or appropriate cognitive function to be able to use it safely. It would appear that a chair with a ‘safe’ remote cannot be purchased by the Home and there do not appear to be any regulatory or manufacturing standards (over and above manufacturing standards for consumers) that require these types of chairs to have this, or some alternative, safety feature that limits the use of the controls. I was told that the only way to render the remote ‘safe’ was to turn the power off at the mains, which in itself could create health and safety issues if the chair needed to be operated quickly.
” 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 assess and mitigate the risk of cognitively impaired residents accessing riser-recliner chair controls
Wider context from the report “I am concerned that these chairs are common place in care home settings where residents suffer from cognitive impairment. The risks of another resident with dementia accessing the controls of the riser-recliner chair(s) was not foreseen by the Home and so was not factored into any operative risk assessment at the time; hence no measures were in place to minimise the risk. There remains a real and immediate risk that those with a cognitive impairment that manifests itself in a compulsion to fiddle and/or press buttons, can create a risk of death to other residents in the same care facility or setting. If this particular care home group did not foresee the risk then it is likely that others have not foreseen it either.
I was told at the Home had made enquiries with manufacturers of these standard riser-recliner chairs about the ability to ‘lock’ the remote control and/or find a safe was of storing it so that it is not accessible to anyone who does not have the authority, training or appropriate cognitive function to be able to use it safely. It would appear that a chair with a ‘safe’ remote cannot be purchased by the Home and there do not appear to be any regulatory or manufacturing standards (over and above manufacturing standards for consumers) that require these types of chairs to have this, or some alternative, safety feature that limits the use of the controls. I was told that the only way to render the remote ‘safe’ was to turn the power off at the mains, which in itself could create health and safety issues if the chair needed to be operated quickly.
” 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 Health and safety risk from disabling riser-recliner chair controls at the mains
Wider context from the report “I am concerned that these chairs are common place in care home settings where residents suffer from cognitive impairment. The risks of another resident with dementia accessing the controls of the riser-recliner chair(s) was not foreseen by the Home and so was not factored into any operative risk assessment at the time; hence no measures were in place to minimise the risk. There remains a real and immediate risk that those with a cognitive impairment that manifests itself in a compulsion to fiddle and/or press buttons, can create a risk of death to other residents in the same care facility or setting. If this particular care home group did not foresee the risk then it is likely that others have not foreseen it either.
I was told at the Home had made enquiries with manufacturers of these standard riser-recliner chairs about the ability to ‘lock’ the remote control and/or find a safe was of storing it so that it is not accessible to anyone who does not have the authority, training or appropriate cognitive function to be able to use it safely. It would appear that a chair with a ‘safe’ remote cannot be purchased by the Home and there do not appear to be any regulatory or manufacturing standards (over and above manufacturing standards for consumers) that require these types of chairs to have this, or some alternative, safety feature that limits the use of the controls. I was told that the only way to render the remote ‘safe’ was to turn the power off at the mains, which in itself could create health and safety issues if the chair needed to be operated quickly.
” 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 Risk of death to other residents from cognitively impaired residents operating riser-recliner chair controls
Wider context from the report “I am concerned that these chairs are common place in care home settings where residents suffer from cognitive impairment. The risks of another resident with dementia accessing the controls of the riser-recliner chair(s) was not foreseen by the Home and so was not factored into any operative risk assessment at the time; hence no measures were in place to minimise the risk. There remains a real and immediate risk that those with a cognitive impairment that manifests itself in a compulsion to fiddle and/or press buttons, can create a risk of death to other residents in the same care facility or setting. If this particular care home group did not foresee the risk then it is likely that others have not foreseen it either.
I was told at the Home had made enquiries with manufacturers of these standard riser-recliner chairs about the ability to ‘lock’ the remote control and/or find a safe was of storing it so that it is not accessible to anyone who does not have the authority, training or appropriate cognitive function to be able to use it safely. It would appear that a chair with a ‘safe’ remote cannot be purchased by the Home and there do not appear to be any regulatory or manufacturing standards (over and above manufacturing standards for consumers) that require these types of chairs to have this, or some alternative, safety feature that limits the use of the controls. I was told that the only way to render the remote ‘safe’ was to turn the power off at the mains, which in itself could create health and safety issues if the chair needed to be operated quickly.
” 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 CQC cannot take further enforcement action because there is insufficient evidence linking the incident directly to a registered person.
Verbatim wording from the response “investigator from CQC’s national enforcement team; investigations are now complete, and it has been adjudged that CQC has no basis to take further action as there is insufficient evidence linking this directly to a registered person. The family were made aware of the outcome of CQC’s decision and CQC will continue to monitor the provider.” Source location Response from Department of Health and Social Care
Open published response
27 Oct 2023 Gerald Roy Cruse · Prevention of Future Deaths report Avon
View report summary
Concerns raised 7 Insufficient specialist medical capacity for timely and proactive care of older hospital patients View source Inadequate ambulance staff training in recognising and dealing with patients who have fallen View source Failure of ambulance staff to recognise falls risk and initiate further action View source Failure to identify and apply learning from falls-related incidents View source Failure to complete falls risk assessments in accordance with JRCALC guidelines View source Lack of clear guidelines for holistic management of older hospital patients View source Hospital falls causing fatal injuries View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Gerald Roy Cruse · 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
Gerald Cruse fell from a bed while being assisted to use the toilet in an ambulance cohort area after admission following a fall at home. He sustained multiple rib fractures, a haemopneumothorax and surgical emphysema, later developed pneumonia, and died in hospital. Concerns included inadequate falls-risk assessment and recognition by ambulance staff, a lack of identified learning after investigation, and wider concerns about the organisation of care for older patients requiring both surgical and geriatric medical input.
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 Insufficient specialist medical capacity for timely and proactive care of older hospital patients
Wider context from the report “(1) That over 75% of patients receiving hospital care are 65 and over. There is a conflict and tension between where within the hospital those patients should be receiving their care. A proportion of these patients require admission to a surgical ward due to the elements of their care which require surgical oversight and management, for example, analgesia through an epidural, insertion of a chest drain. However, this group of patients have multiple co-morbidities and complexities due to their age, which would be better managed by a medical team specialising in care of the elderly. Whilst medical teams can review patients, their limited resources mean it may not be as quickly as it needs to be, and they cannot be proactive in following up on the care of these patients. This results in an increasing risk that these patients will not receive the care they need in a timely manner. There is an increasing need for more doctors specialising in the care of older persons and this is a national issue.
” 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 Inadequate ambulance staff training in recognising and dealing with patients who have fallen
Wider context from the report “(6) An investigation took place but the staff did not identify any learning and did not undertake the case study to help them identify such patients in the future. Bristol Ambulance Emergency Medical Services still run some cohort areas alongside South Western Ambulance NHS Foundation Trust, and continue to convey patients to hospital. The evidence given on behalf of this organisation did not provide reassurance that this is a matter which the ambulance service have adequately addressed. There is a real concern that ambulance staff throughout the organisation may not be adequately trained in recognising and dealing with patients who have had a fall or falls.
” 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 ambulance staff to recognise falls risk and initiate further action
Wider context from the report “(5) The other two ambulance staff did not seem to understand that Mr Cruse was a falls risk , they did not consider that he was at a greater risk of falls and did not consider that any further action should have been considered or 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 Failure to identify and apply learning from falls-related incidents
Wider context from the report “(6) An investigation took place but the staff did not identify any learning and did not undertake the case study to help them identify such patients in the future . Bristol Ambulance Emergency Medical Services still run some cohort areas alongside South Western Ambulance NHS Foundation Trust, and continue to convey patients to hospital. The evidence given on behalf of this organisation did not provide reassurance that this is a matter which the ambulance service have adequately addressed. There is a real concern that ambulance staff throughout the organisation may not be adequately trained in recognising and dealing with patients who have had a fall or falls.
” 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 falls risk assessments in accordance with JRCALC guidelines
Wider context from the report “(4) The paramedic working within the cohort area did not complete a falls risk assessment in accordance with the JRCALC guidelines following the admission of a patient who had just had a fall at home.
” 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 clear guidelines for holistic management of older hospital patients
Wider context from the report “(2) There are currently no clear guidelines as to how these patients should best be managed and there remains a serious risk that the care they receive is not holistic .
” 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 Hospital falls causing fatal injuries
Wider context from the report “(3) Patients falling in hospitals and sustaining injuries which lead to their death remains a matter of grave concern.
” Open source report
20 Oct 2023 Thomas Doyle · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Poor standard of clinical records View source Failure to commence a diagnostic pathway for suspected sepsis when indicated 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
Thomas Doyle · 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
Thomas Doyle, a 90-year-old man, was admitted to hospital with back and chest pain and subsequently developed sepsis while in hospital, dying on 25 January 2023. The concerns included poor clinical records and failure to commence the diagnostic pathway for sepsis when indicated on admission, contrary to local policy and national guidance.
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 Poor standard of clinical records
Wider context from the report “1. The trust’s clinical records were of a particularly poor standard which impeded the Trust’s governance investigation and the inquest investigation in determining what, if any considerations was given to the possibility that Mr Doyle was suffering from an infection.
” 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 commence a diagnostic pathway for suspected sepsis when indicated
Wider context from the report “2. The Trust’s failure to commence a diagnostic pathway to investigate sepsis when clearly indicated on Mr Doyle’s admission , as required by both local policy and national guidance.
” Open source report
Concerns raised 7 Failure to identify the need for genetic testing before the Pathology report View source Chronic shortage of Paediatric Pathologists View source Limited use of molecular autopsy after sudden death in childhood View source Failure of the SUDIC Protocol to reflect the development of molecular autopsy View source Limited use of molecular autopsy to detect familial genetic variants View source Insufficient time for timely Coronial and Forensic Paediatric Pathology work View source Delays in Paediatric Pathology reports View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Tyler Jay Ryan · 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
Tyler Jay Ryan, aged 11, was found collapsed in his bedroom on 12 February 2021 and died after resuscitation attempts. Genetic testing identified two RYR2 variants associated with CPVT, following earlier differing pathological opinions. The report raised concerns about delays in paediatric pathology reporting and the delayed identification of families who may need genetic testing, as well as the need for wider use of molecular autopsy and revision of the SUDIC Protocol.
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 identify the need for genetic testing before the Pathology report
Wider context from the report “2. The delay in Paediatric Pathology Reports results in the delayed detection of the need for genetic testing amongst surviving siblings of children who die of Sudden Death in Childhood. Currently, it is not until the Pathologist provides a report that the need for genetic testing is identified . Reports can take up to two years to be filed.
” 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 Chronic shortage of Paediatric Pathologists
Wider context from the report “1. ████████ and ████████ each gave evidence that the delay in Paediatric Pathology reports is due to a chronic shortage in recruitment and retention of Paediatric Pathologists in the UK . This shortage is systemic. Currently only 50 out of 80 national vacancies for Paediatric Pathologists are filled . Coronial and Forensic work is undertaken by these Pathologists on a private basis, in addition to their NHS work. This provides insufficient time to carry out this work in a timely fashion. There is an acute shortage of Subspeciality Paediatric Pathologists, with just one Paediatric Orthopedic Pathologist undertaking Forensic and Coronial work in the UK .
” 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 Limited use of molecular autopsy after sudden death in childhood
Wider context from the report “3. ████████ and ████████ gave evidence that more widespread use of molecular autopsy would assist in detecting genetic abnormalities in children who have died suddenly , leading to greater opportunities to prevent future deaths within their families and in other families.
” 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 the SUDIC Protocol to reflect the development of molecular autopsy
Wider context from the report “5. ████████ gave evidence that the development of the use of molecular autopsy calls for a revision of the SUDIC Protocol also known as the Kennedy Protocol .
” 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 Limited use of molecular autopsy to detect familial genetic variants
Wider context from the report “4. ████████, Consultant Clinical Geneticist gave evidence that Tyler is, to date, the only human in history to have been found to have these two RYR2 variants which is significant to his family and to the wider scientific community. Greater use of molecular autopsy would save lives within families and in other families . The detection of these variants is directly relevant to others and the prevention of future deaths .
” 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 time for timely Coronial and Forensic Paediatric Pathology work
Wider context from the report “1. ████████ and ████████ each gave evidence that the delay in Paediatric Pathology reports is due to a chronic shortage in recruitment and retention of Paediatric Pathologists in the UK. This shortage is systemic. Currently only 50 out of 80 national vacancies for Paediatric Pathologists are filled. Coronial and Forensic work is undertaken by these Pathologists on a private basis, in addition to their NHS work . This provides insufficient time to carry out this work in a timely fashion . There is an acute shortage of Subspeciality Paediatric Pathologists, with just one Paediatric Orthopedic Pathologist undertaking Forensic and Coronial work in the UK.
” 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 Paediatric Pathology reports
Wider context from the report “2. The delay in Paediatric Pathology Reports results in the delayed detection of the need for genetic testing amongst surviving siblings of children who die of Sudden Death in Childhood . Currently, it is not until the Pathologist provides a report that the need for genetic testing is identified. Reports can take up to two years to be filed .
” Open source report
17 Oct 2023 Marnie Emma Hill · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 5 Lack of rules governing counsellors’ operation and record keeping View source Lack of requirements for counsellors to inform medical professionals or other appropriate support providers View source Lack of regulation and licensing of the counselling profession View source Lack of requirements for counsellors to report disclosed risks of self-harm, suicide or harm to others View source Lack of requirements for counsellors’ further training and continual professional development View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Marnie Emma Hill · 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
Marnie Emma Hill was found collapsed and unresponsive on a bed at a property where she was temporarily residing on 15 May 2022. The report raised concerns that the lack of regulation of counselling could lead to future deaths, including because counsellors are not required to report risks or share records with healthcare professionals.
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 rules governing counsellors’ operation and record keeping
Wider context from the report “1. During the inquest evidence was heard that:
i. There is no regulation of counsellors in England and Wales and this could lead to future deaths.
ii. ████████ is a private counsellor with 30 years’ experience who provided support to Marnie prior to her death. She confirmed that counselling is not a regulated professional and there are courses available at a cost of £29 for a 6 week course, after which a person can receive a diploma and call themselves a counsellor. There is no requirement for them to do further training or continual professional development. There are no rules or regulations about how counsellors should operate, for example how they keep and share records .
iii. Information shared by an individual to a counsellor may disclose a risk of self harm or suicide, or harm to another and there is no requirement for a counsellor to report that information to any third party.
iv. ████████ ████████ gave evidence that the lack of regulation and licensing of counsellors could lead to a lot of damage being done to individuals seeking help and that this could present a risk to life as there is no regulation around informing medical professionals or others who can provided further support and care to the individual.
v. Evidence was also given by ████████, one of the GPs who provided care to Marnie, that receipt of records from others such as counsellors, especially at the end of the counselling, would assist her in providing care to patients.
2. I have concerns with regard to the following:
i. There is a risk of future deaths occurring due to the lack of regulation of the counselling profession.
” 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 requirements for counsellors to inform medical professionals or other appropriate support providers
Wider context from the report “1. During the inquest evidence was heard that:
i. There is no regulation of counsellors in England and Wales and this could lead to future deaths.
ii. ████████ is a private counsellor with 30 years’ experience who provided support to Marnie prior to her death. She confirmed that counselling is not a regulated professional and there are courses available at a cost of £29 for a 6 week course, after which a person can receive a diploma and call themselves a counsellor. There is no requirement for them to do further training or continual professional development. There are no rules or regulations about how counsellors should operate, for example how they keep and share records.
iii. Information shared by an individual to a counsellor may disclose a risk of self harm or suicide, or harm to another and there is no requirement for a counsellor to report that information to any third party.
iv. ████████ ████████ gave evidence that the lack of regulation and licensing of counsellors could lead to a lot of damage being done to individuals seeking help and that this could present a risk to life as there is no regulation around informing medical professionals or others who can provided further support and care to the individual .
v. Evidence was also given by ████████, one of the GPs who provided care to Marnie, that receipt of records from others such as counsellors, especially at the end of the counselling, would assist her in providing care to patients.
2. I have concerns with regard to the following:
i. There is a risk of future deaths occurring due to the lack of regulation of the counselling profession.
” 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 regulation and licensing of the counselling profession
Wider context from the report “1. During the inquest evidence was heard that:
i. There is no regulation of counsellors in England and Wales and this could lead to future deaths.
ii. ████████ is a private counsellor with 30 years’ experience who provided support to Marnie prior to her death. She confirmed that counselling is not a regulated professional and there are courses available at a cost of £29 for a 6 week course, after which a person can receive a diploma and call themselves a counsellor. There is no requirement for them to do further training or continual professional development. There are no rules or regulations about how counsellors should operate, for example how they keep and share records.
iii. Information shared by an individual to a counsellor may disclose a risk of self harm or suicide, or harm to another and there is no requirement for a counsellor to report that information to any third party.
iv. ████████ ████████ gave evidence that the lack of regulation and licensing of counsellors could lead to a lot of damage being done to individuals seeking help and that this could present a risk to life as there is no regulation around informing medical professionals or others who can provided further support and care to the individual.
v. Evidence was also given by ████████, one of the GPs who provided care to Marnie, that receipt of records from others such as counsellors, especially at the end of the counselling, would assist her in providing care to patients.
2. I have concerns with regard to the following:
i. There is a risk of future deaths occurring due to the lack of regulation of the counselling profession .
” 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 requirements for counsellors to report disclosed risks of self-harm, suicide or harm to others
Wider context from the report “1. During the inquest evidence was heard that:
i. There is no regulation of counsellors in England and Wales and this could lead to future deaths.
ii. ████████ is a private counsellor with 30 years’ experience who provided support to Marnie prior to her death. She confirmed that counselling is not a regulated professional and there are courses available at a cost of £29 for a 6 week course, after which a person can receive a diploma and call themselves a counsellor. There is no requirement for them to do further training or continual professional development. There are no rules or regulations about how counsellors should operate, for example how they keep and share records.
iii. Information shared by an individual to a counsellor may disclose a risk of self harm or suicide, or harm to another and there is no requirement for a counsellor to report that information to any third party .
iv. ████████ ████████ gave evidence that the lack of regulation and licensing of counsellors could lead to a lot of damage being done to individuals seeking help and that this could present a risk to life as there is no regulation around informing medical professionals or others who can provided further support and care to the individual.
v. Evidence was also given by ████████, one of the GPs who provided care to Marnie, that receipt of records from others such as counsellors, especially at the end of the counselling, would assist her in providing care to patients.
2. I have concerns with regard to the following:
i. There is a risk of future deaths occurring due to the lack of regulation of the counselling profession.
” 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 requirements for counsellors’ further training and continual professional development
Wider context from the report “1. During the inquest evidence was heard that:
i. There is no regulation of counsellors in England and Wales and this could lead to future deaths.
ii. ████████ is a private counsellor with 30 years’ experience who provided support to Marnie prior to her death. She confirmed that counselling is not a regulated professional and there are courses available at a cost of £29 for a 6 week course, after which a person can receive a diploma and call themselves a counsellor. There is no requirement for them to do further training or continual professional development . There are no rules or regulations about how counsellors should operate, for example how they keep and share records.
iii. Information shared by an individual to a counsellor may disclose a risk of self harm or suicide, or harm to another and there is no requirement for a counsellor to report that information to any third party.
iv. ████████ ████████ gave evidence that the lack of regulation and licensing of counsellors could lead to a lot of damage being done to individuals seeking help and that this could present a risk to life as there is no regulation around informing medical professionals or others who can provided further support and care to the individual.
v. Evidence was also given by ████████, one of the GPs who provided care to Marnie, that receipt of records from others such as counsellors, especially at the end of the counselling, would assist her in providing care to patients.
2. I have concerns with regard to the following:
i. There is a risk of future deaths occurring due to the lack of regulation of the counselling profession.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a public consultation on criteria for deciding when statutory regulation of healthcare professions is appropriate.
Verbatim wording from the response “Between 6 January 2022 and 31 March 2022 the Department of Health and Social Care, on behalf of the UK Government and the devolved administrations, ran a public consultation seeking views on the criteria for determining when statutory regulation of a healthcare profession is appropriate. Further information about this consultation is available at:
https://www.gov.uk/government/consultations/healthcare-regulation-deciding-when-statutory-regulation-is-appropriate” 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 Keep professions subject to statutory regulation under review to assess whether regulatory oversight remains proportionate to public risk.
Verbatim wording from the response “The Government keeps the professions subject to statutory regulation under review. Bringing a profession into statutory regulation is a lengthy and costly legal process. It is restrictive by its very nature and can act as a barrier to entry and inhibit the flexibility of a profession to grow and develop to meet patient needs. Other important considerations that need to be addressed before bringing a profession into regulation including the impact on the profession, which body should regulate and the geographical extent of regulation across the UK. Failure to undertake this work before legislating to regulate a profession could lead to unintended consequences that run counter to public protection.” 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 Training standards and practice requirements set by independent counselling organisations are outside Government oversight.
Verbatim wording from the response “All of the organisations utilising the SCoPEd framework are independent, representative bodies for the practice of counselling and psychotherapy. As such, they do not fall under Government oversight and therefore any decisions about the training standards and practice requirements for the professions they represent are a matter for those organisations and their members.” 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 safeguards, including accredited voluntary registers and employer checks, support patient safety for people using counselling services.
Verbatim wording from the response “People should be able to expect good quality psychotherapy or counselling services, which bring about a positive impact on their mental health and recovery. Although counsellors are not subject to statutory regulation, there are other safeguards in place to support patient safety for people using counselling services.” 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 There is no immediate case to change which professions are subject to statutory regulation.
Verbatim wording from the response “While we believe that there is no immediate case to change the groups that are regulated, the consultation asked for views on how the powers to introduce and remove professions from regulation might be used in the future and:” 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 Independent counselling organisations and their members are responsible for decisions about training standards and practice requirements.
Verbatim wording from the response “All of the organisations utilising the SCoPEd framework are independent, representative bodies for the practice of counselling and psychotherapy. As such, they do not fall under Government oversight and therefore any decisions about the training standards and practice requirements for the professions they represent are a matter for those organisations and their members.” Source location Response from Department of Health and Social Care
Open published response
16 Oct 2023 Claire Twinn · Prevention of Future Deaths report East London
View report summary
Concerns raised 5 Failure to make reasonable adjustments for communication and impaired respiratory function when making clinical decisions View source Failure to record clear safety-netting advice to carers View source Delays in reporting radiological chest x-rays View source Lack of specialised learning disability nursing input to facilitate clear communication View source Failure to record discharge and non-admission decisions concerning oxygen monitoring and remedial oxygen therapy View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Claire Twinn · 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
Claire Twinn, a 47-year-old woman with Down’s syndrome, severe learning disability, and complex heart and lung conditions, became unwell and attended hospital with low oxygen saturations and symptoms including cough, sickness, and diarrhoea. She was diagnosed with suspected bilateral pneumonia, discharged on oral antibiotics, and found deceased by her family the following morning. The principal concerns were that she was discharged rather than admitted for monitoring and oxygen therapy, reasonable adjustments and specialised learning disability nursing input were not provided, safety-netting advice was not recorded, and the chest X-ray report was delayed.
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 make reasonable adjustments for communication and impaired respiratory function when making clinical decisions
Wider context from the report “1. Ms Twinn’s disability played a role in the provision of sub-optimal care, reasonable adjustment was not made for; her inability to communicate clearly and her impaired respiratory function when arriving at clinical decisions .
” 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 record clear safety-netting advice to carers
Wider context from the report “2. Neither the trust decision to discharge Ms Twinn and not admit for continued monitoring of oxygen levels and remedial oxygen therapy, nor clear safety-netting advice to carers was recorded in the clinical record .
” 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 reporting radiological chest x-rays
Wider context from the report “4. A radiological report of the chest x-ray taken on 15th December 2023 was not reported until 25th December 2023 .
” 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 specialised learning disability nursing input to facilitate clear communication
Wider context from the report “3. Ms Twinn’s treatment did not involve any specialised learning disability nursing input to facilitate clear communication with Ms Twinn.
” 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 record discharge and non-admission decisions concerning oxygen monitoring and remedial oxygen therapy
Wider context from the report “2. Neither the trust decision to discharge Ms Twinn and not admit for continued monitoring of oxygen levels and remedial oxygen therapy , nor clear safety-netting advice to carers was recorded in the clinical record .
” 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 Roll out Oliver McGowan mandatory learning disability and autism training for health and care staff.
Verbatim wording from the response “Introducing mandatory training is an important way in which we can address persistent disparities in health and care outcomes for people with a learning disability and autistic people by ensuring that the health and care workforce have the right knowledge and skills, including appropriate communication. That is why, from 1 July 2022, CQC registered service providers are required to ensure their staff receive learning disability and autism training appropriate to their role, as set out in the Health and Care Act 2022.” Source location Response from Department of Health and Social Care
Open published response
13 Oct 2023 Peter Carr · Prevention of Future Deaths report North London
View report summary
Concerns raised 3 Lack of ongoing consultant dermatology oversight during inpatient stays View source Lack of biopsy within 24 hours for acute severe skin conditions View source Lack of consultant dermatology input within 24 hours for acute severe skin conditions 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
Peter Carr · 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
Peter Carr developed a severe rash and was admitted to North Middlesex Hospital, where he was later found to have a drug reaction consistent with Stevens-Johnson Syndrome. The principal concern was that patients with acute, severe skin conditions may not receive consultant dermatology input, timely biopsy, and ongoing dermatological oversight during an inpatient stay.
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 ongoing consultant dermatology oversight during inpatient stays
Wider context from the report “That patients who contact medical services with acute, severe, skin conditions as primary presentations, or as a component of a complex presentation, may not have consultant dermatology input and biopsy within 24 hours and ongoing consultant dermatology oversight for the duration of an inpatient stay .
” 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 biopsy within 24 hours for acute severe skin conditions
Wider context from the report “That patients who contact medical services with acute, severe, skin conditions as primary presentations, or as a component of a complex presentation, may not have consultant dermatology input and biopsy within 24 hours and ongoing consultant dermatology oversight for the duration of an inpatient stay.
” 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 consultant dermatology input within 24 hours for acute severe skin conditions
Wider context from the report “That patients who contact medical services with acute, severe, skin conditions as primary presentations, or as a component of a complex presentation, may not have consultant dermatology input and biopsy within 24 hours and ongoing consultant dermatology oversight for the duration of an inpatient stay.
” Open source report
Concerns raised 5 Excessive waiting times for NHS mental health services View source Failure to refer students to NHS mental health services when they are receiving other support View source Unclear allocation of school-procured psychology support View source Lack of a clear process for receiving outputs from support services View source Lack of a clear process for referring students to support services View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alex Dews · 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 Dews went to a bridge at Dearne Valley Country Park on 14 July 2022, fell into shallow water, and died at Sheffield Children’s Hospital on 18 July 2022. The report raises concerns about school documentation and assessment processes, barriers to referral to NHS mental health services, unclear allocation of school-procured psychology support, and inadequate communication with the support provider.
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 Excessive waiting times for NHS mental health services
Wider context from the report “1. Alex was not referred by school to NHS mental health services as a result of their experience that if Alex was in receipt of any other support he would not be accepted onto the waiting list (which would be in excess of 10 months to be seen) .
” 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 refer students to NHS mental health services when they are receiving other support
Wider context from the report “1. Alex was not referred by school to NHS mental health services as a result of their experience that if Alex was in receipt of any other support he would not be accepted onto the waiting list (which would be in excess of 10 months to be seen).
” 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 Unclear allocation of school-procured psychology support
Wider context from the report “2. The school chose to provide Alex with school procured psychology support however the process of allocation of provision was not clear .
” 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 clear process for receiving outputs from support services
Wider context from the report “3. The school did not have a clear communication process with the provider of support to either refer the student into services or to receive outputs from those services once the student completed their sessions
” 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 clear process for referring students to support services
Wider context from the report “3. The school did not have a clear communication process with the provider of support to either refer the student into services or to receive outputs from those services once the student completed their sessions
” 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 expanding and transforming NHS mental health care for children and young people.
Verbatim wording from the response “More generally, we are aware that some children and young people are not able to access support they need in a timely manner. Through the NHS Long Term Plan, we are continuing to expand and transform NHS mental health care and spend on children and young people’s mental health services has increased from £841 million in 2019/20 to just over £1 billion in 2022/23.” Source location Response from Department of Health and Social Care
Open published response
5 Oct 2023 Iris Elaine Fordham · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Culture of indifference to safe and effective practice View source Failure of clinical staff to read essential parts of the clinical record when providing care View source Failure to address individual care failings through disciplinary or regulatory channels View source Failure to complete falls care plans View source Poor quality of clinical record keeping View source Failure to complete falls risk assessments View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Iris Elaine Fordham · 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
Iris Elaine Fordham was admitted to hospital after an unwitnessed fall and concerns about her ability to keep herself safe due to Alzheimer’s disease. Failures to complete a falls risk assessment, falls care plan and enhanced care assessment led to the removal of 1:1 care, after which she sustained a fractured neck of femur in a further unwitnessed fall. She underwent surgical repair and died in a step-down care centre; concerns included poor clinical record-keeping, failures in falls-risk management and the absence of action through disciplinary or regulatory channels.
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 Culture of indifference to safe and effective practice
Wider context from the report “4. The fact that the failures at (2) & (3) were not detected and remediated by successive clinical staff members suggests that they did not read essential parts of the clinical record when providing care. The cumulative failings, on the part of multiple healthcare professionals suggests a culture of indifference inimical to the provision of safe and effective practice.
” 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 clinical staff to read essential parts of the clinical record when providing care
Wider context from the report “4. The fact that the failures at (2) & (3) were not detected and remediated by successive clinical staff members suggests that they did not read essential parts of the clinical record when providing care . The cumulative failings, on the part of multiple healthcare professionals suggests a culture of indifference inimical to the provision of safe and effective practice.
” 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 address individual care failings through disciplinary or regulatory channels
Wider context from the report “5. The Trust has not considered any step to resolve individual failings in care through disciplinary or regulatory channels .
” 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 falls care plans
Wider context from the report “3. The consequence of (2) was that no falls care plan was completed .
” 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 Poor quality of clinical record keeping
Wider context from the report “1. The poor quality of recording clinical records impeded the Trust's governance processes, in that the author of a serious incident investigation was unable to rely on clear evidence to understand why essential actions were not carried out in Ms Fordham's care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to complete falls risk assessments
Wider context from the report “2. The Trust failed to complete a falls risk assessment of Ms Fordham.
” Open source report
29 Sep 2023 John Trevor WINSWORTH · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 3 Delays in admission to Accident and Emergency Department View source Delays in ambulance response to calls View source Continuing delays in ambulance attendance to calls View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Trevor WINSWORTH · 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 Trevor Winsworth, aged 92, was found on the floor at his home on 14 February 2023 and later died in hospital on 21 February 2023 after a traumatic intracranial bleed following a fall. The report raises concerns about delays in ambulance attendance, delays in admission to the Accident and Emergency Department, and continuing delays by the ambulance service in responding to calls.
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 admission to Accident and Emergency Department
Wider context from the report “2. The ambulance arrived at the Norfolk and Norwich University Hospital at 10.52 hours and Mr Winsworth was not able to be admitted to Accident and Emergency Department until 14.42 hours; over 3 hours following admission, due to pressure on the hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance response to calls
Wider context from the report “1. The ambulance service was called at 11.55 hours on 14 February 2023 and the call was graded as a Category 3 call, requiring a response within 2 hours. The ambulance arrived at 09.30 hours on 15 February 2023. The time between calling the ambulance and the ambulance arriving on scene was in excess of 19 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 Continuing delays in ambulance attendance to calls
Wider context from the report “3. Considerable delays in attendance by EAST (East of England Ambulance Service Trust) to calls continues.
” 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 Maintain the increased staffed, permanent hospital bed capacity in 2024/25.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” 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 Scale up virtual ward capacity beyond 10,000 beds, with over 11,000 beds available nationally.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” 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 Publish the delivery plan for recovering urgent and emergency care services.
Verbatim wording from the response “As the Minister responsible for urgent and emergency care services, I recognise the significant pressure the urgent and emergency care system is facing. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes across this fiscal year. The plan is available at https://www.england.nhs.uk/wp-content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf.” 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 Deliver 5,000 more staffed, permanent hospital beds than planned for 2022/23.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” 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 working with NHS England to reduce ambulance response times.
Verbatim wording from the response “However, I recognise there is still more to do to reduce response times further, and the Government will continue to work with NHS England to achieve this.” 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 Deliver new ambulances and specialist mental health vehicles.
Verbatim wording from the response “Your report highlights that EEAST were under high demand at the time of the incident. Alongside the local actions outlined above, a primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” 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 £1.6 billion over two years to support timely and effective hospital discharge.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” 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 additional ambulance funding to expand capacity and improve response times, maintaining the additional capacity in 2024/25.
Verbatim wording from the response “Your report highlights that EEAST were under high demand at the time of the incident. Alongside the local actions outlined above, a primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” Source location Response from Department of Health and Social Care
Open published response
29 Sep 2023 Frederick William LE GRICE · Prevention of Future Deaths report Essex
View report summary
Concerns raised 3 Lack of awareness among patients and clinicians of Nitrofurantoin lung-damage risk View source Risk of Nitrofurantoin-induced lung damage View source Failure to provide clear and effective guidance on Nitrofurantoin lung-damage warning symptoms View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Frederick William LE GRICE · 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
Frederick William LE GRICE had prostate problems and recurrent urinary tract infections treated with nitrofurantoin. After taking the drug for several years, he developed coughing, breathlessness and interstitial lung disease; he later died from pneumonia, with interstitial lung disease and nitrofurantoin toxicity contributing. The concerns relate to limited awareness and unclear guidance for clinicians and patients about nitrofurantoin-associated lung damage and the need to recognise and monitor respiratory symptoms.
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 awareness among patients and clinicians of Nitrofurantoin lung-damage risk
Wider context from the report “(1) There is a known albeit rare side effect of Nitrofurantoin, of it causing lung damage. Nevertheless, neither the deceased himself, nor the clinicians involved in the deceased’s urinary care, who due to its specialism also have a prescribing function, were aware of the risk of lung damage from Nitrofurantoin.
(2) It is not very clear in the guidance to general practitioners or patients generally, that the patient and the treating clinicians should be particularly alert to any signs of coughing or breathlessness, and that if they are present, it may well suggest that Nitrofurantoin is causing damage to the patient’s lungs. Such damage is likely to be irreversible.
(3) I am concerned as to the effectiveness of the guidance and information available:
(i) to general practitioners and prescribers treating those using urinary catheters and/or suffering from urinary tract infections;
(ii) clinical staff in urology care;
(iii) patients themselves
Of the danger that Nitrofurantoin might cause lung damage, and (a) the need for all to be particularly vigilant as to symptoms and signs such as coughing or difficulty in breathing, and the desirability of their breathing and respiratory abilities being regularly monitored when a patient is using Nitrofurantoin (b) produce leaflets/information resources to that effect.
” 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 Risk of Nitrofurantoin-induced lung damage
Wider context from the report “(1) There is a known albeit rare side effect of Nitrofurantoin, of it causing lung damage. Nevertheless, neither the deceased himself, nor the clinicians involved in the deceased’s urinary care, who due to its specialism also have a prescribing function, were aware of the risk of lung damage from Nitrofurantoin.
(2) It is not very clear in the guidance to general practitioners or patients generally, that the patient and the treating clinicians should be particularly alert to any signs of coughing or breathlessness, and that if they are present, it may well suggest that Nitrofurantoin is causing damage to the patient’s lungs. Such damage is likely to be irreversible.
(3) I am concerned as to the effectiveness of the guidance and information available:
(i) to general practitioners and prescribers treating those using urinary catheters and/or suffering from urinary tract infections;
(ii) clinical staff in urology care;
(iii) patients themselves
Of the danger that Nitrofurantoin might cause lung damage, and (a) the need for all to be particularly vigilant as to symptoms and signs such as coughing or difficulty in breathing, and the desirability of their breathing and respiratory abilities being regularly monitored when a patient is using Nitrofurantoin (b) produce leaflets/information resources to that effect.
” 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 clear and effective guidance on Nitrofurantoin lung-damage warning symptoms
Wider context from the report “(1) There is a known albeit rare side effect of Nitrofurantoin, of it causing lung damage. Nevertheless, neither the deceased himself, nor the clinicians involved in the deceased’s urinary care, who due to its specialism also have a prescribing function, were aware of the risk of lung damage from Nitrofurantoin.
(2) It is not very clear in the guidance to general practitioners or patients generally, that the patient and the treating clinicians should be particularly alert to any signs of coughing or breathlessness, and that if they are present, it may well suggest that Nitrofurantoin is causing damage to the patient’s lungs. Such damage is likely to be irreversible.
(3) I am concerned as to the effectiveness of the guidance and information available:
(i) to general practitioners and prescribers treating those using urinary catheters and/or suffering from urinary tract infections;
(ii) clinical staff in urology care;
(iii) patients themselves
Of the danger that Nitrofurantoin might cause lung damage, and (a) the need for all to be particularly vigilant as to symptoms and signs such as coughing or difficulty in breathing , and the desirability of their breathing and respiratory abilities being regularly monitored when a patient is using Nitrofurantoin (b) produce leaflets/information resources to that effect.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The MHRA does not regulate additional prescribing advice sources, including NICE guidelines or local guidance.
Verbatim wording from the response “The MHRA is an Executive Agency of the Department of Health and Social Care (DHSC) with responsibility for the regulation of medicinal products in the UK. The MHRA ensures that medicines are efficacious and acceptably safe, and that any possible side effects which have been recognised to occur with use of a medicine are appropriately described in the authorised product information. This comprises the Summary of Product Characteristics (SmPC, intended for healthcare professionals), labelling, and Patient Information Leaflet (PIL, provided to patients in each medicine pack). The MHRA does not regulate any additional sources of advice healthcare professionals may use when prescribing medicines, such as NICE (National Institute for Health and Care Excellence) guidelines or any local guidance.” Source location Response from Department of Health and Social Care
Open published response
28 Sep 2023 Scott James DONOGHUE · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 2 Lack of consistency and continuity among care staff View source Inadequacy of HBTT treatment as an alternative to hospital admission 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 James DONOGHUE · 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 James DONOGHUE had a history of anxiety and depression, previous suicide attempts, and was receiving support from the Home Based Treatment Team after attending the Humber Bridge intending to end his life. He died by hanging himself at home on 24 May 2022. The principal concerns were the lack of continuity among staff overseeing his care and the adequacy of the Home Based Treatment Team as an alternative to hospital admission.
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 consistency and continuity among care staff
Wider context from the report “(1) It was evident that the lack of consistency in staff dealing with Mr Donoghue’s care was a factor in his ability to engage and be honest with those having oversight of him at a very fragile time in his treatment.
(2) Evidence was heard that the HBTT system is an inadequate treatment as an alternative to hospital admission and although peoples’ care in HBTT had improved, a real continuity of staff could only occur with a substantive change which would include additional funding, recruitment of appropriate staff and an ability to retain staff. I was informed that if these issues were addressed it would allow more capacity to manage consistency alongside the other demands of the service.
(3) It is worthy of note that this is the 2nd inquest heard within 3 weeks in this jurisdiction whereby inconsistency of care staff has been cited as an issue in a suicide . The other inquest was the death of a 20 year old woman.
” 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 Inadequacy of HBTT treatment as an alternative to hospital admission
Wider context from the report “(1) It was evident that the lack of consistency in staff dealing with Mr Donoghue’s care was a factor in his ability to engage and be honest with those having oversight of him at a very fragile time in his treatment.
(2) Evidence was heard that the HBTT system is an inadequate treatment as an alternative to hospital admission and although peoples’ care in HBTT had improved, a real continuity of staff could only occur with a substantive change which would include additional funding, recruitment of appropriate staff and an ability to retain staff. I was informed that if these issues were addressed it would allow more capacity to manage consistency alongside the other demands of the service.
(3) It is worthy of note that this is the 2nd inquest heard within 3 weeks in this jurisdiction whereby inconsistency of care staff has been cited as an issue in a suicide. The other inquest was the death of a 20 year old woman.
” 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 Invest in recruiting and retaining additional mental health workers.
Verbatim wording from the response “The Government is also investing in the recruitment and retention of more mental health workers. As of December 2023, there were 148,951 full time equivalents, which is 33,402 more than December 2019 (a 29% increase). We are also continuing to increase our education and training commissions (across all mental health training programmes) alongside continuing to develop new roles and using existing roles to transform service delivery.” Source location 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 The Trust’s action plan and CQC monitoring are the established arrangements for addressing the identified safety concerns.
Verbatim wording from the response “Following the last inspection of Humber Teaching Hospitals NHS Foundation Trust’s Home-Based Treatment Team in 2019, the Care Quality Commission (CQC) rated the trust as good overall. The key question ‘safe’ was rated as requires improvement. The Trust submitted an action plan to explain how it would comply with its legal obligations following the publication of the report and, in line with its usual practice, the CQC uses the information received to monitor providers of health and social care services and take appropriate regulatory action when needed.” Source location Response from Department of Health and Social Care
Open published response
19 Sep 2023 Lauren Elizabeth Bridges · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 9 Failure of record-keeping systems to support direct transfer and sharing of clinical information View source Lack of consistent adoption and awareness of delayed-discharge protocols across independent providers View source Reliance of delayed-discharge protocols on home-team engagement View source Out-of-Area patients remaining away from home because of delayed discharge or repatriation View source Underfunding for local mental health beds View source Lack of a national standard process for independent-sector referrals and discharge or repatriation View source Inadequate communication between mental health care providers and relevant parties View source Variation in commissioning-body processes and communication requests View source Over-reliance by the NHS on independent providers for mental health beds View source See 6 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
Lauren Elizabeth Bridges · 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
Lauren Elizabeth Bridges, who was detained under the Mental Health Act and treated in out-of-area mental health placements, died on 26 February 2022 after a ligaturing incident two days earlier. The report identified concerns about delayed discharge and repatriation, the distance from home, missed opportunities to move her closer to home, and inadequate communication between relevant organisations. It also identified wider concerns about shortages of local mental health beds and reliance on independent 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 record-keeping systems to support direct transfer and sharing of clinical information
Wider context from the report “The jury identified inadequate and insufficient communication between Dorset Healthcare NHS Trust, The Priory and relevant parties.
I heard evidence that Dorset Healthcare NHS Trust have appointed a designated Care Co-ordinator for its Out-of-Area patients. Having a single point of contact will alleviate some of the communication issues identified.
I heard evidence from The Priory as to some of the challenges it faces when dealing with the NHS commissioning bodies, be they Hospital Trusts or Integrated Care Boards. The Priory is just one of the several independent providers of mental health care.
1. The Priory deals with 42 NHS separate commissioning bodies.
2. There are multiple software programmes for record keeping for these organisations, which makes transfer and sharing of clinical information cumbersome and difficult, as direct sharing is not possible.
3. These bodies have varying processes and requests for communication.
4. There is no national standard process for referrals into the independent sector nor for discharge/repatriation to the ‘home team’.
” 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 consistent adoption and awareness of delayed-discharge protocols across independent providers
Wider context from the report “The protocol is heavily reliant on engagement from, and co-operation of, the numerous NHS commissioning bodies. The protocol requires a low threshold for the escalation of delays to the appropriate manager and/or commissioner at the ‘home service’.
There are over 60 independent providers for in-patient mental health services.
The initiative taken by the Priory is to be applauded but it is just one of many independent providers for some 42 separate NHS commissioning bodies. There is a clear danger that it will not be adopted by the other independent providers , indeed there is no reason for them to be aware of its existence . In the premises, Out-of-Area delayed discharge, and its detrimental effect on a patient’s mental health, will remain a matter of concern.
” 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 Reliance of delayed-discharge protocols on home-team engagement
Wider context from the report “With regard to delayed discharge/repatriation of an Out-of-Area patient I heard evidence that The Priory have devised a protocol/standing operating procedure in respect of delayed discharge, which should reduce the risks of a patient being left miles from home at all and in any event reduce the time taken to repatriate. However, it relies on the ‘home team’s’ engagement in the process .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Out-of-Area patients remaining away from home because of delayed discharge or repatriation
Wider context from the report “With regard to delayed discharge/repatriation of an Out-of-Area patient I heard evidence that The Priory have devised a protocol/standing operating procedure in respect of delayed discharge, which should reduce the risks of a patient being left miles from home at all and in any event reduce the time taken to repatriate . However, it relies on the ‘home team’s’ engagement in the process.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Underfunding for local mental health beds
Wider context from the report “This is the second inquest I have heard where the delayed discharge/repatriation of an Out-of-Area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Lauren was 20 years of age. The other inquest involved a 15 years old patient - 115 miles from home.
Both of these cases illustrate,
a) Underfunding for local mental health beds .
b) An over-reliance by the NHS on independent providers for mental health beds.
” 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 national standard process for independent-sector referrals and discharge or repatriation
Wider context from the report “The jury identified inadequate and insufficient communication between Dorset Healthcare NHS Trust, The Priory and relevant parties.
I heard evidence that Dorset Healthcare NHS Trust have appointed a designated Care Co-ordinator for its Out-of-Area patients. Having a single point of contact will alleviate some of the communication issues identified.
I heard evidence from The Priory as to some of the challenges it faces when dealing with the NHS commissioning bodies, be they Hospital Trusts or Integrated Care Boards. The Priory is just one of the several independent providers of mental health care.
1. The Priory deals with 42 NHS separate commissioning bodies.
2. There are multiple software programmes for record keeping for these organisations, which makes transfer and sharing of clinical information cumbersome and difficult, as direct sharing is not possible.
3. These bodies have varying processes and requests for communication.
4. There is no national standard process for referrals into the independent sector nor for discharge/repatriation to the ‘home team’.
” 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 Inadequate communication between mental health care providers and relevant parties
Wider context from the report “The jury identified inadequate and insufficient communication between Dorset Healthcare NHS Trust, The Priory and relevant parties .
I heard evidence that Dorset Healthcare NHS Trust have appointed a designated Care Co-ordinator for its Out-of-Area patients. Having a single point of contact will alleviate some of the communication issues identified.
I heard evidence from The Priory as to some of the challenges it faces when dealing with the NHS commissioning bodies, be they Hospital Trusts or Integrated Care Boards. The Priory is just one of the several independent providers of mental health care.
1. The Priory deals with 42 NHS separate commissioning bodies.
2. There are multiple software programmes for record keeping for these organisations, which makes transfer and sharing of clinical information cumbersome and difficult, as direct sharing is not possible.
3. These bodies have varying processes and requests for communication.
4. There is no national standard process for referrals into the independent sector nor for discharge/repatriation to the ‘home team’.
” 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 Variation in commissioning-body processes and communication requests
Wider context from the report “The jury identified inadequate and insufficient communication between Dorset Healthcare NHS Trust, The Priory and relevant parties.
I heard evidence that Dorset Healthcare NHS Trust have appointed a designated Care Co-ordinator for its Out-of-Area patients. Having a single point of contact will alleviate some of the communication issues identified.
I heard evidence from The Priory as to some of the challenges it faces when dealing with the NHS commissioning bodies, be they Hospital Trusts or Integrated Care Boards. The Priory is just one of the several independent providers of mental health care.
1. The Priory deals with 42 NHS separate commissioning bodies.
2. There are multiple software programmes for record keeping for these organisations, which makes transfer and sharing of clinical information cumbersome and difficult, as direct sharing is not possible.
3. These bodies have varying processes and requests for communication.
4. There is no national standard process for referrals into the independent sector nor for discharge/repatriation to the ‘home team’.
” 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 Over-reliance by the NHS on independent providers for mental health beds
Wider context from the report “This is the second inquest I have heard where the delayed discharge/repatriation of an Out-of-Area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Lauren was 20 years of age. The other inquest involved a 15 years old patient - 115 miles from home.
Both of these cases illustrate,
a) Underfunding for local mental health beds.
b) An over-reliance by the NHS on independent providers for mental health beds .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with NHS England to ensure systems prioritise eliminating inappropriate out-of-area placements, focusing on discharge and patient flow.
Verbatim wording from the response “All systems that still have inappropriate out of area placements have been required to refresh their local plans to ensure these placements are eliminated everywhere as soon as reasonably possible. NHS England continues to work with the worst performing areas and support them to improve and we are working with NHS England to ensure that systems prioritise this, including a focus on discharge and flow.” 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 Develop and publish statutory guidance for discharge from mental health inpatient settings.
Verbatim wording from the response “The Department has also worked with NHS England and other system partners to develop statutory guidance for discharge from all mental health inpatient settings, which was published in January 2024. This sets out how NHS bodies and local authorities can work together to support the discharge process, improving flow and ensuring the right support in the community. The guidance is available at: Hospital discharge and community support guidance - GOV.UK (www.gov.uk)” 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 Provide additional funding to support adult social care and NHS discharges, including from mental health inpatient settings.
Verbatim wording from the response “To support adult social care and discharges across the NHS, including from mental health inpatient settings, up to £2.8 billion was made available in 2023/24 and £4.7 billion in 2024/25, reducing bed occupancy.” Source location 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 Integrated care boards are responsible for developing three-year plans to localise and realign inpatient mental health care, including independent-sector provision.
Verbatim wording from the response “Turning to your concerns around an over-reliance by the NHS on independent providers for mental health beds, private companies have always played a role in the NHS and patients should expect a safe and good quality service regardless of whether their care is delivered by independent sector or public sector providers. As set out in NHS England’s response to your report, all integrated care boards have been tasked with developing 3-year plans to localise and realign inpatient mental health care, including care provided by the Independent Sector, as part of NHS England’s mental health, learning disability and autism inpatient quality transformation programme.” Source location Response from Department of Health and Social Care
Open published response
15 Sep 2023 Riya HIRANI · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Failure to provide appropriate treatment and hospital admission for a seriously ill child View source Failure to escalate care in response to clearly expressed parental concerns about a deteriorating child View source Failure to recognise the severity of a seriously ill child’s condition View source Failure to seek or provide ready access to a second medical opinion when serious illness is disputed 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
Riya HIRANI · 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
Riya Hirani, aged nine, was transferred to Great Ormond Street Hospital after presenting in cardiac arrest, having previously been assessed and discharged from Northwick Park Hospital. The concerns were that the severity of her illness was not recognised, despite her mother's repeated concerns, and that she was not given intravenous antibiotics, admitted, or escalated for a second opinion. Riya died five days after the cardiac arrest; her recorded cause of death included hypoxic ischaemic encephalopathy, out-of-hospital cardiac arrest, invasive group A streptococcal infection and influenza B infection.
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 appropriate treatment and hospital admission for a seriously ill child
Wider context from the report “Riya’s mother took her to hospital a full day before Riya’s fatal collapse, because she believed that Riya was very sick. Unfortunately, the junior doctor who examined and assessed Riya failed to appreciate the severity of her condition. Instead of giving her intravenous antibiotics and admitting her to hospital, he diagnosed a virus and discharged her with advice to take over the counter painkillers and a sheet describing the management of sore throats.
I intend to make a PFD report to the medical director of Northwick Park Hospital about the diagnosis and treatment of Riya’s condition. However, I am writing to you both because it seems to me that there is a fundamental issue regarding the lack of appropriate diagnosis and treatment that is apparent locally but relevant nationally.
When Riya’s mother took her to hospital, she did so because it seemed to her that this illness was qualitatively very different from any other that Riya had suffered in her nine years. In short, Riya’s mum was convinced that Riya was extremely ill, she articulated clearly and at every stage in hospital why she thought that Riya was extremely ill, and she even questioned the doctor about whether this could be a group A streptococcal infection. (There was a well publicised outbreak at the time and the hospital had actually received an alert about this.)
I heard at inquest that, even in the middle of the night, there was a consultant available to give a second opinion if this had been requested by medical personnel. However, no thought was given to seeking a second opinion. I think it highly likely that if it had been open to Riya’s family to seek a second opinion at that point, they would have done so without hesitation.
One of the reasons that coroners are local to an area is because this makes them better placed to recognise any local trends.
Although the events bringing the two children to hospital were very different, as I listened to the evidence at Riya’s inquest I noticed some striking similarities between the circumstances of Riya’s treatment and those of Martha Mills. On each occasion a parent’s articulately expressed and ultimately prescient concerns about a previously healthy but rapidly deteriorating child, did not result in appropriate escalation of care.
I heard the inquest touching Martha’s death last year. I am aware from press reports of the attempts of Martha’s mother to enable families in such a situation to have ready access to a second medical opinion. It seems to me that you should be aware of the circumstances of Riya’s death before you decide how to proceed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate care in response to clearly expressed parental concerns about a deteriorating child
Wider context from the report “Riya’s mother took her to hospital a full day before Riya’s fatal collapse, because she believed that Riya was very sick. Unfortunately, the junior doctor who examined and assessed Riya failed to appreciate the severity of her condition. Instead of giving her intravenous antibiotics and admitting her to hospital, he diagnosed a virus and discharged her with advice to take over the counter painkillers and a sheet describing the management of sore throats.
I intend to make a PFD report to the medical director of Northwick Park Hospital about the diagnosis and treatment of Riya’s condition. However, I am writing to you both because it seems to me that there is a fundamental issue regarding the lack of appropriate diagnosis and treatment that is apparent locally but relevant nationally.
When Riya’s mother took her to hospital, she did so because it seemed to her that this illness was qualitatively very different from any other that Riya had suffered in her nine years. In short, Riya’s mum was convinced that Riya was extremely ill, she articulated clearly and at every stage in hospital why she thought that Riya was extremely ill, and she even questioned the doctor about whether this could be a group A streptococcal infection. (There was a well publicised outbreak at the time and the hospital had actually received an alert about this.)
I heard at inquest that, even in the middle of the night, there was a consultant available to give a second opinion if this had been requested by medical personnel. However, no thought was given to seeking a second opinion. I think it highly likely that if it had been open to Riya’s family to seek a second opinion at that point, they would have done so without hesitation.
One of the reasons that coroners are local to an area is because this makes them better placed to recognise any local trends.
Although the events bringing the two children to hospital were very different, as I listened to the evidence at Riya’s inquest I noticed some striking similarities between the circumstances of Riya’s treatment and those of Martha Mills. On each occasion a parent’s articulately expressed and ultimately prescient concerns about a previously healthy but rapidly deteriorating child, did not result in appropriate escalation of care .
I heard the inquest touching Martha’s death last year. I am aware from press reports of the attempts of Martha’s mother to enable families in such a situation to have ready access to a second medical opinion. It seems to me that you should be aware of the circumstances of Riya’s death before you decide how to proceed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the severity of a seriously ill child’s condition
Wider context from the report “Riya’s mother took her to hospital a full day before Riya’s fatal collapse, because she believed that Riya was very sick. Unfortunately, the junior doctor who examined and assessed Riya failed to appreciate the severity of her condition . Instead of giving her intravenous antibiotics and admitting her to hospital, he diagnosed a virus and discharged her with advice to take over the counter painkillers and a sheet describing the management of sore throats.
I intend to make a PFD report to the medical director of Northwick Park Hospital about the diagnosis and treatment of Riya’s condition. However, I am writing to you both because it seems to me that there is a fundamental issue regarding the lack of appropriate diagnosis and treatment that is apparent locally but relevant nationally.
When Riya’s mother took her to hospital, she did so because it seemed to her that this illness was qualitatively very different from any other that Riya had suffered in her nine years. In short, Riya’s mum was convinced that Riya was extremely ill, she articulated clearly and at every stage in hospital why she thought that Riya was extremely ill, and she even questioned the doctor about whether this could be a group A streptococcal infection. (There was a well publicised outbreak at the time and the hospital had actually received an alert about this.)
I heard at inquest that, even in the middle of the night, there was a consultant available to give a second opinion if this had been requested by medical personnel. However, no thought was given to seeking a second opinion. I think it highly likely that if it had been open to Riya’s family to seek a second opinion at that point, they would have done so without hesitation.
One of the reasons that coroners are local to an area is because this makes them better placed to recognise any local trends.
Although the events bringing the two children to hospital were very different, as I listened to the evidence at Riya’s inquest I noticed some striking similarities between the circumstances of Riya’s treatment and those of Martha Mills. On each occasion a parent’s articulately expressed and ultimately prescient concerns about a previously healthy but rapidly deteriorating child, did not result in appropriate escalation of care.
I heard the inquest touching Martha’s death last year. I am aware from press reports of the attempts of Martha’s mother to enable families in such a situation to have ready access to a second medical opinion. It seems to me that you should be aware of the circumstances of Riya’s death before you decide how to proceed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to seek or provide ready access to a second medical opinion when serious illness is disputed
Wider context from the report “Riya’s mother took her to hospital a full day before Riya’s fatal collapse, because she believed that Riya was very sick. Unfortunately, the junior doctor who examined and assessed Riya failed to appreciate the severity of her condition. Instead of giving her intravenous antibiotics and admitting her to hospital, he diagnosed a virus and discharged her with advice to take over the counter painkillers and a sheet describing the management of sore throats.
I intend to make a PFD report to the medical director of Northwick Park Hospital about the diagnosis and treatment of Riya’s condition. However, I am writing to you both because it seems to me that there is a fundamental issue regarding the lack of appropriate diagnosis and treatment that is apparent locally but relevant nationally.
When Riya’s mother took her to hospital, she did so because it seemed to her that this illness was qualitatively very different from any other that Riya had suffered in her nine years. In short, Riya’s mum was convinced that Riya was extremely ill, she articulated clearly and at every stage in hospital why she thought that Riya was extremely ill, and she even questioned the doctor about whether this could be a group A streptococcal infection. (There was a well publicised outbreak at the time and the hospital had actually received an alert about this.)
I heard at inquest that, even in the middle of the night, there was a consultant available to give a second opinion if this had been requested by medical personnel. However, no thought was given to seeking a second opinion . I think it highly likely that if it had been open to Riya’s family to seek a second opinion at that point, they would have done so without hesitation .
One of the reasons that coroners are local to an area is because this makes them better placed to recognise any local trends.
Although the events bringing the two children to hospital were very different, as I listened to the evidence at Riya’s inquest I noticed some striking similarities between the circumstances of Riya’s treatment and those of Martha Mills. On each occasion a parent’s articulately expressed and ultimately prescient concerns about a previously healthy but rapidly deteriorating child, did not result in appropriate escalation of care.
I heard the inquest touching Martha’s death last year. I am aware from press reports of the attempts of Martha’s mother to enable families in such a situation to have ready access to a second medical opinion. It seems to me that you should be aware of the circumstances of Riya’s death before you decide how to proceed.
” Open source report
15 Sep 2023 Eclipse Morrison · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 10 Failure to ensure appropriate timing and mode of delivery in high-risk pregnancies View source Unavailability of full Badgernet portal access View source Insufficient quality assurance of Badgernet entries View source Lack of clarity in interpreting Montgomery guidance and offering professional opinions on competing risks View source Insufficient technical knowledge and training for junior doctors and locums to identify serious risk factors View source Failure to ensure holistic review of relevant findings when planning timing and mode of birth View source Failure to test staff assimilation of maternity risk knowledge View source Unavailability of an implemented procedure for escalating inconclusive ultrasound measurements in high-risk pregnancies View source Failure to provide counselling supporting fully informed mode-of-delivery decisions where there is risk of shoulder dystocia View source Failure to follow existing maternity policies View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Eclipse Morrison · 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
Eclipse Morrison died at Nottingham City Hospital on 21 July 2021, the day after her birth, following perinatal asphyxia and complications associated with gestational diabetes, excessive fetal growth and shoulder dystocia. The principal concerns included failures to follow up missed appointments, consider and discuss appropriate timing and mode of delivery, identify risk factors during labour, and ensure adequate fetal monitoring. Further concerns related to the implementation and quality assurance of Badgernet, escalation procedures for ultrasound concerns, counselling about shoulder dystocia, and interpretation of Montgomery guidance.
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 ensure appropriate timing and mode of delivery in high-risk pregnancies
Wider context from the report “1. Risk analysis / mode and timing of birth
A significant factor was the failure to consider an elective Caesarean Section (CS). It is not clear why on this history and consideration of mode of delivery did not include a consideration of an elective CS at any stage, by any of the doctors involved.
Evidence was given that existing policies in place at GEH were not followed and the reason for this failure has not been identified.
Whilst Badgernet could be a useful tool, the evidence suggested that it is being regarded as a first line of defence rather than a failsafe. I am told that the Badgernet maternity system implemented in October 2021 will resolve the problems relating to mode and timing of birth, in that the system will require a consultant to approve a decision for CS/induction of labour (IOL) and that IOL’s will not be approved by the labour coordinator unless the paper booking has been approved on paper. However, on the evidence received it is not clear how this will assist if the risk factors and the need to consider IOL/elective CS have not been identified, by junior staff, thus triggering the need for escalation to/approval by a consultant.
I am not clear what has been done to ensure that junior doctors and locums have sufficient technical knowledge to ensure that they are able to identify serious risk factors and alert the consultant to these, so that the consultant may consider the appropriate mode of delivery. No information was provided as to the availability of regular face to face training for all grades concerning high-risk pregnancies not just for career trainees and foundation doctors.
I am told that a memo was sent to all junior doctors reminding them that any plan for either IOL or elective CS must be approved by a consultant and that an induction pack containing that information is provided to new starters and locums.
I have seen the Women’s and Children Clinical Education Guideline introduced in November 2022. I am told that the information was placed in a prominent position on notice boards, staff rooms and in blogs.
It is not clear how the assimilation of this knowledge is tested. It was suggested that this may be in appraisal, but this seems only likely to identify problems after they arise. In any event it seems these methods of dissemination of information and the appraisal system were in place at the time of Eclipse’s birth but did not ensure that the doctors involved in her mother’s care appreciated the impact of the risk factors in this pregnancy.
It was not explained how Badgernet or any policy or procedure in place, would ensure that there is a holistic review (including ultrasound scan findings) when planning for timing and mode of birth.
The concern remains that there will be further failure to ensure that appropriate timing and mode of delivery will be provided in high-risk pregnancies.
” 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 full Badgernet portal access
Wider context from the report “2. Access to Badgernet portal / full implementation of the Badgernet software
It seems that the Badgernet system is being relied on to address a number of issues which were identified in this case, and heavy reliance is being placed on a system which is not yet fully implemented . The concern remains that a critical aspect of this system, access to the portal, will not be in place until autumn 2023 at the earliest .
” 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 quality assurance of Badgernet entries
Wider context from the report “3. Quality Assessment
I am informed that Badgernet can easily identify fields which have not been completed and will prevent a record being closed until the field is completed, but it cannot identify the quality of any such entries . I am told that the quality checks are made on ten sets of notes per month out of an estimated 3,000 records that will be open at any one time. The concern remains that there is insufficient quality assurance in this system.
” 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 clarity in interpreting Montgomery guidance and offering professional opinions on competing risks
Wider context from the report “6. Interpretation of Montgomery
Ante-natal care is unique in that decisions have to be made for the benefit of two patients (the mother and the baby) and the treatment options for each may, as in this case have competing risks and benefits. In addition, in ante-natal care, the circumstances may change and action may need to be taken very quickly.
On the basis of evidence given at the inquest, there seems to be a lack of clarity as to the way in which Montgomery guidance are interpreted. It was acknowledged in evidence that parents often want a steer as to the best/safest course of action and that may require medical professionals to express opinions as to the weight to be placed on different risk factors. In some cases, parents may prefer to rely on the viewpoint of an experienced medical professional. It seems that medical professionals do not feel they can offer this assistance as it might be interpreted as trying to impose their opinion on the parent. The way in which Montgomery is interpreted and the extent to which medical professionals can offer an opinion is of wider concern than just the actions of those at GEH and should be considered by those who produce the guidance and deliver training to medical professionals.
” 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 technical knowledge and training for junior doctors and locums to identify serious risk factors
Wider context from the report “1. Risk analysis / mode and timing of birth
A significant factor was the failure to consider an elective Caesarean Section (CS). It is not clear why on this history and consideration of mode of delivery did not include a consideration of an elective CS at any stage, by any of the doctors involved.
Evidence was given that existing policies in place at GEH were not followed and the reason for this failure has not been identified.
Whilst Badgernet could be a useful tool, the evidence suggested that it is being regarded as a first line of defence rather than a failsafe. I am told that the Badgernet maternity system implemented in October 2021 will resolve the problems relating to mode and timing of birth, in that the system will require a consultant to approve a decision for CS/induction of labour (IOL) and that IOL’s will not be approved by the labour coordinator unless the paper booking has been approved on paper. However, on the evidence received it is not clear how this will assist if the risk factors and the need to consider IOL/elective CS have not been identified, by junior staff, thus triggering the need for escalation to/approval by a consultant.
I am not clear what has been done to ensure that junior doctors and locums have sufficient technical knowledge to ensure that they are able to identify serious risk factors and alert the consultant to these , so that the consultant may consider the appropriate mode of delivery. No information was provided as to the availability of regular face to face training for all grades concerning high-risk pregnancies not just for career trainees and foundation doctors.
I am told that a memo was sent to all junior doctors reminding them that any plan for either IOL or elective CS must be approved by a consultant and that an induction pack containing that information is provided to new starters and locums.
I have seen the Women’s and Children Clinical Education Guideline introduced in November 2022. I am told that the information was placed in a prominent position on notice boards, staff rooms and in blogs.
It is not clear how the assimilation of this knowledge is tested. It was suggested that this may be in appraisal, but this seems only likely to identify problems after they arise. In any event it seems these methods of dissemination of information and the appraisal system were in place at the time of Eclipse’s birth but did not ensure that the doctors involved in her mother’s care appreciated the impact of the risk factors in this pregnancy.
It was not explained how Badgernet or any policy or procedure in place, would ensure that there is a holistic review (including ultrasound scan findings) when planning for timing and mode of birth.
The concern remains that there will be further failure to ensure that appropriate timing and mode of delivery will be provided in high-risk pregnancies.
” 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 holistic review of relevant findings when planning timing and mode of birth
Wider context from the report “1. Risk analysis / mode and timing of birth
A significant factor was the failure to consider an elective Caesarean Section (CS). It is not clear why on this history and consideration of mode of delivery did not include a consideration of an elective CS at any stage, by any of the doctors involved.
Evidence was given that existing policies in place at GEH were not followed and the reason for this failure has not been identified.
Whilst Badgernet could be a useful tool, the evidence suggested that it is being regarded as a first line of defence rather than a failsafe. I am told that the Badgernet maternity system implemented in October 2021 will resolve the problems relating to mode and timing of birth, in that the system will require a consultant to approve a decision for CS/induction of labour (IOL) and that IOL’s will not be approved by the labour coordinator unless the paper booking has been approved on paper. However, on the evidence received it is not clear how this will assist if the risk factors and the need to consider IOL/elective CS have not been identified, by junior staff, thus triggering the need for escalation to/approval by a consultant.
I am not clear what has been done to ensure that junior doctors and locums have sufficient technical knowledge to ensure that they are able to identify serious risk factors and alert the consultant to these, so that the consultant may consider the appropriate mode of delivery. No information was provided as to the availability of regular face to face training for all grades concerning high-risk pregnancies not just for career trainees and foundation doctors.
I am told that a memo was sent to all junior doctors reminding them that any plan for either IOL or elective CS must be approved by a consultant and that an induction pack containing that information is provided to new starters and locums.
I have seen the Women’s and Children Clinical Education Guideline introduced in November 2022. I am told that the information was placed in a prominent position on notice boards, staff rooms and in blogs.
It is not clear how the assimilation of this knowledge is tested. It was suggested that this may be in appraisal, but this seems only likely to identify problems after they arise. In any event it seems these methods of dissemination of information and the appraisal system were in place at the time of Eclipse’s birth but did not ensure that the doctors involved in her mother’s care appreciated the impact of the risk factors in this pregnancy.
It was not explained how Badgernet or any policy or procedure in place, would ensure that there is a holistic review (including ultrasound scan findings) when planning for timing and mode of birth.
The concern remains that there will be further failure to ensure that appropriate timing and mode of delivery will be provided in high-risk pregnancies.
” 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 test staff assimilation of maternity risk knowledge
Wider context from the report “1. Risk analysis / mode and timing of birth
A significant factor was the failure to consider an elective Caesarean Section (CS). It is not clear why on this history and consideration of mode of delivery did not include a consideration of an elective CS at any stage, by any of the doctors involved.
Evidence was given that existing policies in place at GEH were not followed and the reason for this failure has not been identified.
Whilst Badgernet could be a useful tool, the evidence suggested that it is being regarded as a first line of defence rather than a failsafe. I am told that the Badgernet maternity system implemented in October 2021 will resolve the problems relating to mode and timing of birth, in that the system will require a consultant to approve a decision for CS/induction of labour (IOL) and that IOL’s will not be approved by the labour coordinator unless the paper booking has been approved on paper. However, on the evidence received it is not clear how this will assist if the risk factors and the need to consider IOL/elective CS have not been identified, by junior staff, thus triggering the need for escalation to/approval by a consultant.
I am not clear what has been done to ensure that junior doctors and locums have sufficient technical knowledge to ensure that they are able to identify serious risk factors and alert the consultant to these, so that the consultant may consider the appropriate mode of delivery. No information was provided as to the availability of regular face to face training for all grades concerning high-risk pregnancies not just for career trainees and foundation doctors.
I am told that a memo was sent to all junior doctors reminding them that any plan for either IOL or elective CS must be approved by a consultant and that an induction pack containing that information is provided to new starters and locums.
I have seen the Women’s and Children Clinical Education Guideline introduced in November 2022. I am told that the information was placed in a prominent position on notice boards, staff rooms and in blogs.
It is not clear how the assimilation of this knowledge is tested. It was suggested that this may be in appraisal, but this seems only likely to identify problems after they arise. In any event it seems these methods of dissemination of information and the appraisal system were in place at the time of Eclipse’s birth but did not ensure that the doctors involved in her mother’s care appreciated the impact of the risk factors in this pregnancy.
It was not explained how Badgernet or any policy or procedure in place, would ensure that there is a holistic review (including ultrasound scan findings) when planning for timing and mode of birth.
The concern remains that there will be further failure to ensure that appropriate timing and mode of delivery will be provided in high-risk pregnancies.
” 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 an implemented procedure for escalating inconclusive ultrasound measurements in high-risk pregnancies
Wider context from the report “4. Procedure for escalating concerns arising out of Ultrasound Scans (USS)
I understand that the procedure for escalating concerns arising out of a USS where it is not possible to obtain an accurate measurement in a high-risk pregnancy is currently under review . I am told that the new policy is not in place . The concern remains that no date has been set for its implementation.
” 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 counselling supporting fully informed mode-of-delivery decisions where there is risk of shoulder dystocia
Wider context from the report “5. Counselling for mothers at increased risk of shoulder dystocia
I have not seen any indication that all mothers identified to have an increased chance of shoulder dystocia now receive counselling regarding the risks and benefits associated with vaginal birth or CS. Assisting mothers to understand the implications of risks they face is fundamental to supporting them to make fully informed decisions, in accordance with Montgomery. The concern remains that there is no clear plan in place to ensure mothers receive the support they require to make fully informed decisions in relation to mode of delivery where there is risk of shoulder dystocia.
” 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 follow existing maternity policies
Wider context from the report “1. Risk analysis / mode and timing of birth
A significant factor was the failure to consider an elective Caesarean Section (CS). It is not clear why on this history and consideration of mode of delivery did not include a consideration of an elective CS at any stage, by any of the doctors involved.
Evidence was given that existing policies in place at GEH were not followed and the reason for this failure has not been identified.
Whilst Badgernet could be a useful tool, the evidence suggested that it is being regarded as a first line of defence rather than a failsafe. I am told that the Badgernet maternity system implemented in October 2021 will resolve the problems relating to mode and timing of birth, in that the system will require a consultant to approve a decision for CS/induction of labour (IOL) and that IOL’s will not be approved by the labour coordinator unless the paper booking has been approved on paper. However, on the evidence received it is not clear how this will assist if the risk factors and the need to consider IOL/elective CS have not been identified, by junior staff, thus triggering the need for escalation to/approval by a consultant.
I am not clear what has been done to ensure that junior doctors and locums have sufficient technical knowledge to ensure that they are able to identify serious risk factors and alert the consultant to these, so that the consultant may consider the appropriate mode of delivery. No information was provided as to the availability of regular face to face training for all grades concerning high-risk pregnancies not just for career trainees and foundation doctors.
I am told that a memo was sent to all junior doctors reminding them that any plan for either IOL or elective CS must be approved by a consultant and that an induction pack containing that information is provided to new starters and locums.
I have seen the Women’s and Children Clinical Education Guideline introduced in November 2022. I am told that the information was placed in a prominent position on notice boards, staff rooms and in blogs.
It is not clear how the assimilation of this knowledge is tested. It was suggested that this may be in appraisal, but this seems only likely to identify problems after they arise. In any event it seems these methods of dissemination of information and the appraisal system were in place at the time of Eclipse’s birth but did not ensure that the doctors involved in her mother’s care appreciated the impact of the risk factors in this pregnancy.
It was not explained how Badgernet or any policy or procedure in place, would ensure that there is a holistic review (including ultrasound scan findings) when planning for timing and mode of birth.
The concern remains that there will be further failure to ensure that appropriate timing and mode of delivery will be provided in high-risk pregnancies.
” Open source report
13 Sep 2023 Geoffrey Douglas HOAD · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 4 Failure of inter-hospital transfer arrangements to ensure timely transport of patients requiring specialist treatment View source Continuing delays in ambulance attendance View source Delays in ambulance responses to calls View source Continuing delays in ambulance service attendance to calls 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
Geoffrey Douglas HOAD · 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 Douglas Hoad underwent a total hip replacement on 3 August 2022 and subsequently developed a paralytic ileus, respiratory compromise and deteriorating renal function. He was transferred to Norfolk and Norwich University Hospital after an ambulance response that took more than 14 hours, and he died on 7 August 2022 after developing cardiac ischaemia and a myocardial infarction. The principal concern was the continuing considerable delays in attending ambulance calls amid very high demand and pressure on the healthcare system.
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 inter-hospital transfer arrangements to ensure timely transport of patients requiring specialist treatment
Wider context from the report “9. Spire Norwich Hospital does not deal with multi-disciplinary and emergency treatment at its hospital and transfers patients requiring such treatment to local acute Trusts, usually the Norfolk and Norwich University Hospital.
10. Spire Norwich Hospital continues to rely on EEAST to transport such patients to the acute hospital, being fully aware of the demands placed on the EEAST generally and the delays which occur as a result.
11. At the inquest Spire Norwich Hospital placed great reliance on now being part of an Interfacility Transfer Group led by the Norfolk and Norwich University Hospital working with the EEAST to look at a pathway in respect of inter hospital transfers. The evidence of EEAST was that this pathway was not expected to reduce delays in inter hospital transfers.
12. This concern has been raised at previous inquest.
” 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 Continuing delays in ambulance attendance
Wider context from the report “1. Spire Norwich Hospital called the ambulance service on 6 August 2022 at 18.16 hours. The call was coded as a Category 3 call, requiring a response within 2 hours. The Spire Hospital were told the response would be 6 hours.
2. The ambulance service was called again at 23.45 hours and the call was again coded as a Category 3 call.
3. The ambulance service was called again on 7 August 2022 at 07.38 hours and the call was now coded as a Category 2 call, requiring a response within 40 minutes and with an average time of 18 minutes.
4. Due to continuing demand on the ambulance service, an ambulance did not become available until 08.16 hours. The ambulance arrived on scene at 08.26 hours.
5. The time between calling the ambulance service and an ambulance arriving was in excess of 14 hours.
6. Evidence was heard as to the very high call demand overnight on the 6th and 7th August 2022 and with regard to the significant pressure the healthcare system was and remains under.
7. Evidence was also heard as to the steps being taken by EEAST in an attempt to deal with this pressure on the healthcare system.
8. Despite the steps being taken by the EEAST, considerable delays in attending to calls continue.
” 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 ambulance responses to calls
Wider context from the report “8. Despite the steps being taken by the EEAST, considerable delays in attending to calls continue . The Trust is of the view that only by reducing system pressures as a whole, including hospital handover delays and community services being able to deal with their patients, will pressure on the ambulance service be alleviated to enable them to respond effectively and in a timely manner to their patients . This is to a great extent outside the control of the regional EEAST.
” 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 Continuing delays in ambulance service attendance to calls
Wider context from the report “8. Despite the steps being taken by the EEAST, considerable delays in attending to calls continue .
” 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 Deliver new ambulances and specialist mental health vehicles.
Verbatim wording from the response “Your report highlights that EEAST were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” 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 Maintain additional ambulance capacity funded to expand capacity and improve response times.
Verbatim wording from the response “Your report highlights that EEAST were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” 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 Publish the delivery plan for recovering urgent and emergency care services.
Verbatim wording from the response “As the Minister responsible for urgent and emergency case services, I recognise the significant pressure the urgent and emergency care system is facing. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times, including to reduce Category 2 response times (including for serious conditions such as heart attacks and strokes) to 30 minutes on average this year. The plan is available at:
https://www.england.nhs.uk/wp-content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf” 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 working with NHS England to reduce ambulance response times.
Verbatim wording from the response “However, I recognise there is still more to do to reduce response times further, and the Government will continue to work with NHS England to achieve this.” 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 Specific local action to reduce ambulance response times is assigned to EEAST and Norfolk and Norwich University Hospitals NHS Foundation Trust.
Verbatim wording from the response “Your report raised concerns about the response time performance of East of England Ambulance Service NHS Trust (EEAST). I note that you have raised these concerns with EEAST and Norfolk and Norwich University Hospitals NHS Foundation Trust who are best placed to respond on the specific action being taken locally to support reduced ambulance response times.” Source location Response from Department of Health and Social Care
Open published response
13 Sep 2023 Melissa Hannah Kerr · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 5 Failure to ensure that patients travelling to Turkey for the procedure are made aware of its risks and high mortality rate View source Failure to ensure preoperative review by a surgeon View source Use of surgical practices abroad regarded as unsafe in the UK View source Limited preoperative psychological and physical assessment View source Lack of effective controls over the provision of the surgery abroad View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Melissa Hannah Kerr · 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
Melissa Kerr underwent liposuction and a Brazilian Buttock Lift in Istanbul on 19 November 2019 and became unwell during surgery before being declared dead. The concerns included limited assessment and information about the risks, limited documentary evidence, and surgical techniques that increased the risk of fat embolism. The report also raised concerns about patients travelling abroad for the procedure without being aware of its risks and where there are limited controls over the surgery.
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 ensure that patients travelling to Turkey for the procedure are made aware of its risks and high mortality rate
Wider context from the report “2. I am concerned that patients travelling to Turkey for this procedure are not being made aware of the risks and the high mortality rate associated with this surgery
” 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 preoperative review by a surgeon
Wider context from the report “3. I am also concerned that patients are travelling abroad where there are no or limited controls with regard to such surgery taking place. Evidence was heard there Ms Kerr was not seen by a surgeon before the date of the procedure . There was limited psychological and physical assessment prior to the procedure proceeding.
” 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 Use of surgical practices abroad regarded as unsafe in the UK
Wider context from the report “4. I appreciate the UK Government has no control over what happens abroad. However I am concerned that citizens are travelling abroad for such procedures unaware of the risks involved and that practices are used which are regarded as unsafe in the UK .
” 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 Limited preoperative psychological and physical assessment
Wider context from the report “3. I am also concerned that patients are travelling abroad where there are no or limited controls with regard to such surgery taking place. Evidence was heard there Ms Kerr was not seen by a surgeon before the date of the procedure. There was limited psychological and physical assessment prior to the procedure proceeding .
” 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 effective controls over the provision of the surgery abroad
Wider context from the report “3. I am also concerned that patients are travelling abroad where there are no or limited controls with regard to such surgery taking place . Evidence was heard there Ms Kerr was not seen by a surgeon before the date of the procedure. There was limited psychological and physical assessment prior to the procedure proceeding.
” 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 Visit Türkiye to discuss regulatory protections and identify UK-Turkish cooperation to reduce future patient risks.
Verbatim wording from the response “The Department has been consulting with the Foreign, Commonwealth and Development Office, NHS England, the Devolved Governments and other relevant stakeholders to obtain a better picture of the impact of medical tourism on patient safety and the NHS. My officials will also be visiting Türkiye shortly to meet with their counterparts. The intention is to discuss the regulatory framework, and the protections that are in place for UK nationals, and to identify concrete areas where the UK and Turkish authorities should work together to reduce the risks to patients in the future.” 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 Consider how to communicate medical-tourism risks and appropriate postoperative aftercare, including when it may be safe to travel home.
Verbatim wording from the response “The Government is considering how we can most effectively communicate with those considering medical treatment abroad, to ensure people are better informed about the risks ahead of surgery and understand the need to ensure appropriate aftercare, including considering when it may be safe to travel home.” Source location Response from Department of Health and Social Care
Open published response
11 Sep 2023 Amanda Jane Kramer · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Failure to review Zopiclone use despite high-risk medication-taking behaviour View source Central nervous system depression risk from Zopiclone View source Dependency risk from Zopiclone View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Amanda Jane Kramer · 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
Amanda Jane Kramer, aged 56, was found unresponsive at home on 31 December 2022 and died from an overdose of prescribed zopiclone. The report raised concerns that zopiclone had been prescribed for approximately 18 years without clear evidence that its ongoing need, associated risks, or adherence to dosage instructions had been reviewed, including after previous deliberate overdoses of prescribed medication.
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 review Zopiclone use despite high-risk medication-taking behaviour
Wider context from the report “1. Zopiclone is a drug licenced for the treatment of short-term insomnia. The risks associated with the drug are first, that it is a central nervous system depressant and second, that patients prescribed the drug can form a dependency upon it.
2. Mrs Kramer was prescribed Zopiclone for 18 years.
3. Despite the deceased being under the care of both a GP and a secondary mental health trust prior to her death. No clear evidence emerged in this inquest that anyone had reviewed Mrs Kramer's use of this drug even when Mrs Kramer had demonstrated a pattern of high-risk behaviour by deliberately overdosing on prescribed medication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Central nervous system depression risk from Zopiclone
Wider context from the report “1. Zopiclone is a drug licenced for the treatment of short-term insomnia. The risks associated with the drug are first, that it is a central nervous system depressant and second, that patients prescribed the drug can form a dependency upon it.
2. Mrs Kramer was prescribed Zopiclone for 18 years.
3. Despite the deceased being under the care of both a GP and a secondary mental health trust prior to her death. No clear evidence emerged in this inquest that anyone had reviewed Mrs Kramer's use of this drug even when Mrs Kramer had demonstrated a pattern of high-risk behaviour by deliberately overdosing on prescribed medication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Dependency risk from Zopiclone
Wider context from the report “1. Zopiclone is a drug licenced for the treatment of short-term insomnia. The risks associated with the drug are first, that it is a central nervous system depressant and second, that patients prescribed the drug can form a dependency upon it.
2. Mrs Kramer was prescribed Zopiclone for 18 years.
3. Despite the deceased being under the care of both a GP and a secondary mental health trust prior to her death. No clear evidence emerged in this inquest that anyone had reviewed Mrs Kramer's use of this drug even when Mrs Kramer had demonstrated a pattern of high-risk behaviour by deliberately overdosing on prescribed medication.
” 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 Prescribing and medication review decisions rest with the GP or responsible clinician, who must determine treatment with the patient.
Verbatim wording from the response “As I am sure you will be aware, GPs and other prescribers are ultimately responsible for their own prescribing decisions. The decision to prescribe a particular product is a clinical one and should be based on the patient’s medical needs. The process of reviewing medication is one in which the GP or responsible clinician work together” Source location Response from Department of Health and Social Care
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations