7 Sep 2023 Sultana Choudhury · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Failure to withhold low molecular weight heparin VTE prophylaxis in the presence of active bleeding View source Failure to diagnose ongoing renal haemorrhage View source Failure to adequately monitor patients during admission 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
Sultana Choudhury · 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
Sultana Choudhury died in hospital on 17 December 2022 after suffering a renal haemorrhage following a renal biopsy, leading to hypovolaemia and cardiac arrest. The concerns included failure to diagnose the ongoing haemorrhage, administration of VTE prophylaxis despite haematuria, and inadequate monitoring during her admission.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to withhold low molecular weight heparin VTE prophylaxis in the presence of active bleeding
Wider context from the report “2. The clinical decision to administer VTE prophylaxis in the form of low molecular weight heparin on admission to a patient with a patent bleed, evidenced by haematuria .
” 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 diagnose ongoing renal haemorrhage
Wider context from the report “1. The trust’s failure to diagnose an obvious ongoing renal haemorrhage in a patient with; a recent history of renal biopsy, worsening clinical observations in keeping with hypovolaemia and a plummeting haemoglobin count.
” 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 adequately monitor patients during admission
Wider context from the report “3. The failure to adequately monitor Mrs Choudhury during her 3-day admission that allowed her to deteriorate into a preventable peri-arrest state.
” Open source report
1 Sep 2023 Harold Derek PEDLEY Otherwise known as Derek PEDLEY · Prevention of Future Deaths report Blackpool and the Fylde
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Concerns raised 4 Failure to provide GPs with a realistic picture of hospital waiting times View source Inability of emergency departments to triage patients during OPEL 4 pressures View source Use of hospital pressures as a default explanation for substandard patient care View source Failure to notify receiving doctors when patients arrive at the hospital View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Harold Derek PEDLEY Otherwise known as Derek PEDLEY · 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
Harold Derek Pedley, known as Derek, attended hospital after referral by his GP with abdominal pain and vomiting, but remained in the Emergency Department waiting area for almost two hours without being assessed or spoken to by a medical professional, and died before he was called. The report raised concerns about hospital pressures at OPEL 4, the inability to triage patients and notify expecting doctors, and the risk that patients may arrive expecting prompt assessment when this cannot be provided.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide GPs with a realistic picture of hospital waiting times
Wider context from the report “• Concern 3 - Finally, it is relevant to point out that Derek had not moved for some time before a medical professional called for Derek. I formed the view that there had been a reluctance on his Friend’s part to request assistance due to the pressures staff were clearly under, but also because he had already handed in Derek’s paperwork and was expecting some assistance imminently which did not arrive. I feel Derek and his Friend thought as they knew doctors had discussed his case with his GP and that his attendance was expected they did not need to raise a concern until it was too late. In actual fact, such are the pressures Emergency Departments are working under, this may not be the case. It is not for me to be prescriptive about what should be done, but unless GPs are provided with a realistic picture about how quickly their patients may be seen once they arrive at hospital (even if they have been in communication with the hospital doctors) their patients may arrive at hospital expecting to be seen quickly, when in reality this may not be the case particularly when the department is under significant pressures .
” 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 Inability of emergency departments to triage patients during OPEL 4 pressures
Wider context from the report “• Concern 1 – that the medical professionals who work in a hospital emergency department are routinely expected to do so when the OPEL 4 applies, a recognition they are performing their roles when the hospital is “unable to deliver comprehensive care, and patient safety is at risk”. Such pressures may serve to leave the Emergency Department unable to triage patients such as Derek , and have no time to notify the doctors expecting his arrival (in this case doctors on the Surgical Assessment Unit) who are consequently left unaware that a patient has in fact arrived, all of which serves to place vulnerable patients such as Derek Pedley at serious risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Use of hospital pressures as a default explanation for substandard patient care
Wider context from the report “• Concern 2 - that there is a risk that the pressures on hospitals become so significant they are used as a default explanation for levels of patient care that fall below what they would wish to deliver . I found that the hospital Trust did not seek to do so in this case, but it seems to me there is a risk this could happen. The pressures are indeed significant, but ultimately this case involves a 90 year old man with what appears to be an acute medical problem finding himself attending his local emergency department, not being spoken to / triaged by a medical professional for almost two hours, and dying by the time he is called for. There is a clear risk that puts patients at risk and it would be remiss of me not to raise it.
” 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 notify receiving doctors when patients arrive at the hospital
Wider context from the report “• Concern 1 – that the medical professionals who work in a hospital emergency department are routinely expected to do so when the OPEL 4 applies, a recognition they are performing their roles when the hospital is “unable to deliver comprehensive care, and patient safety is at risk”. Such pressures may serve to leave the Emergency Department unable to triage patients such as Derek, and have no time to notify the doctors expecting his arrival (in this case doctors on the Surgical Assessment Unit) who are consequently left unaware that a patient has in fact arrived , all of which serves to place vulnerable patients such as Derek Pedley at serious risk.
” 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 Monitoring waiting-time performance and risk at Blackpool Teaching Hospitals NHS Foundation Trust is the Care Quality Commission’s responsibility.
Verbatim wording from the response “I understand that Lancashire and South Cumbria Integrated Care Board have responded to you directly on the specific actions being taken locally to address the concerns you have raised. Further, the CQC has advised my officials that they continue to have regular engagement with Blackpool Teaching Hospitals NHS Foundation Trust to monitor waiting time performance and risk.” 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 Specific local actions addressing the concerns are the responsibility of Lancashire and South Cumbria Integrated Care Board.
Verbatim wording from the response “I understand that Lancashire and South Cumbria Integrated Care Board have responded to you directly on the specific actions being taken locally to address the concerns you have raised. Further, the CQC has advised my officials that they continue to have regular engagement with Blackpool Teaching Hospitals NHS Foundation Trust to monitor waiting time performance and risk.” Source location Response from Department of Health and Social Care
Open published response
31 Aug 2023 Donna Levy · Prevention of Future Deaths report East London
View report summary
Concerns raised 5 Failure to escalate care in response to deteriorating health and self-neglect risks View source Failure to undertake an adequately scoped serious investigation of community care incidents View source Domiciliary care visits failing to provide personal care View source Failure to undertake or consider a formal Mental Capacity Act assessment View source Failure to make formal mental health referrals for reluctance to accept offered care View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Donna Levy · 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
Donna Levy was admitted to hospital critically unwell after severe self-neglect, with extensive skin lesions, an infected pressure sore, oedematous and ulcerated lower limbs, and clinical signs of sepsis and acute kidney injury. She underwent surgical debridement but died in hospital on 14 December 2022 from complications associated with the pressure sore. Concerns included the failure to escalate her care despite deteriorating health, the absence of a formal Mental Capacity Act assessment or mental health referral, and the decision not to undertake a Serious Investigation.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate care in response to deteriorating health and self-neglect risks
Wider context from the report “2. In the two months prior to her final admission into hospital Ms Levy was being regularly assessed by district nurses, the community matron and her GP. Despite the obvious nature of her deteriorating health, no meaningful steps were taken to escalate the care she received to mitigate the risks of her self-neglect .
” 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 undertake an adequately scoped serious investigation of community care incidents
Wider context from the report “6. The Trust responsible for community care did not undertake a Serious Investigation . The decision was justified on the basis that Ms Levy’s pressure sore was insufficiently significant to justify further inquiry. The decision was, in the view of the court flawed as evidence heard indicated that the pressure sore was in fact far more serious than appreciated at the time of community treatment. Further, restricting the scope of a serious incident report to the extent of a single pressure sore, neglected to take in the wider physical health problems suffered by Ms Levy that were obvious at that time .
” 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 Domiciliary care visits failing to provide personal care
Wider context from the report “1. Since 2020 Ms Levy had been provided with domiciliary care commissioned by the local authority. At the time of her death twice daily visits were undertaken . Ms Levy was utilising state funded domiciliary care visits to deliver fast food to her home, no personal care was being provided . Carers had escalated to the local authority Ms Levy’s reluctance to accept personal care and raised safeguarding reports regarding Ms Levy’s living conditions.
” 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 undertake or consider a formal Mental Capacity Act assessment
Wider context from the report “3. The inquest heard that as Ms Levy was believed to have capacity throughout this period, and consequently it was determined that there were on practical steps that could have been taken to improve the provision of care to her.
4. No formal Mental Capacity Act assessment was ever undertaken or considered .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to make formal mental health referrals for reluctance to accept offered care
Wider context from the report “5. No formal referral was made to mental health services regarding Ms Levy’s reluctance to take advantage of offered care .
” Open source report
30 Aug 2023 Allison Vivian Jacome Aules · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Under-resourcing of CAMHS services View source Lack of consultant psychiatrist leadership within CAMHS teams 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
Allison Vivian Jacome Aules · 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
Allison Aules was referred to a child and adolescent mental health service in May 2021 following concerns including self-harm, low mood and anxiety, but her referral was delayed and the eventual assessment was incomplete. She was discharged without a documented risk management plan, and was found suspended in her bedroom on 18 July 2022; the investigation states that she died on 19 July 2022 as a result of suicide, contributed to by neglect. The principal concerns were failings in care and the under-resourcing of CAMHS services, including delays in assessment and concern that continuing under-resourcing amid rising demand could result in similar deaths.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Under-resourcing of CAMHS services
Wider context from the report “The Inquest identified multiple failings in the care provided to Allison. The failings occurred within a children and adolescent mental health service which was significantly under resourced .
The Inquest heard evidence that the under resourcing of CAMHS services is not confined to this local Trust but is a matter of National concern.
The under resourcing of CAMHS services contributed to delays in Allison being assessed by the mental health team. The delay between triage to assessment was 9 months. The Inquest heard evidence that this delay is not unusual within CAMHS teams across the country.
There was very little evidence of any consultant psychiatrist leadership within the CAMHS team. The Inquest heard of the difficulties in recruiting suitably qualified psychiatrists to CAMHS teams.
The Inquest heard that funding for CAMHS teams within the allocation of funding for general mental health is poor.
The Inquest heard that the number of children presenting to CAMHS teams is increasing significantly. The number of referrals of children to the local CAMHS team in the early 2010s was between 10 – 12 per week. The current number of referrals is in the region of 140 patients per week.
There is a concern that ongoing under resourcing of CAMHS services (whilst demand continues to increase) , will result in future similar 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 Lack of consultant psychiatrist leadership within CAMHS teams
Wider context from the report “The Inquest identified multiple failings in the care provided to Allison. The failings occurred within a children and adolescent mental health service which was significantly under resourced.
The Inquest heard evidence that the under resourcing of CAMHS services is not confined to this local Trust but is a matter of National concern.
The under resourcing of CAMHS services contributed to delays in Allison being assessed by the mental health team. The delay between triage to assessment was 9 months. The Inquest heard evidence that this delay is not unusual within CAMHS teams across the country.
There was very little evidence of any consultant psychiatrist leadership within the CAMHS team . The Inquest heard of the difficulties in recruiting suitably qualified psychiatrists to CAMHS teams .
The Inquest heard that funding for CAMHS teams within the allocation of funding for general mental health is poor.
The Inquest heard that the number of children presenting to CAMHS teams is increasing significantly. The number of referrals of children to the local CAMHS team in the early 2010s was between 10 – 12 per week. The current number of referrals is in the region of 140 patients per week.
There is a concern that ongoing under resourcing of CAMHS services (whilst demand continues to increase), will result in future similar deaths.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Attract, train, recruit, retain and reskill the current and future mental health workforce.
Verbatim wording from the response “We are committed to attracting, training, and recruiting the mental health workforce of the future as well as retaining and re-skilling our current workforce. 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 and enhance service user experiences. The NHS aims to meet this commitment through a range of different training programmes, including:” 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 new mental health workforce roles and use existing roles to transform service delivery and improve service user experiences.
Verbatim wording from the response “We are committed to attracting, training, and recruiting the mental health workforce of the future as well as retaining and re-skilling our current workforce. 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 and enhance service user experiences. The NHS aims to meet this commitment through a range of different training programmes, including:” 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 Increase the mental health workforce by 27,000 staff, with three quarters of the target delivered by December 2023.
Verbatim wording from the response “We are also 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. In December 2023, there were nearly 149,000 full time equivalents in the mental health workforce. This is over 10,300 more (7.5% increase) since December 2022.” 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 Continue increasing education and training commissions across mental health training programmes.
Verbatim wording from the response “We are committed to attracting, training, and recruiting the mental health workforce of the future as well as retaining and re-skilling our current workforce. 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 and enhance service user experiences. The NHS aims to meet this commitment through a range of different training programmes, including:” Source location Response from Department of Health and Social Care
Open published response
17 Aug 2023 Luke Matthew Brooks · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Lack of a register providing local authorities with current private landlord address and contact details View source Ambulance-service policies advising people with non-immediately-life-threatening chest pain to attend A&E alone 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
Luke Matthew Brooks · 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
Luke Matthew Brooks died unexpectedly at home on 25 October 2022 after approximately one week of cold/flu-like symptoms. The inquest recorded acute respiratory distress syndrome due to Aspergillus pneumonia. Concerns included the absence of a register of private landlords and an ambulance-service policy advising people with non-immediately life-threatening chest pain to attend A&E on their own.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a register providing local authorities with current private landlord address and contact details
Wider context from the report “1. There is no register of Private landlords available in England. The court heard this was without other countries within the UK who had a national register. The lack of this meant that Local authorities could be hampered in not knowing up to date address/contact details when they were made aware of concerns with a privately rented property. This is particularly important when the issue is one which is potentially life threatening ie asbestos in a property, dangerous items such as inappropriate cord blinds in a property with children or excessive damp.
” 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 Ambulance-service policies advising people with non-immediately-life-threatening chest pain to attend A&E alone
Wider context from the report “2. NWAS had a local policy of advising people who described symptoms of chest pain (not immediate life threatening) to attend A&E on their own. Whilst NWAS have now revised this policy to remove this, it is not known if this could be set out in the local policies of other ambulance services .
” 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 other ambulance services in England have blanket policies advising chest-pain patients not to travel independently to A&E.
Verbatim wording from the response “The report raises concerns about the advice North West Ambulance Service NHS Trust (NWAS) gave to Mr Brooks which was to advise people who describe the symptoms of chest pain not to make their own way to A&E. Your report raised a concern that although NWAS had revised this policy other ambulance services may have similar policies.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 3 Delays in hospital handover reducing ambulance availability View source Failure to provide timely category 2 ambulance responses View source Failure by NHS Trusts to understand and embed image-reporting guidance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Lee Dryden · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lee Dryden had a displaced tracheotomy tube associated with emphysema, and critical scan findings on 15 December 2021 were not followed by successful contact or timely review. He suffered a cardiac arrest on 16 December 2021, resulting in a hypoxic brain injury, and died on 12 January 2022. The principal concerns were failures in communicating and acting on critical imaging findings and the delayed ambulance response to his mother's call.
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 hospital handover reducing ambulance availability
Wider context from the report “2. The Ambulance Service graded Lee's mother's call to them on the 15th December 2021 as a category 2 call which has two targets as described in evidence, the first being a response time of 20 minutes call time and that 9 out of 10 calls would be responded to within 40 minutes. Yorkshire Ambulance Service were unable to respond to Lee's call until 2 hours and 26 minutes had passed. Yorkshire Ambulance Service were on their highest level of escalation at that time with significant delays at hospital handover caused or contributed to the delay in an ambulance being available to Lee .
” 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 timely category 2 ambulance responses
Wider context from the report “2. The Ambulance Service graded Lee's mother's call to them on the 15th December 2021 as a category 2 call which has two targets as described in evidence, the first being a response time of 20 minutes call time and that 9 out of 10 calls would be responded to within 40 minutes. Yorkshire Ambulance Service were unable to respond to Lee's call until 2 hours and 26 minutes had passed . Yorkshire Ambulance Service were on their highest level of escalation at that time with significant delays at hospital handover caused or contributed to the delay in an ambulance being available to Lee.
” 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 by NHS Trusts to understand and embed image-reporting guidance
Wider context from the report “1. There is Royal College Guidance as to how and by what means the images are reported from external organisations such as Medical Alliance to NHS Trusts however this appears to not be understood or embedded by NHS Trusts .
” 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 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 DHSC
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 Deliver 5,000 additional staffed, permanent hospital beds and maintain the capacity uplift.
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 DHSC
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 and maintain additional ambulance capacity through dedicated funding.
Verbatim wording from the response “Your report highlights that YAS 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” Source location Response from DHSC
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 Publish the delivery plan for recovering urgent and emergency care services.
Verbatim wording from the response “Your report also raised concerns about response times by Yorkshire Ambulance Service NHS trust (YAS) including the impacts of handover delays. I note NHS England also responded on the action they are taking in relation to this concern. 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 reduce Category 2 ambulance response times to 30 minutes on average. The plan is available at B2034-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf (england.nhs.uk)” Source location Response from DHSC
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 £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 DHSC
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 Deliver new ambulances and specialist mental health vehicles.
Verbatim wording from the response “Your report highlights that YAS 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” Source location Response from DHSC
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 Scale up virtual ward capacity to more than 10,000 beds 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 DHSC
Open published response
24 Jul 2023 Christine Goodfriday Nakaefeero · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Failure of VTE risk assessment criteria to include relevant risk factors View source Failure to maintain patients within the gynaeology care pathway and ensure timely surgery 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
Christine Goodfriday Nakaefeero · 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
Christine Goodfriday Nakaefeero was found unresponsive at home on 21 June 2022 and died from a pulmonary embolism caused by a deep vein thrombosis. The report raises concerns that recommended hysterectomy surgery for her uterine fibroids was not arranged, and that the VTE assessment did not account for her large fibroids and use of tranexamic acid.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of VTE risk assessment criteria to include relevant risk factors
Wider context from the report “2. The clinicians treating Ms Nakaefeero assessed her VTE risk utilising an established algorithm based on national guidance. The assessment was undertaken appropriately but it failed to identify two risk factors which made the formation of a DVT more likely, namely, large uterine fibroids and the use of tranexamic acid. I have concerns that the omission of these factors in the assessment criteria limited the effectiveness of the risk assessment.
” 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 maintain patients within the gynaeology care pathway and ensure timely surgery
Wider context from the report “1. Ms Nakaefeero was assessed at a Gynae-oncology clinic in early 2019. The patient was diagnosed as not suffering from any form of cancer and was therefore referred on to the “benign” gynaeology team.
Ms Nakaefeero was advised that it was likely that the most effective treatment for her condition was a hysterectomy. It was expected that the likely wait for this treatment would be 6 months.
Ms Nakaefeero was not allocated an appointment and therefore had not received the necessary surgery by the time of her death in June 2022. Had the surgery been undertaken it is probable that she would not have developed a pulmonary embolism.
Although the trust has investigated these circumstances and implemented change, no clear explanation could be offered for why the deceased slipped out of this care pathway. I am not satisfied that the risk of re-occurrence has been properly addressed.
” 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 The established VTE risk assessment tool remains appropriate, with insufficient evidence to adapt or change it.
Verbatim wording from the response “The Trust also explained to CQC that it was seeking expert advice from Professor Roopen Arya, Professor of Thrombosis and Haemostasis at King’s College Hospital and Director of the National VTE Exemplar Centres Network in England. Professor Arya advised the Trust that the use of the tool to assess VTE risk and determine intervention was appropriate and that at that time there was insufficient evidence to adapt or change this. I am aware that the Trust is also continuing to monitor the information it received from national bodies that informed how it implements best practice on prevention of VTE.” Source location Response from Department of Health and Social Care
Open published response
21 Jul 2023 Thomas Barton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Risk of deconditioning and infection for frail elderly patients during unnecessary hospital stays View source Insufficient availability of suitable social care causing delayed hospital discharges 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
Thomas Barton · 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 Barton was admitted to hospital for a urinary tract infection and remained there while arrangements for additional care at home were organised. He contracted COVID-19 during the delayed discharge, deteriorated with dysphagia and aspiration pneumonia, and was discharged to a nursing home on end-of-life care, where he died. The principal concern was that delays in discharge caused by limited social care availability placed frail elderly patients at increased risk of deconditioning, infection and preventable death.
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 Risk of deconditioning and infection for frail elderly patients during unnecessary hospital stays
Wider context from the report “The inquest heard that the delayed discharge of Mr Barton from hospital was due to the challenges of putting an appropriate social care package in place. The evidence before the inquest was that delayed discharges such as Mr Barton’s put the lives of frail elderly patients at risk as it is far more likely that they will become deconditioned and develop an infection if they spend unnecessary time in hospital . The evidence was that delayed discharges such as Mr Barton’s were not uncommon due to the demand on social care and the availability of suitable care. The evidence was that speedier discharges would occur if there was improved availability of social care and that this would improve outcomes for elderly patients and reduce the risk of preventable deaths occurring.
” 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 availability of suitable social care causing delayed hospital discharges
Wider context from the report “The inquest heard that the delayed discharge of Mr Barton from hospital was due to the challenges of putting an appropriate social care package in place . The evidence before the inquest was that delayed discharges such as Mr Barton’s put the lives of frail elderly patients at risk as it is far more likely that they will become deconditioned and develop an infection if they spend unnecessary time in hospital. The evidence was that delayed discharges such as Mr Barton’s were not uncommon due to the demand on social care and the availability of suitable care . The evidence was that speedier discharges would occur if there was improved availability of social care and that this would improve outcomes for elderly patients and reduce the risk of preventable deaths occurring.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with NHS and local authorities to roll out care transfer hubs across the country for complex discharges.
Verbatim wording from the response “In January 2023, NHS England published the Urgent and Emergency Care Recovery Plan. This year, and in line with the commitments in this plan, we continue to work with the NHS and local authorities to roll out care transfer hubs in every part of the country to manage discharges for patients with more complex needs. These hubs bring together professionals from the NHS and local authority to manage discharges for people with more complex needs, who need extra support when being discharged.” 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 Hospital Discharge and Community Support Guidance setting out hospital discharge and community support processes.
Verbatim wording from the response “It is our priority to ensure that all patients receive safe and timely discharges from hospital. The Hospital Discharge and Community Support Guidance published by the Department of Health and Social Care, sets out how the discharge process should operate in practice, and how NHS bodies and Local Authorities should work together to plan and implement hospital discharge, recovery and reablement in the community. NHS bodies and local authorities have a statutory duty to cooperate in exercising their” 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 and increase the Adult Social Care Discharge Fund to support additional care packages, beds, equipment and social care workforce capacity.
Verbatim wording from the response “We put in place £500million for the 2022/2023 Adult Social Care Discharge Fund and this enabled more people to be discharged from hospital in a timely manner. We have since increased the Fund to £600million for the 23/24 and to £1billion for 24/25. This funding has so far been used to deliver additional care packages and beds, provide equipment to support people in returning home, and boost the social care workforce. Local authorities and NHS integrated care boards have the flexibility to spend their allocations in ways they deem most appropriate for their local area. Funding must be spent on measures which seek to free up the maximum number of hospital beds and reduce bed days lost, for example short-term packages of care, community-based reablement capacity, or building the workforce capacity needed to continue to support care users.” Source location Response from Department of Health and Social Care
Open published response
21 Jul 2023 Corinne Haslam · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Emergency Department environments unsuitable for delivering care to patients experiencing severe and enduring mental illness View source Failure of electronic records systems to support transfer of clinical information between mental health and physical health specialists View source Lack of clear guidance for undertaking and repeating Venous Thromboembolism risk assessments View source Barriers to obtaining physical health specialist input for mental health ward patients 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
Corinne Haslam · 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
Corinne Haslam died at Tameside General Hospital on 18 March 2022 following complications involving myocardial ischaemia, acute exacerbation of chronic obstructive pulmonary disease, left ventricular hypertrophy and treated pulmonary thromboemboli. Concerns included barriers to obtaining physical-health specialist input for mental-health ward patients, incompatible electronic records between Mental Health and Acute Trusts, and unclear guidance on venous thromboembolism risk assessments.
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 Emergency Department environments unsuitable for delivering care to patients experiencing severe and enduring mental illness
Wider context from the report “1. The court heard evidence as to the barriers which exist and make it difficult for staff working on mental health wards to obtain input from physical health specialists without sending a patient to hospital via the Emergency Department.
Whilst there are occasions where review in an Emergency Department is most appropriate, the court also heard evidence that these can be extremely busy and intensive environments which may not be a conducive to delivering care for patients experiencing severe and enduring mental illness ;
” 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 electronic records systems to support transfer of clinical information between mental health and physical health specialists
Wider context from the report “2. It is a matter of concern that Mental Health Trusts and Acute Trusts operate different (apparently incompatible) electronic records systems . The absence of such a unified records system creates obstacles as to the transfer of important clinical information between mental health and physical health specialists (and vice versa) , with an inherent risk to patient safety arising from such information being held in silos .
” 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 guidance for undertaking and repeating Venous Thromboembolism risk assessments
Wider context from the report “3. It is a matter of concern that ward-based nursing staff do not appear to have been provided with clear and unambiguous guidance as to the circumstances when a risk assessment for Venous Thromboembolism (‘VTE’) should be undertaken following admission to a ward, and the circumstances in which such risk assessment should be repeated .
” 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 Barriers to obtaining physical health specialist input for mental health ward patients
Wider context from the report “1. The court heard evidence as to the barriers which exist and make it difficult for staff working on mental health wards to obtain input from physical health specialists without sending a patient to hospital via the Emergency Department .
Whilst there are occasions where review in an Emergency Department is most appropriate, the court also heard evidence that these can be extremely busy and intensive environments which may not be a conducive to delivering care for patients experiencing severe and enduring mental illness;
” 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 Issues concerning Pennine Care NHS Foundation Trust should be addressed in the Trust’s response.
Verbatim wording from the response “I note that you have also addressed matters of concern to the Chief Executive of Pennine Care NHS Foundation Trust and I would expect the Trust’s response to address those issues.” 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 Shared care records are considered a safe and secure way to bring together separate records from different health and care organisations.
Verbatim wording from the response “With regard to the compatibility of electronic patient records, a shared care record joins up information based on an individual rather than an organisation, and is a safe and secure way of bringing an individual’s separate records from different health and care organisations together.” Source location Response from Department of Health and Social Care
Open published response
19 Jul 2023 Bernhard John Marek · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Delays in ambulance offloading at Emergency Departments View source Delays in ambulance attendance for frail elderly patients with hip fractures View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Bernhard John Marek · 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
Bernhard John Marek sustained an accidental fall, suffered a fractured neck of femur, and died in hospital on 6 January 2023 after developing pneumonia. Concerns included prolonged ambulance waits for frail elderly patients with hip fractures and delays in ambulances offloading patients at emergency departments.
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 ambulance offloading at Emergency Departments
Wider context from the report “The resource issues faced by the ambulance service were exacerbated by long delays faced by ambulances to offload patients at Emergency Departments .
” 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 attendance for frail elderly patients with hip fractures
Wider context from the report “The inquest was told that the wait time that was given at the time of the initial call was due to demand on the ambulance service and that such delays were not unusual throughout December due to demand and resources . As a consequence frail elderly patients such as Mr Marek with hip fractures were regularly waiting significant periods of time for the ambulance service .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £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 £200 million of additional ambulance funding to expand capacity and improve response times.
Verbatim wording from the response “Your report highlights that NWAS 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” 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 the additional ambulance capacity during 2024/25.
Verbatim wording from the response “£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 Scale up national virtual ward capacity to more than 10,000 beds.
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 Deliver 5,000 additional staffed, permanent hospital beds compared with 2022/23 plans.
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 Maintain the hospital bed capacity uplift during 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 Deliver new ambulances and specialist mental health vehicles.
Verbatim wording from the response “£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 a two-year delivery plan to recover urgent and emergency care services.
Verbatim wording from the response “I recognise the significant pressure the urgent and emergency care system is facing. In January 2023 we published our ambitious 2-year Delivery plan for recovering urgent and emergency care services to drive sustained improvements in urgent and emergency care waiting times. Our ambitions for this year are to improve A&E waiting times to a minimum of 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/B2304-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf” Source location Response from Department of Health and Social Care
Open published response
19 Jul 2023 Thelma Mary Radmore · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure of ward discharge processes to maintain patient flow View source Delays in initiating pressure ulcer prevention measures View source Insufficient Emergency Department capacity causing prolonged patient delays View source Delays in ambulance access and transfer to Emergency Departments 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
Thelma Mary Radmore · 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
Thelma Mary Radmore was taken to hospital after a prolonged wait for an ambulance and then waited over 26 hours in the Emergency Department before transfer to a ward. She developed an unstageable sacral pressure ulcer and contracted Influenza A and Covid-19 in hospital, deteriorating rapidly before her death. The report identified concerns about delays caused by demand for ambulance, Emergency Department and bed capacity, and the effect of those delays on pressure-ulcer prevention.
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 ward discharge processes to maintain patient flow
Wider context from the report “1. The inquest heard that the long wait for an ambulance and prolonged delay in the Emergency Department were due to demand on services and resources available. The inquest heard evidence that the ambulance service challenges were exacerbated by waits outside Emergency Departments for space to become available for patients;
2. The wait Mrs Radmore experienced with the ambulance crew in the corridor was due to demand for space within the Emergency Department due to patient numbers and issues with patient flow due to challenges in discharging patients from wards ;
3. In Mrs Radmore’s case the long delays meant that steps to reduce the risk from pressure ulcers such as a suitable mattress could not be taken at an early stage;
4. The inquest was told the situation had been ongoing throughout the preceding days and such delays were not unusual across the North West and nationally.
” 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 initiating pressure ulcer prevention measures
Wider context from the report “1. The inquest heard that the long wait for an ambulance and prolonged delay in the Emergency Department were due to demand on services and resources available. The inquest heard evidence that the ambulance service challenges were exacerbated by waits outside Emergency Departments for space to become available for patients;
2. The wait Mrs Radmore experienced with the ambulance crew in the corridor was due to demand for space within the Emergency Department due to patient numbers and issues with patient flow due to challenges in discharging patients from wards;
3. In Mrs Radmore’s case the long delays meant that steps to reduce the risk from pressure ulcers such as a suitable mattress could not be taken at an early stage ;
4. The inquest was told the situation had been ongoing throughout the preceding days and such delays were not unusual across the North West and nationally.
” 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 Emergency Department capacity causing prolonged patient delays
Wider context from the report “1. The inquest heard that the long wait for an ambulance and prolonged delay in the Emergency Department were due to demand on services and resources available. The inquest heard evidence that the ambulance service challenges were exacerbated by waits outside Emergency Departments for space to become available for patients;
2. The wait Mrs Radmore experienced with the ambulance crew in the corridor was due to demand for space within the Emergency Department due to patient numbers and issues with patient flow due to challenges in discharging patients from wards;
3. In Mrs Radmore’s case the long delays meant that steps to reduce the risk from pressure ulcers such as a suitable mattress could not be taken at an early stage;
4. The inquest was told the situation had been ongoing throughout the preceding days and such delays were not unusual across the North West and nationally.
” 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 access and transfer to Emergency Departments
Wider context from the report “1. The inquest heard that the long wait for an ambulance and prolonged delay in the Emergency Department were due to demand on services and resources available. The inquest heard evidence that the ambulance service challenges were exacerbated by waits outside Emergency Departments for space to become available for patients;
2. The wait Mrs Radmore experienced with the ambulance crew in the corridor was due to demand for space within the Emergency Department due to patient numbers and issues with patient flow due to challenges in discharging patients from wards;
3. In Mrs Radmore’s case the long delays meant that steps to reduce the risk from pressure ulcers such as a suitable mattress could not be taken at an early stage;
4. The inquest was told the situation had been ongoing throughout the preceding days and such delays were not unusual across the North West and nationally.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with NHS England to reduce ambulance response times and A&E waiting times.
Verbatim wording from the response “However, I recognise there is still more to do to reduce response times and waiting times further, and the Government will continue to work with NHSE to achieve this.” 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 Put Same Day Emergency Care services in place across every hospital with a major emergency department.
Verbatim wording from the response “Same Day Emergency Care (SDEC) services will also be in place across every hospital with a major emergency department, helping avoid unnecessary overnight stays in hospital. The SDEC model helps to reduce pressure on emergency departments because patients can be rapidly assessed, diagnosed, and treated without being admitted to a ward, and if clinically safe to do so, will go home the same day their care is provided.” 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 two-year funding to support timely and effective hospital discharge.
Verbatim wording from the response “A key part of the plan has been to increase hospital capacity to improve patient flow. This will help reduce overcrowding in A&E, speeding up the handover of ambulance patients so ambulances can swiftly get back on the roads. To help deliver these improvements, we achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds 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 have also 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 Fund additional ambulance capacity and maintain the resulting capacity uplift through 2024/25.
Verbatim wording from the response “Regarding ambulance response times, 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 Deliver 5,000 additional staffed, permanent hospital beds and maintain this capacity uplift through 2024/25.
Verbatim wording from the response “A key part of the plan has been to increase hospital capacity to improve patient flow. This will help reduce overcrowding in A&E, speeding up the handover of ambulance patients so ambulances can swiftly get back on the roads. To help deliver these improvements, we achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds 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 have also 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
14 Jul 2023 PETER MARTIN AARON FLEMING · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 9 Failure of medication-management processes to identify proposed carbamazepine treatment View source Lack of care-coordinators for seriously mentally ill patients View source Lack of GP resources for proactively checking collection of prescribed medication View source Delays in primary care organisations providing important patient updates to GPs View source Unavailability of approved mental health practitioners within 24 hours View source Unavailability of mental health places of safety View source Failure of digital systems used by different health organisations to communicate View source Unavailability of mental health inpatient beds View source Ineffective communication between specialist mental health teams 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
PETER MARTIN AARON FLEMING · 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 Martin Aaron Fleming was found deceased in his flat on 10 November 2022 after taking a deliberate overdose of prescribed medication; his cause of death was confirmed as carbamazepine toxicity and the conclusion was suicide. The report raised concerns about inadequate mental health resources, ineffective communication between specialist teams and health organisations, delays in medication provision, and shortcomings in medication management and monitoring.
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 medication-management processes to identify proposed carbamazepine treatment
Wider context from the report “3. Carbamazepine management was proposed in 2012 to manage the deceased’s mental health however this was not picked up by his GP and was only noted by a BSMHFT consultant in August 2022 . Therefore, the deceased went 10 years without this medication. BSMHFT could not explain at the inquest why this omission had not been identified sooner . BSMHFT’s RCA action plan does not have any action to avoid a repeat occurrence. My concern is this RCA indicates a problem with process and systems and further consideration is required to avoid a repeat occurrence.
” 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 care-coordinators for seriously mentally ill patients
Wider context from the report “1. There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull . In the summer of 2022 Birmingham and Solihull Mental Health Trust (‘BSMHFT’) wanted to admit the deceased to an inpatient psychiatric unit, however, no bed was available, and he remained in the community. Shortly before his death, the deceased had been detained by the police under section 136 of the mental health act. There was no available ‘place of safety’ and he had to be taken to an emergency department. The police, BSMHFT, and hospital Drs agreed the deceased needed to be assessed under the mental health act, however Birmingham City Council could not provide an approved mental health practitioner (‘AMPH’) to attend in a 24-hour period. When the section 136 lapsed the deceased was discharged home after a review by a mental health nurse. At the time of his death the deceased was on BSMHFT’s waiting list for a care-coordinator. The lack of care-coordinators , mental health inpatient beds, ‘place of safety’, and AMHPs, presents a risk seriously mentally ill people are not receiving necessary treatment. The evidence is that these issues are a consequence of a chronic lack of resources at a local and national level. The Birmingham and Solihull coroners have been repeating identical concerns in Prevention of Future Death Reports for many years.
” 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 GP resources for proactively checking collection of prescribed medication
Wider context from the report “5. The deceased’s GP raised concerns that current resources do not allow GPs to pro-actively check patients are collecting prescribed medication due to excessive patient lists . My concern is that this is a consequence of lack of resources at a national level .
” 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 primary care organisations providing important patient updates to GPs
Wider context from the report “4. The deceased’s GP raised concerns that different health organisations use different digital systems that do not communicate with each other. Further, GPs often do not get important patient updates from primary care organisations for many days or weeks . (See examples above: the GP did not pick up the carbamazepine prescription, and could not prescribe the medication in October 2022). My concern is communication between different health organisations is not as effective as it could be and important information is being missed , and consequently a material delay in treatment is occurring .
” 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 approved mental health practitioners within 24 hours
Wider context from the report “1. There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull. In the summer of 2022 Birmingham and Solihull Mental Health Trust (‘BSMHFT’) wanted to admit the deceased to an inpatient psychiatric unit, however, no bed was available, and he remained in the community. Shortly before his death, the deceased had been detained by the police under section 136 of the mental health act. There was no available ‘place of safety’ and he had to be taken to an emergency department. The police, BSMHFT, and hospital Drs agreed the deceased needed to be assessed under the mental health act, however Birmingham City Council could not provide an approved mental health practitioner (‘AMPH’) to attend in a 24-hour period . When the section 136 lapsed the deceased was discharged home after a review by a mental health nurse. At the time of his death the deceased was on BSMHFT’s waiting list for a care-coordinator. The lack of care-coordinators, mental health inpatient beds, ‘place of safety’, and AMHPs , presents a risk seriously mentally ill people are not receiving necessary treatment. The evidence is that these issues are a consequence of a chronic lack of resources at a local and national level. The Birmingham and Solihull coroners have been repeating identical concerns in Prevention of Future Death Reports for many years.
” 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 mental health places of safety
Wider context from the report “1. There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull. In the summer of 2022 Birmingham and Solihull Mental Health Trust (‘BSMHFT’) wanted to admit the deceased to an inpatient psychiatric unit, however, no bed was available, and he remained in the community. Shortly before his death, the deceased had been detained by the police under section 136 of the mental health act. There was no available ‘place of safety’ and he had to be taken to an emergency department. The police, BSMHFT, and hospital Drs agreed the deceased needed to be assessed under the mental health act, however Birmingham City Council could not provide an approved mental health practitioner (‘AMPH’) to attend in a 24-hour period. When the section 136 lapsed the deceased was discharged home after a review by a mental health nurse. At the time of his death the deceased was on BSMHFT’s waiting list for a care-coordinator. The lack of care-coordinators, mental health inpatient beds, ‘place of safety’ , and AMHPs, presents a risk seriously mentally ill people are not receiving necessary treatment. The evidence is that these issues are a consequence of a chronic lack of resources at a local and national level. The Birmingham and Solihull coroners have been repeating identical concerns in Prevention of Future Death Reports for many years.
” 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 digital systems used by different health organisations to communicate
Wider context from the report “4. The deceased’s GP raised concerns that different health organisations use different digital systems that do not communicate with each other . Further, GPs often do not get important patient updates from primary care organisations for many days or weeks. (See examples above: the GP did not pick up the carbamazepine prescription, and could not prescribe the medication in October 2022). My concern is communication between different health organisations is not as effective as it could be and important information is being missed, and consequently a material delay in treatment is occurring.
” 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 mental health inpatient beds
Wider context from the report “1. There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull. In the summer of 2022 Birmingham and Solihull Mental Health Trust (‘BSMHFT’) wanted to admit the deceased to an inpatient psychiatric unit, however, no bed was available , and he remained in the community. Shortly before his death, the deceased had been detained by the police under section 136 of the mental health act. There was no available ‘place of safety’ and he had to be taken to an emergency department. The police, BSMHFT, and hospital Drs agreed the deceased needed to be assessed under the mental health act, however Birmingham City Council could not provide an approved mental health practitioner (‘AMPH’) to attend in a 24-hour period. When the section 136 lapsed the deceased was discharged home after a review by a mental health nurse. At the time of his death the deceased was on BSMHFT’s waiting list for a care-coordinator. The lack of care-coordinators, mental health inpatient beds , ‘place of safety’, and AMHPs, presents a risk seriously mentally ill people are not receiving necessary treatment. The evidence is that these issues are a consequence of a chronic lack of resources at a local and national level. The Birmingham and Solihull coroners have been repeating identical concerns in Prevention of Future Death Reports for many years.
” 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 Ineffective communication between specialist mental health teams
Wider context from the report “2. BSMHFT utilizes self-contained specialist teams. The deceased was treated by (a) crisis team/home treatment team, (b) community mental health team, and (b) psychiatric liaison team. The evidence demonstrated communication between the specialist teams was not effective and this caused delays. For example, the psychiatric liaison team nurse that reviewed the deceased updated the community mental health team. However, the GP could not prescribe the deceased’s medication in October 2022 because it had not been approved by the community mental health team consultant via an ESCA and the deceased went without his medication. The deceased’s GP had to contact the community mental health team directly notwithstanding the psychiatric liaison nurse’s involvement. The deceased cited this delay as making his mental health worse shortly before his death. My concern is communication between the specialist teams is not effective enough . BSMHFT’s RCA action plan is to seek assurance from the CCG/ICB that communication between the specialist teams is being strengthened. My concern is that this does not go far enough and there should be consideration of a formal process or policy.
” 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 Increase the national mental health workforce by more than 10,000 full-time equivalent staff compared with June 2022.
Verbatim wording from the response “The 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, the mental health workforce increased by over 10,000 full-time equivalent staff in June 2023 compared to June 2022, and our aim is to grow the mental health workforce by an additional 27,000 staff by March 2024, compared to 2018/19.” 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 Integrate serious mental illness services and expand community mental health services through integrated care systems.
Verbatim wording from the response “A concern was also raised regarding a lack of communication between different health organisations. We are working towards better integration of services though the role of integrated care systems. As part of this, we are integrating services for serious mental illness, expanding community mental health services to reduce reliance on inpatient treatment, so that” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest at least £2.3 billion annually by March 2024 to expand and transform mental health services.
Verbatim wording from the response “In your report a concern was also raised regarding the lack of resources available at a national level which restricts patients from getting the mental health support that they require. We are investing at least £2.3 billion of additional funding a year by March 2024 to expand and transform mental health services in England so that two million more people can get the mental health support they need. We also provided a record investment of £15.9 billion in mental health across 2022/23, representing 27.7% more than in 2018/19.” 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 increased national mental health funding, including a record £15.9 billion investment in 2022/23.
Verbatim wording from the response “In your report a concern was also raised regarding the lack of resources available at a national level which restricts patients from getting the mental health support that they require. We are investing at least £2.3 billion of additional funding a year by March 2024 to expand and transform mental health services in England so that two million more people can get the mental health support they need. We also provided a record investment of £15.9 billion in mental health across 2022/23, representing 27.7% more than in 2018/19.” 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 Grow the mental health workforce by an additional 27,000 staff by March 2024 compared with 2018/19.
Verbatim wording from the response “The 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, the mental health workforce increased by over 10,000 full-time equivalent staff in June 2023 compared to June 2022, and our aim is to grow the mental health workforce by an additional 27,000 staff by March 2024, compared to 2018/19.” 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 Local areas are responsible for establishing policies, training, and processes supporting appropriate responses from mental health services.
Verbatim wording from the response “A number of the concerns you have raised in this report relate to policies and training requirements at a local level. It is for these local areas to ensure they have the processes in place to support mental health services, so that people with suspected mental health problems receive the appropriate response at all times.” 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 Relevant trusts are responsible for staffing and operating mental health services.
Verbatim wording from the response “The 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, the mental health workforce increased by over 10,000 full-time equivalent staff in June 2023 compared to June 2022, and our aim is to grow the mental health workforce by an additional 27,000 staff by March 2024, compared to 2018/19.” Source location Response from Department of Health and Social Care
Open published response
13 Jul 2023 Mackenzie COOPER · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Lack of a system for sharing current defibrillator service status with ambulance Trusts View source Lack of a safe system for maintaining community public access defibrillators in working order View source Failure to ensure staff training or communication supports safe decisions about defibrillator readiness View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mackenzie COOPER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mackenzie Cooper died on 29 September 2022 after being electrocuted while working at a residential property, resulting in cardiac arrhythmia. During the emergency response, a community public access defibrillator supplied from a local Co-op store could not be used because it was missing its pads. Concerns included the device being supplied in a non-workable condition and the absence of clear systems for maintaining defibrillators and sharing their operational status with ambulance services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for sharing current defibrillator service status with ambulance Trusts
Wider context from the report “Central England Co-operative
1. The community public access defibrillator in your store was supplied to a member of the public in a non-workable condition. There appears to be either no system for replacing the pads between uses, or an unsafe system in operation.
2. There appears to be either a training or communication issue in that staff appear to have known the device was missing vital equipment, but the device was supplied anyway.
The Department for Health and Social Care
3. In December 2022, the Government committed to making available over £1 million for the purchase of more community public access defibrillators, in recognition of the fact that these devices have the potential to save lives. I am concerned that without a clear system for ensuring (a) the maintenance and good order of all community public access defibrillators, and (b) a system for sharing with all ambulance Trusts the current status of defibrillators i.e. when they are out of service due to missing parts/maintenance , members of the public might be directed to a device that cannot be used, as in this case.
” 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 safe system for maintaining community public access defibrillators in working order
Wider context from the report “Central England Co-operative
1. The community public access defibrillator in your store was supplied to a member of the public in a non-workable condition. There appears to be either no system for replacing the pads between uses, or an unsafe system in operation.
2. There appears to be either a training or communication issue in that staff appear to have known the device was missing vital equipment, but the device was supplied anyway.
The Department for Health and Social Care
3. In December 2022, the Government committed to making available over £1 million for the purchase of more community public access defibrillators, in recognition of the fact that these devices have the potential to save lives. I am concerned that without a clear system for ensuring (a) the maintenance and good order of all community public access defibrillators , and (b) a system for sharing with all ambulance Trusts the current status of defibrillators i.e. when they are out of service due to missing parts/maintenance, members of the public might be directed to a device that cannot be used, as in this case.
” 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 staff training or communication supports safe decisions about defibrillator readiness
Wider context from the report “Central England Co-operative
1. The community public access defibrillator in your store was supplied to a member of the public in a non-workable condition. There appears to be either no system for replacing the pads between uses, or an unsafe system in operation.
2. There appears to be either a training or communication issue in that staff appear to have known the device was missing vital equipment, but the device was supplied anyway.
The Department for Health and Social Care
3. In December 2022, the Government committed to making available over £1 million for the purchase of more community public access defibrillators, in recognition of the fact that these devices have the potential to save lives. I am concerned that without a clear system for ensuring (a) the maintenance and good order of all community public access defibrillators, and (b) a system for sharing with all ambulance Trusts the current status of defibrillators i.e. when they are out of service due to missing parts/maintenance, members of the public might be directed to a device that cannot be used, as in this case.
” 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 Require defibrillator guardians to check devices every 90 days and update their operational status on The Circuit.
Verbatim wording from the response “All AEDs detailed on The Circuit have a guardian who holds responsibility for ensuring the AED is defib ready. There is a requirement for guardians to check the AED every 90 days and confirm this on The Circuit; if an AED has not been checked and updated by the guardian on The Circuit then the AED will automatically be shown as not emergency ready. Guardians are notified via email of when a defib is taken offline either due to being deployed or not being checked. When a call handler directs a person to an AED, that specific AED is taken out of use and a request sent to the AED guardian to check it and notify The Circuit when it is operational again.” Source location Response from DHSC
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 Automatically flag unchecked or deployed defibrillators as unavailable, notify guardians, and require operational confirmation before restoring availability.
Verbatim wording from the response “All AEDs detailed on The Circuit have a guardian who holds responsibility for ensuring the AED is defib ready. There is a requirement for guardians to check the AED every 90 days and confirm this on The Circuit; if an AED has not been checked and updated by the guardian on The Circuit then the AED will automatically be shown as not emergency ready. Guardians are notified via email of when a defib is taken offline either due to being deployed or not being checked. When a call handler directs a person to an AED, that specific AED is taken out of use and a request sent to the AED guardian to check it and notify The Circuit when it is operational again.” Source location Response from DHSC
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 Require grant-funded defibrillators to be registered on The Circuit and synchronised with ambulance dispatch systems.
Verbatim wording from the response “The Government has provided funding of £1m for a grant scheme to buy life-saving defibrillators for community spaces, which launched in September 2023. All Automatic External Defibrillators (AED’s) granted by the fund must be registered on The Circuit – The British Heart Foundation’s national defibrillator database which is synchronised with the Computer Aided Dispatch systems of the 14 Ambulance Trusts in the UK and holds the location and where required access codes for defibrillators.” Source location Response from DHSC
Open published response
12 Jul 2023 Mohammed Khalid HUSSAIN · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 8 Failure to safely effect medication changes View source Failure to safely communicate high clozapine levels View source Ineffective pharmacy processes due to lack of resources View source Failure of the internal investigation process to identify central issues View source Lack of understanding of clozapine level monitoring, interpretation and response View source Failure to learn from a previous Regulation 28 report View source Failure to highlight high clozapine results in routinely used clinical notes View source Failure to monitor clozapine and norclozapine levels View source See 5 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
Mohammed Khalid HUSSAIN · 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
Mohammed Khalid HUSSAIN was found collapsed on the bathroom floor at his home on 28 November 2022 and was confirmed deceased shortly afterwards. The medical cause of death was determined to be sudden cardiac death in schizophrenia. Concerns included inadequate systems for monitoring, communicating and acting on high clozapine levels and medication changes, as well as deficiencies in internal investigation, understanding of clozapine and pharmacy resourcing.
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 safely effect medication changes
Wider context from the report “2. Medication changes: After a review on 14/10/22, when a high level of clozapine was noted from a blood test on 03/05/22, the consultant indicated that medication should reduce on the next prescription. This was communicated by email to the care coordinator however this was not read or acted upon. The inquest heard how there was no safe system to effect medication changes .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to safely communicate high clozapine levels
Wider context from the report “1. Monitoring clozapine levels: The inquest heard evidence that there was a clear system to monitor monthly blood test results looking for low white cell count, however there was no clear system for monitoring the actual clozapine and nor clozapine levels. In addition the inquest heard how there was no safe system to communicate high levels of clozapine .
” 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 Ineffective pharmacy processes due to lack of resources
Wider context from the report “7. Pharmacy resourcing: The inquest heard evidence that processes within the pharmacy were not effective due to a lack of resources .
” 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 internal investigation process to identify central issues
Wider context from the report “6. Quality of the internal investigation process: The initial investigation report did not raise significant issues regarding the monitoring of clozapine and importantly whether Mr Hussain did in fact have toxicity. It was only when ████████ wrote a report on 26/03/23 (7months after the death) that this issue was highlighted and addressed. This raises a concern about the quality of the internal investigation process and whether it is able to identify central issues in a particular case .
” 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 understanding of clozapine level monitoring, interpretation and response
Wider context from the report “4. Understanding of clozapine: I heard evidence that there was a lack of understanding of when to measure clozapine levels, how to interpret high clozapine levels and then how to respond to a high level .
” 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 learn from a previous Regulation 28 report
Wider context from the report “5. August 2020 Regulation 28 report: I sent a Regulation 28 report in August 2020 (case of Ian Allen) which identified that there was no system in place to ensure abnormal clozapine levels were escalated and acted upon and that there was a lack of understanding of the importance of clozapine monitoring and how frequently levels should be monitored. Given this report there is a concern that the Trust has not learnt from the previous Regulation 28 report .
” 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 highlight high clozapine results in routinely used clinical notes
Wider context from the report “3. How to record high clozapine levels: The clozapine and nor clozapine levels are recorded in the pharmacy section of the records. There was no system for highlighting high clozapine results in the rio notes which are routinely used by all 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 Failure to monitor clozapine and norclozapine levels
Wider context from the report “1. Monitoring clozapine levels: The inquest heard evidence that there was a clear system to monitor monthly blood test results looking for low white cell count, however there was no clear system for monitoring the actual clozapine and nor clozapine levels . In addition the inquest heard how there was no safe system to communicate high levels of clozapine.
” Open source report
30 Jun 2023 Victoria STOREY · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3 Uncertainty about the contents of illicit potent synthetic opiates View source Illicit marketing of potent synthetic opiates as common pharmaceutical opiates View source Failure to control potent synthetic opiates under Class A and Schedule 1 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
Victoria STOREY · 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
Victoria Storey was found deceased in her bedroom on 3 September 2022 after taking an accidental overdose of a potent synthetic opioid that was not licensed for medicinal use. The report raised concerns that the substance was illicitly traded and marketed as common pharmaceutical opiates, that its contents were unknown to users, and that it was not then controlled under the relevant drug legislation despite its high risk of fatal overdose.
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 Uncertainty about the contents of illicit potent synthetic opiates
Wider context from the report “- Due to the nature of the drug in potent synthetic opiates, there is no way for the end user to know what the illicit substance contains.
” 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 Illicit marketing of potent synthetic opiates as common pharmaceutical opiates
Wider context from the report “- ████████ is illicitly traded and marketed as common pharmaceutical opiates. It has potent analgesic effects but is not approved for medicinal use due to the increased risk of adverse events.
” 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 control potent synthetic opiates under Class A and Schedule 1
Wider context from the report “- The Home Office requested advice from the Advisory Council on the Misuse of Drugs (ACMD) on the appropriate domestic control of ████████, and was advised by the ACMD on 18th July 2022 that ████████ (and other similar compounds) should be placed in schedule 1 of the Misuse of Drugs Regulations 2001 and listed as Class A drugs under the Misuse of Drugs Act 1971. However, at present the Act and Regulations have not been amended to include ████████ and it is unclear if and when this will take place. ████████ is not therefore currently controlled under Class A, Schedule 1, Misuse of Drugs Act 1971 despite its heroin-like effects with a high risk of fatal overdose.
” Open source report
28 Jun 2023 Hilary THOMAS · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5 Failure to follow guidance on proceeding with CT scans without waiting for blood test results View source Failure to escalate eligible emergency department patients for consultant review View source Delays in reviewing available blood test results View source Insufficient hospital resources to manage patient volume View source Failure to adopt and provide staff awareness and training on consultant review guidance 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
Hilary THOMAS · 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
Hilary THOMAS attended hospital with abdominal pain on 28 and 29 October 2022, then reattended on 30 October in a shocked and profoundly unwell state. She underwent emergency surgery for ischaemic bowel caused by adhesions but died on 31 October 2022. The principal concerns were delayed review of blood test results, failure to escalate her case for consultant review, and delay in arranging a CT scan.
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 follow guidance on proceeding with CT scans without waiting for blood test results
Wider context from the report “3. The doctor treating Mrs Thomas on her second attendance decided to wait for blood test result before ordering a CT scan under the misunderstanding that these were required to assess the possibility of renal toxicity from dye used during the scan . The inquest heard evidence that a CT scan should have been undertaken and there was no need to wait for blood test results . This raised a concern that staff at the Trust are unaware of this guidance .
” 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 eligible emergency department patients for consultant review
Wider context from the report “2. Mrs Thomas reattended hospital with severe pain, was over age 70 and an unscheduled return within 72 hours. The Doctor should have considered and followed national guidance from the Royal College of Emergency medicine published in June 2016 (consultant sign off) which confirmed Mrs Thomas should have been reviewed by a consultant. Mrs Thomas was not escalated for consultant review . There was no evidence at the inquest that this guidance has been adopted by the Trust nor that staff are aware of it and have been trained on it.
” 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 reviewing available blood test results
Wider context from the report “1. Witnesses explained at the inquest that the volume of patients attending hospital is at a level the like of which has never been seen and current resources are unable to deal with that volume. This had a direct impact on Mrs Thomas's death as the doctor treating her was unable to review her blood tests results until the evening handover, 6 and a half hours after the results were available by which time Mrs Thomas had left the 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 Insufficient hospital resources to manage patient volume
Wider context from the report “1. Witnesses explained at the inquest that the volume of patients attending hospital is at a level the like of which has never been seen and current resources are unable to deal with that volume . This had a direct impact on Mrs Thomas's death as the doctor treating her was unable to review her blood tests results until the evening handover, 6 and a half hours after the results were available by which time Mrs Thomas had left the 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 adopt and provide staff awareness and training on consultant review guidance
Wider context from the report “2. Mrs Thomas reattended hospital with severe pain, was over age 70 and an unscheduled return within 72 hours. The Doctor should have considered and followed national guidance from the Royal College of Emergency medicine published in June 2016 (consultant sign off) which confirmed Mrs Thomas should have been reviewed by a consultant. Mrs Thomas was not escalated for consultant review. There was no evidence at the inquest that this guidance has been adopted by the Trust nor that staff are aware of it and have been trained on it .
” 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 and maintain an uplift of 5,000 staffed, permanent hospital beds to increase capacity and improve patient flow.
Verbatim wording from the response “A key part of the plan has been to increase hospital capacity to improve patient flow and reduce overcrowding in A&E. 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 virtual ward capacity to more than 10,000 beds nationally to support hospital capacity and patient flow.
Verbatim wording from the response “A key part of the plan has been to increase hospital capacity to improve patient flow and reduce overcrowding in A&E. 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 £1.6 billion over two years to support timely and effective discharge from hospital.
Verbatim wording from the response “A key part of the plan has been to increase hospital capacity to improve patient flow and reduce overcrowding in A&E. 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 position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust is responsible for locally increasing hospital capacity and resources to manage increased patient attendances.
Verbatim wording from the response “Your report raised concerns about the capacity of Birmingham Heartlands Hospital to deal with the volume of patient attendances. I note that the University Hospitals Birmingham NHS Foundation Trust has written to you separately. The trust’s response acknowledges the emergency general surgery service has become increasingly busy following the pandemic. The trust has set out the specific actions they are taking locally to increase capacity and resources to manage the increased volume of patient attendances. This includes the provision of additional consultant resource.” Source location Response from Department of Health and Social Care
Open published response
26 Jun 2023 Mark Steven Wright · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Failure to respond to calls within target timeframes View source Insufficient resources to meet service demand View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mark Steven Wright · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mark Steven Wright deliberately overdosed on prescribed quetiapine at home during the night of 14 June or early hours of 15 June 2022, and was pronounced deceased after an ambulance arrived. The report identifies delays in the ambulance response, including SECAMBS operating under Stage 4 of its Surge Management Plan, as a significant concern because demand exceeded available resources and calls could not be answered within target timeframes.
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 respond to calls within target timeframes
Wider context from the report “There is a risk of a future recurrence of the situation which arose on 14 June 2022 given that SECAMBS is regularly operating at Stage 4 of its Surge Management Plan, meaning that demand for the service is significantly outstripping available resources and the service is not capable of responding to calls within target timeframes .
” 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 resources to meet service demand
Wider context from the report “There is a risk of a future recurrence of the situation which arose on 14 June 2022 given that SECAMBS is regularly operating at Stage 4 of its Surge Management Plan , meaning that demand for the service is significantly outstripping available resources and the service is not capable of responding to calls within target timeframes.
” 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 Boost the number of paramedics by up to 15,600 through the NHS Long Term Workforce Plan.
Verbatim wording from the response “Regarding staffing capacity, we have made significant investments in the ambulance workforce – the number of NHS ambulance staff and support staff has increased by over 50% since 2010. To help ensure we have the ambulance workforce to meet the future demands on the service, the NHS Long Term Workforce Plan sets out plans to boost the number of paramedics by up to 15,600 to deliver services in ambulance and other care settings.” 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 and maintain expanded ambulance capacity, including new ambulances and specialist mental health vehicles.
Verbatim wording from the response “The report highlights that SECamb was under high demand at the time of the incident. A primary aim of our recovery 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 Deliver 5,000 additional staffed, permanent hospital beds backed by dedicated funding.
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 over 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 have also 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 funding to support timely and effective discharge from hospital.
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 over 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 have also 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 Increase the NHS ambulance and support workforce.
Verbatim wording from the response “Regarding staffing capacity, we have made significant investments in the ambulance workforce – the number of NHS ambulance staff and support staff has increased by over 50% since 2010. To help ensure we have the ambulance workforce to meet the future demands on the service, the NHS Long Term Workforce Plan sets out plans to boost the number of paramedics by up to 15,600 to deliver services in ambulance and other care settings.” 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 the hospital bed capacity uplift 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 over 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 have also 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 urgent and emergency care recovery plan.
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 Scale up virtual ward capacity to more than 10,000 beds 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 over 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 have also 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
26 Jun 2023 Keith Nielsen · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Insufficient service resources for responding to calls within target timeframes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Keith Nielsen · 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
Keith Nielsen fell at home, sustained a head injury while taking Warfarin, and died in hospital on 23 March 2022. The concerns included the handling of his 999 call, including the no-send disposition despite his circumstances, and repeated operation of the ambulance service at Stage 4 of its Surge Management Plan, with demand exceeding available resources and responses not meeting target timeframes.
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 service resources for responding to calls within target timeframes
Wider context from the report “There is a risk of a future reoccurrence of the situation which arose on 21 March 2022 given that SECAMBS is regularly operating at Stage 4 of its Surge Management Plan , meaning that demand for the service is significantly outstripping available resources and the service is not capable of responding to calls within target timeframes .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the urgent and emergency care recovery plan with targets for improving A&E and Category 2 ambulance response times.
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/B2304-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 Fund and maintain additional ambulance capacity, including new ambulances and specialist mental health vehicles, to improve response times.
Verbatim wording from the response “The report highlights that SECAmb was under high demand at the time of the incident. A primary aim of our recovery 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” 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 Set out plans through the NHS Long Term Workforce Plan to increase paramedic numbers by up to 15,600.
Verbatim wording from the response “Regarding staffing capacity, we have made significant investments in the ambulance workforce – the number of NHS ambulance staff and support staff has increased by over 50% since 2010. To help ensure we have the ambulance workforce to meet the future demands on the service, the NHS Long Term Workforce Plan sets out plans to boost the number of paramedics by up to 15,600 to deliver services in ambulance and other care settings.” Source location Response from Department of Health and Social Care
Open published response
22 Jun 2023 Stephen Norman RICHARDSON · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1 Lack of acute psychiatric beds for immediate inpatient assessment, treatment and care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen Norman RICHARDSON · 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
Stephen Norman Richardson died on 28 September 2019 after a self-inflicted ligature incident at the Sid Watkins Unit on 24 September 2019, following extensive brain damage and withdrawal of life support by his family. The report identified concerns including failures to secure an acute mental health bed, missed opportunities relating to treatment and risk assessment, inadequate communication and safeguarding planning, and staff not following the correct emergency response procedure. It also noted an ongoing national shortage of acute psychiatric beds.
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 acute psychiatric beds for immediate inpatient assessment, treatment and care
Wider context from the report “It was clear from the investigation that at the time of Stephen ligaturing in May 2019 there was anational shortage of acute psychiatric beds to treat patients in the community suffering with mental disorder of a nature or degree which necessitated immediate assessment treatment and care as an inpatient . The evidence heard has confirmed that that parlous situation has not improved .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England and the Integrated Care Board are responsible for addressing acute psychiatric bed availability and related care quality concerns.
Verbatim wording from the response “I understand that NHS England, in conjunction with Cheshire and Merseyside Integrated Care Board, has already 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 on the specific concern around availability of beds.” Source location Response from Department of Health and Social Care
Open published response
20 Jun 2023 Joan Mary Corcoran · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Failure to provide timely category 2 ambulance responses View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joan Mary Corcoran · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joan Mary Corcoran suffered an accidental fall, underwent surgery for a fractured neck of femur, and subsequently developed pneumonia, an infected wound and increasing frailty. After becoming unwell with chest pains, she experienced a 1-hour 5-minute delay for a category 2 ambulance response and died in the ambulance from complications of heart failure while being transported to hospital. The substantive concern was that ambulance response delays were significantly outside target times and reflected wider system pressures, including demand for ambulances and delays at A&E departments.
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 timely category 2 ambulance responses
Wider context from the report “The inquest heard evidence that under the Department of Health’s Ambulance Response time criteria, a category 2 call should have an average response time of 18 minutes and be within 40 minutes in 9 out of 10 cases .
The evidence before the inquest was that in her case the response time on the category 2 call was 1 hour and 5 minutes - significantly outside the target time . A response within the target time would have meant that she would not have deteriorated and died in the ambulance. She would have been in a hospital with access to treatment available in such a setting.
The evidence before the inquest was that her case was not a one off and delays of this nature had been occurring throughout the day . The mean time for Category 2 response times that day was 1 hour and 22 minutes and the 90th percentile was just over 3 hours .
At 17.58 that day there were 142 emergencies waiting in Greater Manchester alone and 430 across the North West. The average response time at that point for Category 2 patients was 2 hours and 33 minutes . The inquest heard that the cause of these significant delays in patients receiving care in a timely manner was multifactorial and included the demand for ambulances across Greater Manchester and the North West and the long ambulance delays at A and E departments due to the demand on A and E services.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with NHS England 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 Maintain additional ambulance capacity funded to expand services and improve response times.
Verbatim wording from the response “Your report highlights that NWAS 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 Provide funding to support timely and effective hospital discharge by NHS organisations and local authorities.
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 Deliver new ambulances and specialist mental health vehicles.
Verbatim wording from the response “Your report highlights that NWAS 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 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 Maintain the uplift in staffed, permanent hospital bed capacity during 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 and maintain national virtual ward bed capacity above 10,000 beds.
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
16 Jun 2023 Girmaye Guyo Liban · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Lack of a thorough procedure or legal test for assessing nearest relative discharge applications 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
Girmaye Guyo Liban · 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
Girmaye Guyo Liban had a long history of mental health illness and substance abuse, was discharged from detention under the Mental Health Act 1983, remained unwell in the community, went missing on 10 November 2020, and his body was found in a reservoir on 26 November 2020. The concern was that the Nearest Relative Power could enable discharge despite a patient continuing to meet the criteria for detention, without a thorough procedure or legal test for clinicians to apply.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a thorough procedure or legal test for assessing nearest relative discharge applications
Wider context from the report “The Nearest Relative Power may (as it did in this case) present an opportunity for a patient and/or their Nearest Relative to apply to the Responsible Clinician for discharge in circumstances when the patient remains liable for their continued detention. There does not appear to be a thorough procedure or legal test for clinicians to apply , and thus there is a risk that Responsible Clinicians may be faced with circumstances whereby a patient will be discharged from hospital despite them continuing to meet the criteria for detention .
” Open source report
26 May 2023 Conrad Richard James Colson · Prevention of Future Deaths report East London
View report summary
Concerns raised 5 Lack of training for stepdown service teams on BDD diagnosis and associated risks View source Failure to share BDD diagnoses with clinics providing aesthetic dermatology treatment View source Failure to inform patients with BDD of the risks of seeking aesthetic dermatology treatment View source Failure to share risk information and coordinate risk management planning between specialist and stepdown services at discharge View source Lack of national specialist resources for BDD View source See 2 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
Conrad Richard James Colson · 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
Conrad Colson, who had severe body dysmorphic disorder and a previous serious suicide attempt, was found deceased at home on 2 March 2022 after friends became concerned for his welfare. The inquest concluded that he took his own life while accessing aesthetic dermatology treatment, without therapeutic medication or professional mental health support, and after discharge without a robust risk assessment or relapse risk-management plan. Concerns included insufficient liaison and information sharing between mental health services, inadequate consideration of risks associated with aesthetic dermatology treatment, and training and resource gaps relating to body dysmorphic disorder.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of training for stepdown service teams on BDD diagnosis and associated risks
Wider context from the report “3. The Inquest heard that there is a need for training to be provided to step-down service teams in relation to the diagnosis of BDD and the risks associated with it .
” 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 share BDD diagnoses with clinics providing aesthetic dermatology treatment
Wider context from the report “2. Both mental health services were aware that Conrad was accessing aesthetic dermatology treatment. There was a concern that neither service adequately highlighted the risks of accessing such treatment to Conrad or attempted to share information with the skin clinic. The inquest heard that patients with BDD should be fully informed of the risks of seeking aesthetic dermatology treatment and wherever possible, clinics who are providing treatment should be made aware of the BDD diagnosis .
” 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 inform patients with BDD of the risks of seeking aesthetic dermatology treatment
Wider context from the report “2. Both mental health services were aware that Conrad was accessing aesthetic dermatology treatment. There was a concern that neither service adequately highlighted the risks of accessing such treatment to Conrad or attempted to share information with the skin clinic. The inquest heard that patients with BDD should be fully informed of the risks of seeking aesthetic dermatology treatment and wherever possible, clinics who are providing treatment should be made aware of the BDD diagnosis.
” 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 share risk information and coordinate risk management planning between specialist and stepdown services at discharge
Wider context from the report “1. A concern arose at the Inquest hearing in relation to the absence of liaison between the highly specialist services of the CADAT team and the stepdown services provided by NELFT . There was a lack of full information sharing around risk and risk assessment/risk management planning on discharge .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national specialist resources for BDD
Wider context from the report “4. The inquest heard that there is a lack of national resources for BDD . The highly specialised service at South London and Maudsley has a very long waiting list (several months) . This is on a background of concerns of a likely increase in BDD. In light of this concern, I am also providing this report to the Royal College of Psychiatrists, to the Department for Health & Social Care and to NHSE.
” Open source report
22 May 2023 Michael James Francis Bray · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1 Failure to provide timely ambulance responses to Category 2 calls 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
Michael James Francis Bray · 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
Michael James Francis Bray was at home on 9 and 10 October 2021 after drinking alcohol and contacting a crisis helpline while considering hanging himself; he died by hanging between about 1:50 am and 5:53 am on 10 October 2021. The report identified concerns about prolonged delays in responding to Category 2 ambulance calls, including persistently above-target response times, alongside issues concerning inter-agency communication, police and ambulance responses, and welfare checks.
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 timely ambulance responses to Category 2 calls
Wider context from the report “Although it could not be safely said when the deceased died, and therefore it could not safely be said that the delay in the ambulance response probably contributed to the death, the concern is that long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future.
Bearing in mind the national ambulance target response time for a Category 2 call of an average of 18 minutes, with 90% of calls to be responded to within 40 minutes:
The average Category 2 response time for the East of England Ambulance Service NHS Trust (‘EEAST’) in October 2021, the month of this death, was 56 minutes and 2 seconds.
The same average time for January 2023, the most recent month for which data was available, was 49 minutes and 3 seconds.
Every month since the deceased’s death, EEAST’s Category 2 response time has been above the 90th percentile time of 40 minutes.
The average EEAST Category 2 response time for a given month in the period from October 2021 to January 2023 is over 1 hour, with a standard deviation of about 20 minutes.
Therefore, EEAST’s Category 2 response time remains persistently and consistently far off target.
Although I accept on the evidence that action is being taken, on both local and national levels, to prevent future deaths as a result of this issue, the evidence of the results of such actions to date is that these actions have been demonstrably ineffective and have not resulted in a Category 2 average response time for EEAST that is even close to the target time.
The evidence received was that this issue, and the causes for it and the action required, are not just local in nature, but also national.
” 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 Maintain the 5,000-bed hospital capacity uplift during 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” 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 Deliver 5,000 additional staffed, permanent hospital beds compared with 2022/23 plans.
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” 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 Deliver new ambulances and specialist mental health vehicles.
Verbatim wording from the response “A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £220 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
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the delivery plan for recovering urgent and emergency care services.
Verbatim wording from the response “I recognise the significant pressure services are 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 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
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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 £220 million of additional ambulance funding to expand capacity and improve response times.
Verbatim wording from the response “A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £220 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
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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 £1.6 billion available over two years to support timely and effective hospital discharge.
Verbatim wording from the response “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 made £1.6 billion of funding available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E, reducing delays in ambulances handing over patients so they can swiftly get back on the roads.” 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 Maintain the additional ambulance capacity funded for 2023/24 during 2024/25.
Verbatim wording from the response “A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £220 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
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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 Scale up virtual ward capacity to more than 10,000 beds nationally.
Verbatim wording from the response “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 made £1.6 billion of funding available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E, reducing delays in ambulances handing over patients so they can swiftly get back on the roads.” 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 East of England Ambulance Service NHS Trust is best placed to respond on local actions to improve ambulance response times.
Verbatim wording from the response “Your report raises concerns about the ambulance response times by East of England Ambulance Service NHS Trust (EEAST). You have raised these concerns directly with EEAST which is best placed to respond on the specific action being taken locally to improve response times. In preparing this response, Departmental officials have made enquiries with the Care Quality Commission who have also met EEAST to discuss the circumstances around Mr Bray’s death and local action being taken.” Source location Response from Department of Health and Social Care
Open published response
3 May 2023 Sienna Daisy Barber · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Lack of NICE guidance for diagnosing and treating Group A Streptococcus in high-risk groups View source Failure to consider rapid antigen testing for Group A Streptococcus in children under 5 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
Sienna Daisy Barber · 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
Sienna Daisy Barber, a previously healthy child, developed a high temperature and was assessed by her GP, NHS 111 and at hospital before becoming increasingly unwell and dying at Royal Oldham Hospital on 29 January 2022. The report raised concerns about the absence of NICE guidance for diagnosing and treating Group A Streptococcus, particularly for high-risk groups including children under five, and about the lack of recommended rapid antigen testing for this group.
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 NICE guidance for diagnosing and treating Group A Streptococcus in high-risk groups
Wider context from the report “1. The court heard evidence that since 2014 cases of Group A Streptococcus have increased annually. After Sienna’s death in December 2022 there was a significant increase of cases in young children.
Whilst emergency guidance was issued to practitioners in December 2022 this related to the threshold for the administration of treatment in cases where Group A Streptococcus. This guidance has itself now been withdrawn. The court heard that unlike other conditions such as Meningitis there is no NICE guidance for practitioners to assist them with how to diagnose / treat Group A Streptococcus. Apparently there has been previous consideration of this but a decision was taken not to provide such guidance. The court was advised this decision was taken having considered the impact of Group A Streptococcus on the whole of the population. However the court informed that there are three high risk groups, these being ; i) Children under the age of 5, ii) women who have given birth in the last month and iii) the over 75’s.
In my opinion consideration of guidance targeted towards these three high risk groups should be considered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to consider rapid antigen testing for Group A Streptococcus in children under 5
Wider context from the report “2. The court also heard that in 2019 a NICE publication considering rapid antigen testing was published. This did not recommend rapid antigen testing. However this publication excluded consideration of testing in the high risk group, the under 5’s. Rapid antigen testing is carried out in other countries such as the USA and Canada. The court heard Sienna would have been entirely the sort of patient where such testing would have been appropriate on the 25th January 2022 when she was examined at North Manchester and she would have immediately been commenced on the treatment for Group A streptococcus, penicillin.
In my opinion consideration should be given for rapid antigen testing in the under 5’s in such cases.
” Open source report
3 May 2023 Callum Wong · Prevention of Future Deaths report North London
View report summary
Concerns raised 1 Lack of consideration for exceptions to patient confidentiality in cases of mental illhealth 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
Callum Wong · 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
Callum Wong was found having hanged himself on 27 August 2022. The report raised concern about considering exceptions to patient confidentiality in cases of mental ill health where informing third parties could provide crucial non-medical support.
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 consideration for exceptions to patient confidentiality in cases of mental illhealth
Wider context from the report “1. Consideration for exceptions to patient confidentiality in cases of mental illhealth, where informing third parties of a patient’s condition may result in crucial non-medical support.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations